Lance J. Hampton

Treatment Strategy for the Adolescent Varicocele

A varicocele is a dilatation of the testicular vein and the pampiniform venous plexus within the spermatic cord. Although rare in pediatric populations, the prevalence of varicoceles markedly increases with pubertal development. Varicoceles are progressive lesions that may hinder testicular growth and function over time and are the most common and correctable cause of male infertility. Approximately 40% of men with primary infertility have a varicocele, and more than half of them experience improvements in semen parameters after varicocelectomy. The decision to treat adolescents with varicocele is a controversial one. The task for pediatricians and urologists is to identify those adolescents who are at greatest risk for infertility in adulthood, in an effort to offer early surgical intervention to those most likely to benefit.

Impact of diagnostic ureteroscopy on intravesical recurrence in patients undergoing radical nephroureterectomy for upper tract urothelial cancer: a systematic review and meta‐analysis

Aim of this study was to analyse the association between the use of diagnostic ureteroscopy (URS) and the development of intravesical recurrence (IVR) in patients undergoing radical nephroureterectomy (RNU) for high‐risk upper tract urothelial carcinoma. A systematic review of the published data was performed up to December 2016, using multiple search engines to identify eligible studies. A formal meta‐analysis was conducted of studies comparing patients who underwent URS before RNU with those who did not. Hazard ratios (HRs), with their 95% confidence intervals (CIs), from each study were used to calculate pooled HRs. Pooled estimates were calculated using a fixed‐effects or random‐effects model according to heterogeneity. Statistical analyses were performed using RevMan, version 5. Seven studies were included in the systematic review, but only six of these were deemed fully eligible for meta‐analysis. Among the 2 382 patients included in the meta‐analysis, 765 underwent diagnostic URS prior to RNU. All examined studies were retrospective, and the majority examined Asian populations. The IVR rate ranged from 39.2% to 60.7% and from 16.7% to 46% in patients with and without prior URS, respectively. In the pooled analysis, a statistically significant association was found between performance of URS prior to RNU and IVR (HR 1.56, 95% CI 1.33–1.88; P < 0.001). There was no heterogeneity in the observed outcomes, according to the I2 statistic of 2% (P = 0.40). Within the intrinsic limitations of this type of analysis, these findings suggest a significant association between the use of diagnostic URS and higher risk of developing IVR after RNU. Further research in this area should be encouraged to further investigate the possible causality behind this association and it potential clinical implications.

RETROPERITONEAL ROBOTIC PARTIAL NEPHRECTOMY: SYSTEMATIC REVIEW AND CUMULATIVE ANALYSIS OF COMPARATIVE OUTCOMES

OBJECTIVES To compare the outcomes of retroperitoneal vs transperitoneal approach for robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS A systematic review of the literature was performed through January 2018 using PubMed, Scopus, and Ovid databases. Article selection proceeded according to the search strategy based on PRISMA criteria. Only studies comparing retroperitoneal to transperitoneal approach for RAPN were deemed eligible for inclusion. RESULTS Seven retrospective case-control studies were identified and included in the analysis, with a total number of 1379 patients (866 for transperitoneal group; 513 for retroperitoneal group). In the retroperitoneal group, tumors were slightly larger [weighted mean difference (WMD): 0.29 cm; 95% confidence interval (CI): 0.04-0.54; p = 0.02], and more frequently located posterior/lateral (odds ratio: 0.61; 95% CI: 0.41-0.90; p = 0.01). In two of the studies only posterior tumors had been included. Both operating time (WMD 20.17 min; 95% CI 6.46-33.88; p = 0.004) and estimated blood loss (WMD 54.57 mL; 95% CI 6.73-102.4; p = 0.03) were significantly lower in the retroperitoneal group. In addition, length of stay was significantly shorter in the retroperitoneal group (WMD 0.46 days; CI 95% 0.15-0.76; p = 0.003). No differences were found regarding overall (p = 0.67) and major (p = 0.82) postoperative complications, warm ischemia time (p = 0.96), and positive surgical margins (p = 0.95). CONCLUSIONS Retroperitoneal RAPN can offer in select patients similar outcomes to those of the most common transperitoneal RAPN. Furthermore, it may be particularly advantageous for posterior upper pole and perihilar tumors and associated with reduction in operative time and hospital stay. Robotic surgeons should be ideally familiar with both approaches to adapt their surgical strategy to confront renal neoplasms from a position of technical advantage and ultimately optimize outcomes.

