Gino J. Vricella

Percutaneous Cryoablation of Renal Masses: Impact of Patient Selection and Treatment Parameters on Outcomes

OBJECTIVES To evaluate whether the trend in patient selection or perioperative parameters were associated with treatment outcomes after percutaneous cryoablation (PCA) of renal masses. METHODS We retrospectively analyzed our urological oncology database and identified 52 patients treated for a total of 54 renal masses. Univariate analysis was performed to evaluate whether the variables of age, gender, tumor size, number of probes used, total freezing time, preoperative creatinine, American Society of Anesthesia class, body mass index, or age-adjusted Charlson comorbidity index (CCI) score had an impact on the outcomes of treatment failure or the complication rate. RESULTS During a mean follow-up of 21 months, recurrence-free, overall, and disease-specific (based on radiographic follow-up and biopsy) survival were 96.2%, 98.1% and 100%, respectively. The mean age-adjusted CCI score for patients with postoperative complications was 6.5, compared with a mean score of 3.0 in patients without postoperative complications (P = .02). The complication rate was also significantly higher when a greater number of cryoprobes were used during PCA (P < .005). None of the variables analyzed were predictive of treatment failure. CONCLUSIONS Of the pre- and intraoperative variables studied, age-adjusted CCI score and number of cryoprobes used were the only variables with predictive value for outcomes in regard to treatment failure or complications. As investigators continue using cryoablation to treat renal masses, it is important to be able to completely and honestly counsel patients regarding the likelihood of complications and need for subsequent therapy in the setting of treatment failure.

Does Size Really Matter? The Impact of Prostate Volume on the Efficacy and Safety of GreenLight HPS™ Laser Photoselective Vaporization of the Prostate

PURPOSE To evaluate the efficacy and safety of GreenLight HPS™ laser photoselective vaporization of the prostate (PVP) for the treatment of benign prostatic hyperplasia (BPH) in patients with different prostate volumes. PATIENTS AND METHODS Between July 2006 and February 2011, 207 consecutive patients were identified from a prospectively maintained urologic database. Based on preoperative prostate volume measured by transrectal ultrasonography, patients were stratified into two groups: ≥ 80 cc (group 1, n=57) and < 80 cc (group 2, n=150). Transurethral PVP was performed using a 120W GreenLight HPS side-firing laser system. American Urological Association Symptom Score (AUASS), quality-of-life (QoL) score, maximum flow rate (Qmax), and postvoid residual (PVR) volume were measured preoperatively and at 1 and 4 weeks and 3, 6, 12, 18, 24, and 36 months postoperatively. RESULTS Among the preoperative parameters evaluated, there were significant differences (P<0.05) in the incidence of preoperative urinary retention (1: 24.6%; 2: 7.3%), serum prostate-specific antigen level (1: 4.5 ± 2.7; 2: 1.8 ± 1.9 ng/mL), QoL (1: 4.2 ± 1.1; 2: 4.7 ± 0.9), and mean prostate volume (1: 118.1 ± 37.9; 2: 48.5 ± 15.5 cc), while AUASS, Qmax, and PVR were similar (P>0.05) between groups. Significant differences (P<0.05) in laser use (1: 22.8 ± 13.3; 2: 10.4 ± 6.4 minutes) and energy usage (1: 152.7 ± 90.6; 2: 70.9 ± 44.8 kJ) were also noted. Clinical outcomes (AUASS, QoL, Qmax, and PVR) showed immediate and stable improvement from baseline (P<0.05) within each group, but no significant differences between the two groups were observed during the follow-up period (P>0.05). The incidence of adverse events was low and similar in both cohorts. CONCLUSIONS These results suggest that prostate volume has little effect on the efficacy and safety of GreenLight HPS laser PVP, and that this technique remains a viable surgical option for BPH, irrespective of preoperative prostate volume.

