Jonathan N. Rubenstein

Managing complicated urinary tract infections: The urologic view

Patients with complicated UTIs are a diverse group. These patients have upper UTIs and structural or functional abnormalities that reduce the efficacy of antimicrobial therapy. They are at increased risk for morbidity such as bacteremia and sepsis, perinephric abscess, renal deterioration, and emphysematous pyelonephritis. Appropriate urinary tract imaging, antimicrobials, medical and surgical therapies, and follow-up are required to avoid potentially devastating outcomes.

The etiology of urolithiasis in HIV infected patients.

PURPOSE It is commonly thought that urinary lithiasis in HIV infected patients on protease inhibitor therapy is composed primarily of the protease inhibitor itself. Since many HIV infected patients on protease inhibitors presenting to our institution had nonprotease inhibitor stones, we investigated potential underlying metabolic abnormalities that may account for the lithogenesis. MATERIALS AND METHODS We retrospectively reviewed all HIV infected patients on protease inhibitors with renal colic and evidence of nephrolithiasis who presented to our institution between June 1996 and January 2001. Patients were evaluated for stone composition and metabolic abnormalities of blood and urine when possible. RESULTS A total of 24 patients were identified, and all were or had been on protease inhibitors (indinavir 14, ritonavir 3, nelfnavir 2, unspecified 5). Of the 14 patients on indinavir only 4 (28.6%) had indinavir containing stones. The remaining stones in this group and in those not on indinavir contained various amounts of calcium oxalate monohydrate and dihydrate, ammonium acid urate and uric acid. Of 10 patients who underwent 24-hour urine collection for metabolic evaluation 8 (80%) had abnormalities, including hypocitraturia in 5, hyperoxaluria in 4, hypomagnesuria in 4, hypercalciuria in 3, increased supersaturation of calcium oxalate in 3 and hyperuricosuria in 2. Abnormalities in the levels of urinary phosphate and sodium were also observed. CONCLUSIONS HIV infected patients form many types of stones, which probably are attributable to underlying metabolic abnormalities rather than the use of protease inhibitors. A complete metabolic evaluation is warranted in these patients, as a means of guiding treatment to prevent future stone episodes, while avoiding the need to alter antiretroviral regimens.

Pyeloureterostomy with Interposition of the Appendix

PURPOSE We describe the successful repair of a 6 cm. ureteral stricture involving the right ureteropelvic junction and proximal ureter using appendix as a ureteral substitute. MATERIALS AND METHODS A 37-year-old man involved in a motorcycle accident presented with a retroperitoneal urinoma and a 6 cm. proximal ureteral stricture. At flank exploration we were unable to perform successfully primary pyeloureterostomy through renal descensus with ureteral mobilization. The appendix was selected to bridge the ureteral defect. The right colon and cecum were mobilized to the area of the diseased ureter and the appendix was transected across the base of the cecum. Ureteral scar tissue was resected and the appendix was interposed in an isoperistaltic orientation from renal pelvis to proximal ureter. RESULTS Convalescence was unremarkable. Retrograde pyelography and flexible ureteroscopy 2 months postoperatively demonstrated a patent anastomosis and viable appendix. The ureteral stent was removed at that time. Excretory urography 3 months postoperatively revealed prompt enhancement of the 2 kidneys and visualization of the 2 ureters. Mercaptoacetyltriglycine-3 renal scan 5 months postoperatively confirmed no scintigraphic evidence of obstruction. The patient was asymptomatic 6 months postoperatively and renal function tests were normal. CONCLUSIONS The appendix can be considered for proximal ureteral defects extending to the right renal pelvis.

AUA Policy Statement on the Use of Multiparametric Magnetic Resonance Imaging in the Diagnosis, Staging and Management of Prostate Cancer

Purpose: We summarize the available data about the clinical and economic effectiveness of magnetic resonance imaging in the diagnosis and management of prostate cancer, and provide practical recommendations for its use in the screening, diagnosis, staging and surveillance of prostate cancer. Materials and Methods: A panel of clinicians with expertise in the diagnosis and management of prostate cancer evaluated the current published literature on the use and effectiveness of magnetic resonance imaging for this disease. When adequate studies were available for analysis, recommendations were made on the basis of data and when adequate studies were not available, recommendations were made on the basis of expert consensus. Results: At this time the data support the use of magnetic resonance imaging in patients with a previous negative biopsy and ongoing concerns about increased risk of prostate cancer. The data regarding its usefulness for initial biopsy suggest a possible role for magnetic resonance imaging in some circumstances. There is currently insufficient evidence to recommend magnetic resonance imaging for screening, staging or surveillance of prostate cancer. Conclusions: Although it adds cost to the management of prostate cancer, magnetic resonance imaging offers superior anatomic detail, and the ability to evaluate cellular density based on water diffusion and blood flow based on contrast enhancement. Imaging targeted biopsy may increase the diagnosis of clinically significant cancers by identifying specific lesions not visible on conventional ultrasound. The clinical indications for the use of magnetic resonance imaging in the management of prostate cancer are rapidly evolving.