Rationale for Robotic-assisted Simple Prostatectomy for Benign Prostatic Obstruction

Current evidence supports the role of robotic-assisted simple prostatectomy as safe and effective minimally invasive surgical treatment of benign prostatic obstruction.

Herniation of a urinary bladder diverticulum: diagnosis and management of a fluctuating inguinal mass

Inguinal herniation of a bladder diverticulum is a rare finding. The diagnosis should be suspected if the size of hernia is variable on urination. These patients may also experience obstructive voiding symptoms. Various imaging modalities may clarify the diagnosis. In our patient, intravenous urography precisely showed a bladder diverticulum in the right inguinal area. The patient underwent open simple prostatectomy and herniorrhaphy. He remains symptom-free on follow-up.

Intrarenal Adrenocortical Adenoma Treated by Robotic Partial Nephrectomy with Adrenalectomy

Abstract Background: We present an intrarenal adrenocortical adenoma discovered incidentally after robot-assisted partial nephrectomy and total adrenalectomy for a suspicious renal mass. Current literature describes the rare occurrence of an adrenocortical adenoma arising from a renal–adrenal fusion. This case represents an uncommon, benign pathology that should be considered in the differential diagnosis of an enhancing renal mass. Case Presentation: The patient is a 62-year-old female found to have an enhancing mass at the anterolateral aspect of the upper pole of the right kidney concerning for renal-cell carcinoma. CT imaging was performed to work up a cause for hyperparathyroidism. During robot-assisted partial nephrectomy, the lesion was found to be partially adherent to the lateral limb of the right adrenal gland. Microscopic evaluation with Melan-A staining showed the mass to be of adrenal origin with benign features and lack of capsulation, indicating an adrenal adenoma arising from intrarenal ectopic adrenal rests. Conclusion: An intrarenal adrenal adenoma arising from ectopic adrenal tissue is a unique pathology that represents a benign differential diagnosis in the evaluation of an enhancing renal mass. However, it cannot be differentiated from renal-cell carcinoma based on cross-sectional imaging alone and requires postoperative pathologic assessment to confirm the diagnosis.

Completely Intracorporeal Robotic-Assisted Laparoscopic Ileovesicostomy

We present a report of a completely intracorporeal robotic-assisted laparoscopic ileovesicostomy with long term follow-up. The patient was a 55-year-old man with paraplegia secondary to tropical spastic paresis resulting neurogenic bladder dysfunction. The procedure was performed using a da Vinci Surgical system (Intuitive Surgical, Sunnyvale, CA) and took 330 minutes with an estimated blood loss of 100 mL. The patient recovered without perioperative complications. He continues to have low pressure drainage without urethral incontinence over two years postoperatively.

Robotic light source failure and recovery: an innovative solution to an uncommon problem.

Since 2003 the increasing use of robotic-assisted laparoscopic prostatectomy has been accompanied by the need to be prepared for a new set of problems in the operating room. Operative complications unique to the robot and its components are rare but can lead to case conversion and procedural abandonment. We describe an innovative solution to the uncommon problem of intraoperative robotic light source failure. Surgeons carrying out such procedures should be aware of this complication and be able to substitute a comparable light source. Possession of an appropriate type of low-cost alternative light source could prevent unnecessary procedural abandonment or open conversion in the setting of mid-operative light source failure.