Michael Santomauro

Rectal cultures before transrectal ultrasound-guided prostate biopsy reduce post-prostatic biopsy infection rates.

OBJECTIVE To test our hypothesis that a targeted rectal screening protocol before transrectal ultrasound (TRUS)-guided biopsy would potentiate streamlined prophylaxis, thereby reducing postbiopsy infectious rates while minimizing unnecessary broad-spectrum antibiotic use. To this end, we instituted preprocedure rectal cultures in an effort to identify fluoroquinolone (FQ)- resistant flora using selective media to optimally direct targeted prophylactic antibiotic administration. The inexorably increasing prevalence of multidrug-resistant microorganisms, notably extended spectrum beta lactamase (ESBL)-producing and FQ-resistant Enterobacteriaceae has increased the post-TRUS prostatic biopsy infection rates, including life-threatening sepsis. METHODS A total of 235 rectal swabs were obtained and plated directly onto MacConkey agar plates containing 10-μg/mL ciprofloxacin. Following the screening procedure, antimicrobial susceptibility results were used to develop a customized antibiotic prophylaxis regimen to be administered before biopsy. Following the biopsy procedure, the patients were seen in follow-up within 7 days, and information was gathered on potential adverse effects, clinical appointments for infections, and potential antibiotics received. RESULTS Thirty-two-patients (14%) had FQ-resistant isolates (most Escherichia coli), and 3 (1.3%) were ESBL-producing isolates. There were no infectious complications identified in this period, (compared with 3 septic complications among 103 biopsies in the 4 months preceding the study). CONCLUSION Rectal cultures obtained before TRUS biopsy, using selective media to identify FQ-resistant Enterobacteriaceae, facilitate targeted antibiotic prophylaxis, and appear to be highly efficacious in reducing infectious complications.

RENAL Nephrometry Score is Associated With Operative Approach for Partial Nephrectomy and Urine Leak

OBJECTIVE To identify whether RENAL nephrometry score is associated with partial nephrectomy (PN) technique. RENAL nephrometry score quantifies anatomic characteristics of renal tumors. Data are limited regarding clinical utility for surgical planning. METHODS Multicenter analysis of patients undergoing PN for renal masses from March 2003 to May 2011. Cohort was stratified by surgical modality: open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), and robotic-assisted laparoscopic partial nephrectomy (RALPN). Demographic and clinicopathological variables were compared between groups; RENAL score was calculated from preoperative imaging. Factors associated with choice of treatment modality and urine leak were entered into multivariable models. RESULTS One hundred fifty-three patients who underwent OPN, 100 patients who underwent LPN, and 31 patients who underwent RALPN were evaluated, the median tumor size (cm) was significantly larger for OPN (OPN 4.2 vs LPN 2.4 vs RALPN 2.0; P < .001); median operative time (minutes) and ischemia time (minutes) were shorter in OPN (OPN 190 and 25 vs LPN 200 and 29 vs RALPN 195 and 30; P = .042 and P < .001). Mean RENAL score was highest in OPN (OPN 8 vs LPN 6.3 vs RALPN 6.4; P < .001). No significant differences were noted in overall/high-grade complication rates (Clavien, P = .441/.985). On multivariate analysis, there was a 55% increased odds of undergoing OPN for each increase in RENAL score (P < .001). Higher RENAL score was associated with increased odds of urine leak (odds ratios [OR], 1.56; P = .002). CONCLUSION RENAL nephrometry score was associated with type of surgical approach (open vs laparoscopic/robotic) and urine leak. RENAL score may be useful as a decision-making tool in evaluation of patients for nephron-sparing surgery (NSS). Further investigation is requisite.

Demographics of Men Receiving Vasectomies in the US Military 2000–2009

Background: We hypothesize that there is a higher incidence of vasectomy within the military at a younger age based on this equal access health care system. Materials and Methods: A review of the CHAMPS military database was conducted for men receiving vasectomies from 2000 to 2009. Age at vasectomy, number of children, race, religion, and marital status were recorded and incidence was computed. Results: Total of 82,945 vasectomies was performed. The overall incidence to have a vasectomy was approximately 7.10 per 1000 men. The highest rate of occurrence was 14.4 per 1000 men in men 30–34 years old. Whites had a higher rate than blacks at 10.03 per 1000 men compared to 6.27 per 1000 men. Protestants had the highest rate at 8.44 per 1000 men, and Jewish people had the lowest at 1.86 per 1000 men. Married men had a rate of 12.3 per 1000 men, whereas single men were 1.03 per 1000 men. Conclusions: The incidence to have a vasectomy in the military was 7.10 per 1000 men, with an age adjusted rate at 8.66 per 1000 men. This information may assist primary care providers in discussing vasectomies as a permanent form of contraception.