Long-Term Efficacy and Durability of Botulinum-A Toxin for Refractory Dysfunctional Voiding in Children

PURPOSE We evaluated our long-term experience with intrasphincteric botulinum toxin A injection in children with dysfunctional voiding. MATERIALS AND METHODS From January 2006 through July 2012 we saw 2,172 neurologically normal children due to dysfunctional voiding. Of patients who presented to these visits we retrospectively identified the charts of 12 with dysfunctional voiding (8 females) in whom urotherapy and medical management failed and who underwent botulinum toxin A injection to the external urinary sphincter. Mean patient age at surgery was 10.5 years (range 4 to 19). Average followup was 45 months (range 20 to 71). Preoperatively and postoperatively all children were evaluated with history and physical examination, voiding diary, renal and pelvic ultrasound with post-void residual volume measurement and uroflowmetry. RESULTS Eight of the 12 children (67%) experienced significant improvement in voiding parameters. Before vs after treatment mean ± SD post-void residual urine volume was 115 ± 83 vs 57 ± 61 ml (p = 0.016) and the mean maximum flow rate was 11.8 ± 8.1 vs 20.4 ± 7.9 ml per second. Half of the cohort required a second injection an average of 15 months later. Three of the 4 patients who failed to show improvement had neuropsychiatric problems and 1 had evidence of bladder underactivity. CONCLUSIONS Our results demonstrate reasonable efficacy and durability of intrasphincteric botulinum toxin A injection in children with refractory dysfunctional voiding. Neuropsychiatric issues appear to negatively influence the success rate. Long-term followup is vital to identify patients in whom repeat injection may be necessary.

Endoscopic snare resection of bladder tumors: evaluation of an alternative technique for bladder tumor resection.

Transurethral resection of bladder tumor (TURBT) is the standard of care for initial bladder tumor management. In response to its shortcomings, we propose an alternative technique for tumor resection and retrieval: The endoscopic snare resection of bladder tumor (ESRBT). Eleven tumors managed by ESRBT were reviewed retrospectively. Via cystoscopy, tumors were resected en bloc with an electrosurgical polypectomy snare and retrieved transurethrally. Safety and efficacy were assessed by clinical and pathologic outcomes. ESRBT was highly effective for appropriate tumors. Tumor size and location varied: Two small, six medium, three large; six lateral wall, two dome, two trigone, one posterior wall. Half of initial urothelial carcinoma specimens contained muscle. There were no intraoperative or postoperative complications (mean follow-up: 17 mos; range 10-25 mos). ESRBT is a feasible technique for the resection of pedunculated bladder tumors. It offers evident and theoretical advantages over TURBT and may augment bladder tumor management. Further study is needed.

Ablative Technologies for Urologic Cancers

Driven by patient preference and a more favorable oncologic prognosis at diagnosis, there has been a paradigm shift in the treatment of urologic cancers. Although the standard of care for most urologic malignancies continues to be surgical extirpation, ablation, in the form of needle-based or extracorporeal approaches, is quickly establishing itself as a viable primary treatment option. If there is anything to be learned from pioneering studies, it is that there must be strict adherence to inclusion criteria for patient enrollment and that there are real limitations with each approach. It is only with this awareness that we can achieve maximal benefit while limiting the number of unnecessary complications and poor oncologic outcomes.

Laparoendoscopic single-site nephrectomy: initial clinical experience in children.

OBJECTIVE To present the initial clinical experience in children undergoing unilateral and bilateral laparoendoscopic single-site nephrectomy. PATIENTS AND METHODS We reviewed our experience with pediatric patients who had undergone single-port nephrectomy (SPN) at our institution since August of 2009. Access was obtained by using the Hassan technique to place a 2-cm SILS™ Port (Covidien Surgical Devices, Norwalk, CT), which contains a gas insufflation channel and three individual cannulas that can readily accommodate laparoscopic instruments up to 12 mm in diameter. Nephrectomy was performed using a standard set of laparoscopic instruments and a rigid 5 mm 30 degree laparoscope (Karl Storz, Tuttlingen, Germany) with an end-on light source. Patient demographics, operative details, and postoperative treatment parameters were collected and recorded. RESULTS SPN was successfully performed in three consecutive pediatric patients (one female and two male patients: aged 11, 10, and 13 years, respectively) without placement of additional trocars or conversion to open surgery. The operative time for the unilateral SPN was 188 minutes, whereas bilateral SPNs required 214 and 300 minutes, respectively. Estimated blood loss for the unilateral and bilateral SPNs was 25, 20, and 30 mL; whereas patients were discharged on postoperative days 1, 3, and 12, respectively. The prolonged hospital stay was secondary to fever and pseudomembranous colitis in a patient with dialysis who also required a blood transfusion. CONCLUSIONS Laparoendoscopic single-site simple nephrectomy is a technically demanding yet feasible procedure in children. Further studies are necessary to define the indications, advantages, and limitations of this technique as compared with standard laparoscopy.

