Erez Lang

Testicular sparing surgery for small masses

OBJECTIVES To determine the proportion of benign testicular lesions among candidates for testicular sparing surgery (TSS) and to assess the safety and efficacy of this procedure. METHODS AND MATERIALS Sixteen patients underwent surgical exploration for testicular tumors with TSS intent in our center. Surgery was performed via an inguinal approach with temporary cord occlusion and frozen section (FS) analysis of the lesions. Benign findings allowed for TSS, whereas cancer prompted total orchiectomy. RESULTS The lesions measured 8-25 mm in the largest diameter. Eleven of the 16 lesions were benign (69%) and TSS was accomplished in these cases. Complete concordance was observed between the results of FS and permanent sections. Of the 5 patients with cancer, 3 had pure seminoma, and embryonal carcinoma and teratoma were found in 1 patient, each. Surveillance was applied in 4 of these patients, and chemotherapy was used in the patient with embryonal carcinoma. With an average follow-up duration of 48 months, all are alive and free of disease. All 11 patients in whom TSS was accomplished had an uneventful postoperative course, and with an average follow-up duration of 28 months, 9 have normal scrotal physical examination and ultrasound, whereas 2 patients were lost to follow-up. CONCLUSIONS Sixty-nine percent of testicular lesions under 25 mm are benign. TSS is safe and effective in patients with small benign lesions. Cancer is reliably detected by FS, and testicular exploration is not associated with local or distant recurrence in any of our patients.

Autonomic Response During Bladder Hydrodistention in Patients with Bladder Pain Syndrome

PURPOSE We determined whether patients with bladder pain syndrome who have typical interstitial cystitis endoscopic findings, including glomerulations and/or Hunner ulcer, have a distinct autonomic response during bladder hydrodistention. MATERIALS AND METHODS Included in the study were 50 consecutive patients (40 females and 10 males) who met International Society for the Study of BPS recommendations. All patients underwent the same clinical evaluation, consisting of medical history, physical examination, urine and blood tests, urine cytology and culture, urinary tract ultrasound and urodynamics. Bladder hydrodistention and biopsies were performed using general anesthesia. Systolic and diastolic blood pressure, and heart rate were recorded after the induction of general anesthesia and at the end of the filling phase. Patients were divided into 2 groups, including patients with and without typical endoscopic findings, respectively. Clinical, histological and urodynamic variables, and autonomic parameters were compared between the 2 groups. RESULTS No significant differences in demographics, symptoms, pain severity, comorbidities, previous surgery, urodynamic variables, anesthetic bladder capacity or histological findings were found between the 2 groups. In patients with endoscopic findings average ± SD systolic and diastolic blood pressure increased by 25 ± 19 and 21 ± 12 mm Hg, respectively, and average heart rate increased by 12 ± 11 beats per minute. All hemodynamic changes were statistically significant (p <0.001). In patients without endoscopic findings a minor decrease in hemodynamic parameters was observed. CONCLUSIONS Patients with bladder pain syndrome who have typical interstitial cystitis findings on endoscopy show a marked autonomic response during bladder hydrodistention, consisting of an increase in heart rate, and systolic and diastolic blood pressure.

Use of Adult Criteria for Slice Imaging May Limit Unnecessary Radiation Exposure in Children Presenting With Hematuria and Blunt Abdominal Trauma

OBJECTIVE To examine whether it would be safe to use adult criteria for imaging in pediatric blunt renal trauma and hematuria. MATERIAL AND METHODS From 1999 to 2007, 46 consecutive children were admitted for renal trauma and hematuria. All had abdominal computed tomography (CT) scan. Patients were divided into 2 groups: microhematuria and macrohematuria. Outcomes analyzed were presence of renal injury per CT, grade of renal injury, and indication for and details of surgical intervention. RESULTS Twenty-seven patients (59%) had microhematuria. Nineteen (41%) had macrohematuria. On abdominal CT scan, no injury was found in 18 patients with microhematuria (67%) and 3 (16%) with macrohematuria. Two microhematuria patients required surgical intervention. In both cases, no actual renal intervention was performed during surgery. Three macrohematuria patients required surgical intervention; all had renal relevant procedures. The performance of the macro-microhematuria distinction in the prediction of renal injury on CT scan is relatively poor: sensitivity 59%, specificity 14%, positive predictive value (PPV) 84%, and negative predictive value (NPV) 62%, whereas the performance of macrohematuria criteria in the prediction of renal-relevant injury is sensitivity 100%, specificity 61%, PPV 18%, and NPV 93%. CONCLUSIONS The yield of abdominal CT in pediatric renal trauma is low in patients presenting with microhematuria. Our data suggest that it may be possible that adult criteria for renal imaging are sufficient for children with abdominal blunt trauma and microhematuria. Adopting such strategy will result in substantial reduction in exposure to radiation, supposedly without increasing the patients risk.