Retrospective Analysis of Percutaneous Stone Surgery Utilizing Nephrostomy Tube versus Tubeless Technique with Fibrin Sealant

Background: Percutaneous nephrolithotomy (PCNL) is the preferred treatment of large renal stones. Using fibrin seal-ants for PCNL is known to be safe and feasible. We evaluated the safety, efficacy, and complication rates of tubeless PCNL using fibrin sealant compared to PCNL performed with nephrostomy tube (NT). Materials and Methods: A retrospective review was completed for PCNL performed from January 2002 to October 2006. A total of 141 PCNL were included (81 tubeless/60 NT). We assessed demographics, stone size, blood loss, renal function, hospital stay, targeted stone free rate, and complications. Results: Patient demographics were similar in both groups. Mean stone size was 2.41 cm2 in the tubeless and 2.83 cm2 in the NT group (p = 0.18). The change in creatinine and hemoglobin were not statistically significant between groups. Hospital stay was 1.07 days in the tubeless group versus 2.37 in the NT group (p < 0.0001), with 93% of patients were discharged on post-operative day one versus only 32%, respectively. Immediate targeted stone free rate was 69% in the tubeless group versus 56% in NT group, which improved to 88% and 76% when considering residual stones fragments <4 mm. Long term stone free rates for the tubeless and NT groups were 96% and 83% (p = 0.08) for fragments <4 mm at a median of 3 and 6 months, respectively. Complications in the tubeless group included one pseudoaneurysm, one urine leak, three small subcapsular hematomas, and two re-admissions (one for flank pain and one for non-cardiac chest pain). In the NT group, there was one aborted procedure, two pseudoaneurysms, one colocutaneous fistula, and two re-admissions (one for flank pain and one for urinary obstruction). Conclusion: Tubeless PCNL with fibrin sealants appears to have similar safety and efficacy to traditional NT. In our practice, tubeless PCNL was associated with a decrease in hospital stay.

Supine Robotic-Assisted Retroperitoneal Lymph Node Dissection for Testicular Cancer

Background and Objectives: Robotic-assisted laparoscopic retroperitoneal lymph node dissection (RPLND) using a lower abdominal approach for testicular cancer is an advanced and relatively new surgical technique. Herein we describe technical modifications, review benefits, and report our initial series. Methods: A retrospective review of 16 patients from Jan 1, 2010 to Dec 31, 2012 who underwent robotic RPLND for nonseminomatous germ cell tumors was performed. Patients were positioned in 15° of Trendelenburg and tilted 15° to the right. An infraumbilical midline camera port, 3 robotic ports, and 2 assistant ports were placed in a lower abdominal configuration. Patient demographic and perioperative outcomes were assessed. Results: Twelve patients underwent staging, prospective nerve-sparing RPLNDs, and 4 underwent postchemotherapy RPLNDs. Mean age was 26.4 years with a mean body mass index of 27.4 kg/m. The cohort had a mean operative time of 357 minutes, mean estimated blood loss of 205 mL, mean hospital stay of 3.6 days, and mean postoperative morphine equivalent use of 47.1 mg. There were no conversions to open RPLND in this cohort. An average of 26.2 lymph nodes were sampled. Conclusions: Inferior approach for robotic RPLND enables a thorough dissection of the retroperitoneum, without repositioning, to meet oncologic goals. Further study to evaluate long-term outcomes is warranted.

Improving urologic cancer care through telemedicine

Surgeons in general and urologists in particular, have played a crucial role in advancing medical technology – from the adoption of innovative technologies to the development of novel surgical procedures to better treat disease. Central to advances in medical technology is telemedicine. Telemedicine is the general name for computer technology that enables exchange of medical information from one location to another with audio and video via telecommunication technology. Telemedicine encompasses a variety of services including telediagnostics and consultation services, remote interdisciplinary treatment planning, teleconferencing, telementoring and telepresence remote surgery.

A Retrospective Review of Factors Associated with Vasovasostomies in United States Military Members

Background: Men seeking a vasectomy should receive counseling prior to the procedure that includes discussion of later seeking a reversal. We sought to determine demographic factors that may predispose patients to possibly later seek a vasectomy reversal. Methods: All U.S. Military electronic health records were searched between 2000 and 2009 for either a vasectomy or vasovasostomy procedure code. Aggregate demographic information was collected and statistical analysis performed. Result: A total of 82,945 patients had a vasectomy of which 4,485 had a vasovasostomy resulting in a vasovasostomy-to-vasectomy rate of 5.04%. The average age at vasovasostomy was 34.9±5.0, with an average interval of 4.1±2.2 years. Men undergoing a vasectomy at a younger age were more likely to have a vasovasostomy. Various religions did have statistically significant differences. Within ethnic groups, only Native Americans [OR=1.39 (95% CI 1.198-1.614)] and Asians [OR=0.501 (95% CI 0.364-0.690)] had statistically significant differences when compared to Caucasians. Men with more children at the time of vasectomy were more likely to have a vasovasostomy. Conclusion: Younger men, Native Americans, and men with more children at vasectomy were more likely to undergo a vasovasostomy. The reason for these differences is unknown, but this information may assist during pre-vasectomy counseling.

Castleman's Disease in the Left Suprarenal Region, Mimicking an Adrenal Neoplasm

We present a rare case of a 16-year-old male patient with Castlemans disease (CD) manifest by a suspicious mass within the left suprarenal region abutting the left adrenal gland, mimicking an adrenal neoplasm. CD is an uncommon and poorly understood lymphoproliferative disorder that, when observed, typically occurs as a mediastinal mass. Two percent of cases reportedly occur in the pararenal region. Although rare, Castlemans disease should be considered in the differential diagnosis of a retroperitoneal mass.