Expression of Monocyte Chemotactic Protein 3 Following Simulated Birth Trauma in a Murine Model of Obesity

OBJECTIVE To determine the effect of obesity on simulated birth trauma in leptin-deficient obese mice as measured by relative monocyte chemotactic protein 3 (MCP-3) expression. MATERIALS AND METHODS A total of 25 wild-type and 25 obese C57BL/6 virgin female mice underwent 1 hour of vaginal distension (VD), sham VD, or anesthesia without VD. Pelvic organ tissues were then harvested either immediately or 24-hours post VD and subsequent real-time polymerase chain reaction analysis was performed. RESULTS Urethral MCP-3 levels in wild-type mice were elevated from baseline at 0 hours with a return to baseline at 24 hours in both VD and sham VD groups. In obese mice, there was a 6-fold elevation in MCP-3 levels at 0 hours after sham VD vs control (P <.05), which then returned to baseline levels at 24 hours. After undergoing VD, MCP-3 levels increased to 6-fold baseline values (P = .002) at 0 hours, with continued elevation in MCP-3 levels to 15 times control levels (P = .0003) at 24 hours. CONCLUSIONS MCP-3 is significantly over-expressed in the urethral tissues of both wild-type and obese mice immediately after any urethral manipulation. At 24 hours, the MCP-3 expression patterns become divergent between VD and sham VD in obese mice. With a greater degree of trauma, MCP-3 continued to rise at 24 hours, suggesting that the underlying obesity resulted in alterations in response to tissue injury, paralleling the degree of injury. Such associations warrant further investigation into the role of MCP-3 as a chemokine for stem cell migration, with implications for subsequent tissue repair mechanisms after birth trauma.

The true risk of blood transfusion after nephrectomy for renal masses: A population-based study

There is a paucity of population‐based analyses of expected outcomes after renal surgery for kidney cancer. Reported blood transfusion rates after nephrectomy show considerable variability, probably as a result of the referral patterns that influence reports from tertiary academic medical centres. With emerging data on the inferior outcomes in patients undergoing allogeneic blood transfusion, we aimed to evaluate the patient, surgeon and hospital factors that influence the receipt of a blood transfusion after nephrectomy. A more detailed understanding of these factors may help in preoperative patient counselling and informed consent.

Setting a new standard: Updating the vaginal distention translational model for stress urinary incontinence

The vaginal distention (VD) translational model for postpartum stress urinary incontinence (SUI) is potentially biased for use in evaluating animals with increasing phenotypic size (obesity) due to a fixed VD volume. Our study had three principle and two secondary aims. First, to examine both ex vivo and in vivo catheter pressure changes during volume distention. Secondly, to determine mean pressure at current volume standard for use as target pressure (TP) for VD under isobaric (IB) conditions. Thirdly, to demonstrate feasibility and equivalence of VD at TP versus isovolumetric (IV) standard. Secondary aims were to demonstrate decreased variability (IB vs. IV) and to review the effect of weight.

Penile Fracture with Associated Urethral Rupture

Penile fracture of the erect penis is an uncommon but emergent urological trauma. Potential outcomes include erectile dysfunction, penile curvature, and urethral injury. Treatment is emergent surgical repair. We present the case of a 42-year-old man with a penile fracture complicated by a urethral rupture and subsequent repair. A discussion of the key aspects of this condition is presented.