Paurush Babbar

Primary bladder lymphoma, diffuse large B-cell type: Case report and literature review of 26 cases.

Primary lymphoma of the urinary bladder is exceedingly rare, representing 0.2% of all extranodal non-Hodgkin′s lymphoma. Although Matsuno et al. and others state the most common type is mucosa-associated lymphoid tissue (MALT) lymphoma, 20% of all the primary lymphomas of the urinary bladder are considered to be high grade neoplasms; the majority being diffuse large B-cell lymphoma (DLBCL). This is a case report of a 48-year-old man that presented with hematuria, frequency, nocturia, and flank pain that was found to have high grade DLBCL. Twenty-six other cases of both low and high grade primary bladder lymphomas were selected in order to provide a thorough comparison of different treatment modalities. Of the cases reviewed, bladder lymphoma was more common in females (2:1). The average age at diagnosis was 63.9 years old (low grade: 68.7 years old, high grade: 58.8 years old). The most common low-grade neoplasm was MALT lymphoma (85.7%). For the low-grade malignancies, the most successful treatments were simple therapies (2 transurethral resection of a bladder tumour [TURBT], 1 antibiotics), solitary chemotherapy, and combination TURBT/chemo; all 3 of which achieved 100% clinical remission (CR) in the cases reviewed. The most common high grade neoplasm was DLBCL (76.9%). The most successful therapies used to treat high grade lesions were solitary chemotherapy (cyclophosphamide, duanorubacin, vincristine, prednisolone [CHOP] or ritoximab, CHOP [R-CHOP]) and combination therapies (2 radiation/CHOP, 2 surgery/CHOP). In the agreement with the current literature, this review has shown that simple therapies (TURBT) are equally as effective as aggressive treatments (chemotherapy, radiation) and should therefore be used as first line treatment in low grade tumors. For high grade malignancies, chemotherapy (R-CHOP or CHOP) alone or combination therapy (CHOP/surgery or CHOP/radiation) is recommended.

Current status of robotic single-port surgery

Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.

Comparative Cost-Effectiveness Analysis of Modified 1-Layer versus Formal 2-Layer Vasovasostomy Technique

PURPOSE Approximately 2% to 6% of men undergoing vasectomy will ultimately have it reversed. Cost is a major consideration for patients and providers with regard to vasovasostomy. Opportunities for cost savings for vasectomy reversal lie in the reduction of variable costs, namely operative time and materials used. In this study we determine the cost benefits of a modified 1-layer vasovasostomy compared to a formal 2-layer vasovasostomy. MATERIALS AND METHODS A retrospective analysis was performed of a single surgeon experience of vasectomy reversals performed from 2010 to 2015. The cohort consisted of men who underwent bilateral vasovasostomy using a formal 2-layer or modified 1-layer technique. The primary end points of the analysis were total operative time; number, cost and type of suture used; and patency/postoperative semen analysis. Bivariate analysis was performed for these continuous variables using the Wilcoxon rank test and the chi-square test was used for categorical variables. RESULTS Of the 106 men who underwent bilateral vasovasostomy 81.1% (86) had a formal and 18.9% (20) had a modified 1-layer repair. The modified 1-layer closure resulted in a significantly shorter operative time, lower microsuture cost and lower overall operative cost compared to formal repair (all p <0.05). There were no statistically significant differences in semen parameters between the 2 techniques at the first postoperative visit. CONCLUSIONS The modified 1-layer vasovasostomy resulted in shorter operative times and lower costs compared to formal repair without compromising postoperative patency. In this era of cost containment the modified repair provides the opportunity to perform vasectomy reversal at a lower cost to patients and providers.

Bilateral primary adrenal non-Hodgkin's lymphoma without adrenal insufficiency

We are presenting a rare case of bilateral adrenal non-Hodgkin′s lymphoma (NHL) that presented as a primary malignancy. An 83-year-old man presented with newly discovered bilateral adrenal incidentalomas, fatigue, and 30 pound weight loss. Of the 116 cases of primary adrenal NHL reported, over half have presented bilaterally and occur with adrenal insufficiency. Therefore, the finding of bilateral adrenal masses requires an urgent work-up of the functional status of the adrenal gland as well as a thorough analysis of the imaging characteristics seen on noncontrast computed tomography (CT) in order to maximize patient survival. Adrenal function testing was normal. Repeat CT imaging revealed rapidly growing lesions with high attenuations; both masses >10 HU. Histological examination of core biopsies discovered malignant lymphoma with no known past history of lymphoma. Our case coincides with the literature, which states that a mass with attenuation >10 HU in the adrenal glands has a high risk of malignancy.

Ex-vivo partial nephrectomy after living donor nephrectomy: Surgical technique for expanding kidney donor pool

Renal transplantation has profound improvements in mortality, morbidity, and overall quality of life compared to renal replacement therapy. This report aims to illustrate the use of ex-vivo partial nephrectomy in a patient with a renal angiomyolipoma prior to living donor transplantation. The surgical outcomes of the donor nephrectomy and recipient transplantation are reported with 2 years of follow-up. Both the donor and recipient are healthy and without any significant comorbidities. In conclusion, urologic techniques such as partial nephrectomy can be used to expand the living donor pool in carefully selected and well informed transplant recipients. Our experience demonstrated a safe and positive outcome for both the recipient and donor, and is consistent with other reported outcomes in the literature.

