Jeffrey A. Leslie

Serendipitous renal cell carcinoma in the post-CT era: continued evidence in improved outcomes

PURPOSE To compare patient and tumor characteristics, including survival data, between serendipitous and non-serendipitously discovered renal cell carcinoma (RCCA) in an era of more frequent use of CT scanning and ultrasonography. MATERIALS AND METHODS The Tumor Registry of the Audie L. Murphy VA Hospital in San Antonio, TX, was reviewed for new diagnoses or initial treatment of RCCA from January 1985 through December 1999. Records were evaluated as to whether the initial diagnosis of RCCA was made serendipitously. Prognostic and epidemiological variables, were collected and disease-specific and overall survival data were computed. RESULTS Of 257 patients with RCCA, 93 (36.2%) presented with serendipitously discovered tumors and 100 presented with metastases at diagnosis. Mean tumor size was smaller in the serendipitous group, compared both pathologically (6.74 cm vs. 4.49 cm, P < 0.0001) and by radiographic measurement (8.04 cm vs. 4.87 cm, P < 0.0001). Sixty-six (71%) of 93 serendipitously discovered tumors were Stage I at diagnosis, vs. only 30 (18.4%) of 163 non-serendipitous tumors (P < 0.0001). When non-serendipitous tumors with metastatic disease at presentation were excluded, the percentage of patients with Stage I disease was lower than for serendipitous tumors (46.8% vs. 71%, P = 0.004). Pathologically confirmed tumor stage was more favorable for serendipitously discovered tumors: 40 of 77 (60%) non-serendipitous tumors were <pT3, vs. 70 of 86 (81.4%) serendipitous tumors (P < 0.0001). Overall and disease-specific survival was better in the serendipitous group as well, with a 5-year disease-specific survival of 94%, contrasted with 35% in the non-serendipitous group (P < 0.0001). CONCLUSIONS The widespread use of CT scanning and ultrasonography has led to a continued increase in the serendipitous diagnosis of a significant number of all RCCA which are associated with significantly lower stage at diagnosis, and thus with significantly improved survival.

Corporeal Grafting for Severe Hypospadias: A Single Institution Experience With 3 Techniques

PURPOSE Correction of severe chordee by corporeal body grafting has been successfully performed using various grafts and biomaterials. We report a single institution comparison of our experience using small intestinal submucosa, tunica vaginalis and dermal grafts at stage 1 hypospadias repair. MATERIALS AND METHODS A retrospective chart review was performed of the records of all patients who underwent staged hypospadias repair from 1985 to 2006 with corporeal body grafting at stage 1 with small intestinal submucosa, tunica vaginalis or dermal grafts. Age at grafting, time between stages, residual chordee at stage 2 repair and the need for additional plication or chordee correction at stage 2 were recorded. RESULTS A total of 71 patients were identified with a median age of 10 months at stage 1 repair and a median of 7.6 months between stages 1 and 2 repair. Dermal grafts, tunica vaginalis and small intestinal submucosa grafts were used in 29, 21 and 20 patients, respectively. One patient received a combination of small intestinal submucosa and tunica vaginalis. None of the patients receiving tunica vaginalis graft required any further correction of chordee. One patient with a dermal graft and 1 receiving small intestinal submucosa required Nesbit plication at stage 2 repair for minor ventral chordee. One patients receiving small intestinal submucosa showed severe fibrosis at the graft site, requiring excision and repeat grafting with tunica vaginalis. This patient has been previously described. The 2 patients with small intestinal submucosa related complications had 4-ply grafts. We have seen no complications associated with 1-ply small intestinal submucosa. At limited followup we have not seen residual chordee after stage 2 repair. CONCLUSIONS In a large group of children requiring corporeal grafting for severe chordee we observed successful chordee correction with 1-ply small intestinal submucosa, tunica vaginalis or dermal grafts.

Feminizing genital reconstruction in congenital adrenal hyperplasia

The past several decades have seen multiple advances in the surgical reconstruction for girls born with Disorders of Sexual Differentiation. This surgery can be technically very demanding, and must be individualized for each patient, as the degree of virilization and level of confluence of the vagina and urogenital sinus will dictate the surgical approach. In this manuscript we present our approach and experience in the surgical options for girls born with Congenital Adrenal Hyperplasia, with special attention regarding clitoroplasty, urogenital mobilization, and vaginoplasty.

Metastatic seminoma presenting with pulmonary embolus, inferior vena caval thrombosis, and gastrointestinal bleeding.