Sterility of Reusable Transrectal Ultrasound Transducer Assemblies for Prostate Biopsy Reprocessed According to Food and Drug Administration Guidelines—Bacteriologic Outcomes in a Clinical Setup

OBJECTIVES To test the effectiveness of the sterilization process of the transducer while applying the Food and Drug Administration recommendations on a routine basis in a high-volume clinical setup. In June 2006, the Food and Drug Administration issued a Public Health notification about reprocessing of the reusable ultrasound transducer assemblies used for transrectal biopsy of the prostate. METHODS Transrectal ultrasound assembly components were systematically swabbed and cultured. The ultrasound gel and disinfectant fluid were also cultured. RESULTS A total of 42 sets of cultures from 4 predetermined locations were obtained (n = 168). Bacterial growth was demonstrated in 2 sets of cultures, both from the transducer working channel (2 of 168, 1.19%): Streptococcus viridans from the distal orifice of the working channel and coagulase-negative staphylococcus from the proximal orifice. No bacterial growth was found in the gel samples or in the disinfectant fluid. No patient experienced a symptomatic urinary tract infection or sepsis, regardless of the culture results. CONCLUSIONS Processing transrectal ultrasound biopsy transducer assemblies using the Food and Drug Administration recommendations achieved sterility in 98.8% of the cultures tested and in 95.2% of the consecutive cycles of equipment preparations.

Decreased Amplitude of Detrusor Overactivity by Repetitive Swallowing

PURPOSE We determined whether swallowing has an effect on the degree of urinary urgency and on the amplitude of detrusor contraction during filling cystometry in patients with detrusor overactivity. MATERIALS AND METHODS Included in study were 20 consecutive patients with detrusor overactivity. During urodynamics the mean peak pressure of each contraction was documented and compared. At the beginning of wave 2 patients were asked to perform 5 repetitive swallows. After each wave patients were asked to grade the severity of urgency on a visual analog scale. RESULTS The mean ± SD peak of the detrusor contraction was 39 ± 15 vs 95 ± 26 cm H(2)O with vs without swallowing (p <0.01). All patients reported that during swallowing the degree of urgency decreased. The mean visual analog scale score for urgency was significantly lower during repetitive swallowing than without swallowing (mean 3.4 ± 1.5 vs 7.7 ± 2.2, p <0.01). CONCLUSIONS The repetitive swallowing maneuver inhibits urinary urgency and detrusor overactivity. The maneuver can be used during bladder training program or when micturition is not desirable.

Increasing medical staff safety by using a closed system for intravesical instillation of mitomycin C.

OBJECTIVES Intravesical treatment with mitomycin C (MMC) after trans-urethral resection of bladder tumor is indicated by the guidelines of the European Association of Urology and the American Urology Association. MMC solution is highly irritative to skin and mucous membranes and may be of potential harm to staff handling it. We describe a closed-system device that we have developed for MMC intravesical instillation immediately after transurethral resection of bladder tumor (TURBT) for bladder cancer. MATERIAL AND METHODS A design was developed based on three requirements of a closed system for intravesical instillation of cytotoxic drug: (1) the connection of the system with the MMC administration device (e.g., syringe) must prevent any spillage or spraying of the drug solution. (2) the system should automatically close in the absence of a syringe at the connecting hub.(3) the system should have a draining mode to enable rapid drug and urine drainage into a commercially available urine bag using conventional attachments. RESULTS In the system developed, MMC syringe is screwed to the connector. The valve is directed to the urinary bladder, and the MMC is injected. At the end of the therapy, the valve is directed to the collecting bag and the MMC and connector are disposed according to the guidelines for hazardous material disposal. CONCLUSIONS To our knowledge, this is the first report of a closed system specifically designed to reduce staff exposure during instillation of MMC. No single case of MMC spill or occupational exposure has been reported since the closed system was introduced.

Correction: Hyperbaric oxygen can induce angiogenesis and recover erectile function

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