Hubert S. Swana

INDUCIBLE NITRIC OXIDE SYNTHASE WITH TRANSITIONAL CELL CARCINOMA OF THE BLADDER

PURPOSE Nitric oxide (NO) plays a critical role as both a cell signaling molecule and as a cytotoxic/cytostatic mediator. Nitric oxide synthase (NOS) present in macrophages and neutrophils produces NO in response to immune stimulation. We evaluated NO production in both bladder tissue and urine from patients with transitional cell carcinoma (TCC) of the bladder. MATERIALS AND METHODS Inducible NOS (iNOS) RNA and protein were evaluated in bladder tissue from patients with and without TCC. Human iNOS-RNA products were identified with the reverse transcriptase-polymerase chain reaction (RT-PCR). Western blot analysis using a polyclonal antibody directed against iNOS recognized immunoreactive iNOS protein. Using the same iNOS antibody, the distribution of iNOS was examined in formalin-fixed, paraffin embedded samples of various grades of TCC. NOS activity was measured in the urine particulate fraction from patients with TCC and from controls by the conversion of [14C]-L-arginine to [14C]-L-citrulline. RESULTS Inducible NOS-RNA products and iNOS specific proteins were found in bladder tissue that contained TCC but not in control bladder tissue. Inducible NOS was uniformly localized in inflammatory cells within the carcinomas. Scattered tumor cells expressed iNOS in 8 of 12 specimens. There was no clear relationship between tumor immunoreactivity and tumor grade. NOS activity in urine from patients with TCC was not significantly elevated or decreased in comparison with control urine. CONCLUSIONS Inducible NOS is expressed by cells comprising and surrounding human bladder tumors. It is primarily localized to inflammatory cells, but also is demonstrated within individual tumor cells.

Renal artery pseudoaneurysm after blunt abdominal trauma : Case report and literature review

Renal vascular injuries such as transection, thrombosis, dissection, and arteriovenous fistula formation are unusual but well-recognized consequences of blunt abdominal trauma. We discuss a rare case of renal artery pseudoaneurysm presenting 6 weeks after blunt abdominal trauma that was successfully treated with selective embolization.

Stentless pediatric robotic pyeloplasty

Objectives: Open dismembered pyeloplasty remains the standard of care for the correction of ureteropelvic junction obstruction in children. We describe our experience with a tubeless, stentless pediatric robotic pyeloplasty technique. Methods: Between October 2008 and September 2009, 12 consecutive children underwent robotic dismembered pyeloplasty. Ureteral stents or nephrostomy tubes were not used. Operative time, hospital stay, days of Jackson–Pratt drainage, and complications were analyzed. Postoperative renal ultrasonography was obtained at 4–6 weeks after surgery. Results: The mean patient age was 9.1 years (3.5–16). The mean operative and console times were 178 (122–250) and 129 (96–193) minutes, respectively. The Jackson–Pratt drain was removed after a mean of 1.8 days (1–4). The mean hospital stay was 2.4 days (1–4.5). There were no complications. Mean follow up was 16 months (12–24 months). All patients had complete resolution of symptoms. Hydronephrosis either completely resolved or significantly decreased in all cases. In cases without complete resolution of hydronephrosis, 99m Tc-MAG-3 diuretic renography showed preservation of renal function without obstruction. Conclusions: Robot-assisted laparoscopic pyeloplasty can be safely performed without internal indwelling stent drainage. In children, this avoids the need for additional anesthesia and stent-related morbidity.

Pseudoexstrophy of the bladder: Case report and literature review

The authors present a case of a boy newborn who had bladder pseudoexstrophy and multiple congenital anomalies. In addition to this unusual variant of the exstrophy-epispadias complex, the patient was found to have a posterior cleft palate, an omphalocele, and an imperforate anus.

Pleurotomy, pneumothorax, and surveillance during living donor nephroureterectomy

OBJECTIVES To determine the incidence of and risk factors associated with pneumothorax after donor nephroureterectomy and to determine the utility of postoperative chest roentgenography. METHODS A retrospective review was made of 130 living donor nephroureterectomies performed at one institution (Yale-New Haven Hospital) using an extraperitoneal flank incision. RESULTS Incidental pleurotomy occurred in 11 cases (8.5%). Rib resection was associated with pleurotomy. Patient age, sex, and side of operation were not associated with pleurotomy. Ten (91 %) of the 11 cases were identified intraoperatively. One unrecognized pneumothorax was identified postoperatively with chest roentgenography; no specific intervention was necessary. CONCLUSIONS The extraperitoneal flank incision poses a significant risk for pneumothorax. Most pneumothoraces will be recognized intraoperatively. No adverse effects were noted secondary to pneumothorax.

Robotic assisted laparoscopic treatment of gonadal vein syndrome in a boy

PURPOSE Gonadal vein syndrome, with ureteral obstruction and compression by an overlying testicular vein is a controversial and rare diagnosis. Open, laparoscopic, and robot-assisted laparoscopic repairs have been described. We report the first case of robot-assisted gonadal vein ligation for treatment of gonadal vein syndrome in a nine year-old boy. MATERIALS AND METHODS A 9 years-old boy presented with a four to six month history of worsening intermittent flank pain, nausea and vomiting. Ultrasound revealed moderate hydronephrosis. Diuretic renography and intravenous pyelography reproduced his pain and demonstrated left-sided hydronephrosis and obstruction. The patient underwent left robot-assisted surgery via a four port approach. The colon was reflected medially. The gonadal vein was dissected off the underlying ureter and ligated using laparoscopic clips. Segmental vein excision and ureterolysis was performed. Inspection of the renal hilum did not reveal any other crossing vessels. RESULTS Operative time was 94 minutes. The patient was discharged 36 hours after surgery. His hydronephrosis has resolved completely. He remains pain-free nine months after surgery. CONCLUSION Robot-assisted laparoscopic vein excision and ureterolysis is a safe option for the management of ureteral obstruction caused by the gonadal vein.

Torsion of the Appendix Testis in a Neonate

Torsion of the appendix testis is a rare cause of scrotal swelling in the neonatal period. We present a case of torsion of the appendix testis in a one-day-old male. We discuss the physical examination and radiologic studies used to make the diagnosis. Nonoperative therapy was recommended and the patient has done well. Recognition of this condition in the neonatal period can prevent surgical intervention and its associated risks.