Testicular cancer metastasis to the retroperitoneum can be associated with a variety of complications due to obstruction or invasion of adjacent structures. In this case report, we present an unusual patient with invasion of the duodenum from germ cell cancer and discuss the management of this challenging scenario.

Adenocarcinoma in a colon conduit

Development of adenocarcinoma in a colon conduit is extremely rare. We report a case of adenocarcinoma manifesting 22 years after formation of a colon conduit. CASE REPORT A 31-year-old white man presented with gross hematuria from the urostomy. The patient had a history of neurogenic bladder (probably due to posterior urethral valves), multicystic dysplastic kidneys and bilateral vesicoureteral reflux found at age 2 months, for which he underwent bilateral cutaneous ureterostomy. At age 17 months he subsequently underwent right nephrectomy for renal nonfunction. Despite revisions of the left ureterostomy, he ultimately required left nephrectomy at age 10 years. That same year he underwent colon conduit urinary diversion in anticipation of a living related renal transplant, which was performed 2 months later. He did well for 22 years until gross hematuria developed. Conduit x-ray, computerized tomography (fig. 1) and endoscopy revealed a 3.5 cm. mid conduit papillary lesion, that was 5 cm. distal to the ureteral anastomosis. Endoscopic resection demonstrated moderately differentiated adenocarcinoma invading the muscularis (fig. 2). The colon conduit was resected and replaced with an ileal conduit. Pathological examination revealed no residual tumor. DISCUSSION

Sonographic Renal Parenchymal Measurements for the Evaluation and Management of Ureteropelvic Junction Obstruction in Children.

Purpose To correlate sonographic renal parenchymal measurements among patients with ureteropelvic junction obstruction (UPJO) labeled society of fetal urology (SFU) hydronephrosis grades 1–4 and to examine whether sonographic renal parenchymal measurements could be used to differentiate conservative vs. surgical management. Materials and methods Retrospective chart review and sonographic renal parenchymal measurements (renal length, medullary pyramid thickness, and renal parenchymal thickness) were performed in patients with SFU grades 1–4 hydronephrosis secondary to UPJO managed between 2009 and 2014. Exclusion criteria included other concomitant genitourinary pathology or incomplete follow-up. Anterior–posterior renal pelvic diameter (APRPD) and radionuclide renography were also evaluated when available. Results One hundred four patients with UPJO underwent 244 renal and bladder ultrasound (1,464 sonographic renal parenchymal measurements in 488 kidneys). Medullary pyramid thickness and renal parenchymal thickness progressively decreased from SFU grades 1–4 (p < 0.05). A similar trend was appreciated when comparing SFU grades 1 and 2 vs. 3 and 4, as well as SFU grades 3 vs. 4 (p < 0.05). SFU grade 3 and 4 patients who underwent pyeloplasty had longer renal length in comparison to those who were managed conservatively (p < 0.02). Conclusion This is the first study that evaluates these objective, quantifiable sonographic renal parenchymal measurements in children with unilateral UPJO. These sonographic renal parenchymal measurements correlate closely with worsening of hydronephrosis graded by the SFU and APRPD classification systems. Prospective studies are needed to elucidate the role of sonographic renal parenchymal measurements in the management of children with UPJO.

Why Desired Newborn Circumcisions Are Not Performed: A Survey

OBJECTIVE To identify why parents who want their child circumcised do not have them circumcised before the window for newborn circumcision (NBC) closes. We evaluate many patients in our pediatric urology clinic for circumcision in the operating room, which is associated with increased inconvenience, morbidity, and cost. METHODS From 2010 to 2013 we surveyed 53 parents seeking NBC for their sons less than 1 month old. We surveyed a second group of 51 parents with sons between 1 month and 2 years old seeking operating room circumcision. Both groups were asked why NBC was not performed in the hospital. RESULTS From the 104 parents surveyed, the primary reasons NBC was not performed in both groups were that the hospital did not offer or provide NBC (23% in the younger group and 20% in the older group) and that the provider who does NBC was not available or able prior to discharge (21% in the younger group and 20% in the older group). Ineffective communication delayed NBC in 26% of the younger group and 9% of the older group. Health problems delayed NBC in 8% of the younger group and 30% of the older group. NBC was only delayed due to parent indecision in 2% of responses in the younger group and 6% in the older group. CONCLUSION Inadequate healthcare system preparation, resources, and communication are the primary reasons NBC is delayed. More work to streamline the process for desired NBC is needed.