The effect of kidney morcellation on operative time, incision complications, and postoperative analgesia after laparoscopic nephrectomy

INTRODUCTION Compare the outcomes between kidney morcellation and two types of open specimen extraction incisions, several covariates need to be taken into consideration that have not yet been studied. MATERIALS AND METHODS We retrospectively reviewed 153 consecutive patients who underwent laparoscopic nephrectomy at our institution, 107 who underwent specimen morcellation and 46 with intact specimen removal, either those with connected port sites with a muscle-cutting incision and those with a remote, muscle-splitting incision. Operative time, postoperative analgesia requirements, and incisional complications were evaluated using univariate and multivariate analysis, comparing variables such as patient age, gender, body mass index (BMI), laterality, benign versus cancerous renal conditions, estimated blood loss, specimen weight, overall complications, and length of stay. RESULTS There was no significant difference for operative time between the 2 treatment groups (p = 0.65). Incision related complications occurred in 2 patients (4.4%) from the intact specimen group but none in the morcellation group (p = 0.03). Overall narcotic requirement was lower in patients with morcellated (41 mg) compared to intact specimen retrieval (66 mg) on univariate (p = 0.03) and multivariate analysis (p = 0.049). Upon further stratification, however, there was no significant difference in mean narcotic requirement between the morcellation and muscle-splitting incision subgroup (p = 0.14). CONCLUSION Morcellation does not extend operative time, and is associated with significantly less postoperative pain compared to intact specimen retrieval overall, although this is not statistically significant if a remote, muscle-splitting incision is made. Morcellation markedly reduces the risk of incisional-related complications.

Safety and efficacy of 12-mm radial dilating ports for laparoscopic access

obturator is removed and its depth adjusted under laparoscopic vision. The dilated fascia and crossed-hatch mesh sheath provide a gas-tight fascial seal, and enable stability and minimize slipping in the fascia. We have found stay sutures to be unnecessary. Additional ports may be placed using the same technique under direct laparoscopic vision. At the end of the procedure, the ports are simply removed and the skin closed, as no fascial sutures are used.

Irritative voiding symptoms and microscopic hematuria caused by intraperitoneal calcified fat necrosis.

A previously healthy 60-year-old man presented with urinary urgency and microhematuria. The workup revealed no urothelial lesions, but did suggest a calcified intraperitoneal mass causing extrinsic compression of the bladder. Laparoscopic exploration revealed a glistening, spherical mass attached by a stalk to the sigmoid colon. Removal and histologic examination of the mass revealed calcified fat necrosis, most likely due to the spontaneous torsion and calcification of an appendix epiploicae. The patients symptoms and microhematuria resolved after removal. This case represents an unusual occurrence of irritative voiding symptoms probably due to the extrinsic compression of the bladder by a mass of membranous fat necrosis.

EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY OF PANCREATIC DUCT STONES USING THE HEALTHTRONICS LITHOTRON LITHOTRIPTOR AND THE DORNIER HM3 LITHOTRIPSY MACHINE

PURPOSE Pancreatic duct stones, which are most often a result of alcohol induced chronic pancreatitis, can lead to chronic abdominal pain, pseudocysts, and exocrine and endocrine failure of the pancreas. Others have reported success using extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for pancreatic stones. We report our experience with pancreatic ESWL using the LithoTron (Healthtronics, Marietta, Georgia) and HM3 (Dornier) lithotripsy machines. MATERIALS AND METHODS We performed pancreatic ESWL in 23 patients in 4 years, including in 12 with the LithoTron and in 11 with the HM3. After ESWL endoscopic retrograde cholangio-pancreatography (ERCP) was performed in all cases. Stone-free status was defined as no stone fragments visualized or the elimination of all post-ESWL stones by ERCP. RESULTS Stone-free status was documented in 83% and 82% of patients treated with the LithoTron and HM3, respectively, and 2 per group later required open surgical intervention. There were no changes in pancreatic enzymes and no cases of sepsis or fever after ERCP. CONCLUSIONS In association with post-procedure ERCP pancreatic ESWL is an effective and safe procedure that enables patients with obstructing pancreatic duct stones recalcitrant to primary endoscopic extraction to avoid a potentially morbid open procedure. The HM3 and LithoTron have comparable efficacy and safety. This modality is particularly effective for a stone aggregate of less than 20 mm., while a larger stone burden of greater than 20 mm. in aggregate and multiple stones are clear risk factors for treatment failure.

Percutaneous Hepatolithotomy: The Northwestern University Experience

Obstruction of intrahepatic ducts by calculi can lead to abdominal pain, cholestasis, abscesses, and cholangitis. Patients with stones recalcitrant to extraction using endoscopic retrograde cholangiopancreatography (ERCP) have traditionally been referred to a general surgeon for open stone extraction or hepatic lobectomy despite its great potential morbidity. Borrowing techniques, instrumentation, and experience in performing percutaneous nephrolithotomy, we describe our experience with percutaneous hepatolithotomy (PHL), a minimally invasive, safe, and effective alternative to open surgery for recalcitrant biliary stones.

ICD-10: Are You Ready?

With the signing of H.R. 4302 (https://beta.congress.gov/bill/113th-congress/house-bill/4302), the implementation date for using ICD-0-CM codes for coding and billing medical encounters in the United States is now scheduled for October 1, 2015. This conversion from using ICD-9-CM codes will be a tremendous change in the way providers and practices deliver health care and could be financially devastating to those who are not properly prepared. Proper preparations will require educating virtually everyone involved in almost every aspect of patient care with a sufficient understanding of ICD-10 language, coding structure, and rules. Vital to this conversion is accurate documentation in the medical records by providers, knowledge of insurance coverage (local and national) rules, and acceptance of those codes by electronic health record systems, clearinghouses, and payors. Early preparation, appropriate education, and proper testing will minimize the financial impact.