PD22-10 PENILE PROSTHESIS IN SOLID ORGAN TRANSPLANT RECIPIENTS – A MATCHED COHORT STUDY

device infections. The coatings primarily target coagulasenegative Staphylococcus species. Traditionally, these organisms have been implicated in the majority of implant infections. We desired to ascertain the spectrum of bacterial species responsible for implant infections in the era following the widespread adoption of infection-retardant coated devices METHODS: The study cohort was derived from two prospective databases of patients undergoing penile implant surgery from two highvolume centers between February, 2004 and July, 2016. Included were those patients undergoing primary implant placement, revision surgery, and external referrals for management of an infected implant. Descriptive data included: patient age, comorbidities, first-time or revision surgery, and the organisms causing infection. Over the last 10 years, both centers have pursued an aggressive policy of performing salvage surgery. Patients who are not candidates for salvage surgery include those with systemic toxicity, purulence, cellulitis, a systemic inflammatory response, and significant soft tissue or urethral destruction. RESULTS: The cohort consisted of 39 patients, including 12 (2.8%) infections following 430 primary implant surgeries, 20 (5.5%) infections following 365 revision surgeries and 6 patients with infected implants referred from external sources (3 primary and 3 revision). Average patient age was 64.2 +/6.7 years. Table 1 depicts the spectrum of organisms encountered. There were no differences between the groups in terms of comorbidities. Based upon the criteria above, only 18 (46%) patients were candidates for salvage surgery, of which 12 (67%) were successful. CONCLUSIONS: The spectrum of bacterial species causing penile implant infections has changed in the era of infection-retardant coated devices. Contemporary infections are much more likely to be caused by Staph. aureus, and nearly 50% of infections are caused by gram negative bacteria. The aggressive nature of these bacteria limits the number of patients who are candidates for salvage surgery, and reduces the likelihood of an infected patient undergoing successful salvage surgery.

Robotic-assisted Laparoscopic Bilateral Nerve Sparing and Apex Preserving Cystoprostatectomy in Young Men With Bladder Cancer

OBJECTIVE To describe our technique and outcomes of robotic-assisted nerve-sparing cystoprostatectomy with prostatic apex preservation and orthotopic ileal conduit urinary diversion in young men undergoing robotic-assisted radical cystectomy (RARC) for the management of urothelial carcinoma. MATERIALS AND METHODS Young men (<40 years old) with the diagnosis of urothelial carcinoma undergoing RARC with orthotopic neobaldder formation were eligible for our technique of nerve-sparing cystoprostatectomy with prostatic apex preservation at the time of orthotopic ileal conduit urinary diversion. During the apical prostatic dissection step of the RARC, the plane of dissection is directed under the dorsal vein complex and through anterior prostatic fibromuscular stroma. This plane is further carried through the prostatic urethra, transecting the most caudal aspect of prostatic peripheral zone posteriorly, to create a long urethra and a posterior urethral plate formed by peripheral zone of the prostate, which serves as a robust, long stump for the subsequent vesicourethral anastomosis. RESULTS From January 2013 to January 2014, 3 men were treated with RARC and intracorporeal neobladder urinary diversion based on the described technique. There were no intraoperative complications. Two patients experienced grade II complications postoperatively. Pathologic assessment demonstrated negative surgical margins in all 3 cases. With mean follow-up time of 28.2 months, 2 out of 3 patients are free from disease recurrence. All patients report daytime urinary continence with no pad usage and potency without the need for phosphodiesterase-5 inhibitors. CONCLUSION RARC with bilateral nerve and apical preservation can be performed safely in appropriately selected young patients with excellent functional and acceptable short-term oncologic results.

Penile-sparing modalities in the management of low-stage penile cancer

Penile-sparing modalities are gaining widespread adoption for the management of low-stage penile cancer due to an increasing demonstration of sound oncologic, cosmetic, sexual, psychosocial, and quality of life outcomes. This review aims to provide a comprehensive overview of the respective treatment options in the armamentarium of the practicing urologist in dealing with this rare but problematic condition.

Robotic Retrocaval Metastasectomy After an Ipsilateral Radical Nephrectomy

OBJECTIVE Robotic management of a retrocaval metastasis can be challenging because of prior surgery leading to scarring and obscure surgical planes around vital structures. We present our robotic approach and technique to manage a large retrocaval, biopsy-proven, metastatic mass after previous laparoscopic right radical nephrectomy with concomitant adrenalectomy 10 years ago. METHODS We present a 62-year-old man who previously underwent a laparoscopic right radical nephrectomy for pT1bNxMx chromophobe renal cell carcinoma (RCC) in 2007. Surveillance imaging in November 2016 indicated a 5-cm retrocaval mass, and biopsy confirmed the metastasis. The patient was positioned in standard robotic positioning for right renal surgery. Meticulous dissection was required to free the duodenum and inferior vena cava from the mass, enabling the mass to be lifted anteriorly. Posteriorly, a labyrinth of vessels required hem-o-lok clips before excision, which allowed complete extraction of the mass. RESULTS Operative time was 234 minutes and estimated blood loss was 40 cc. Final pathology revealed a right 5 cm × 3.1 cm metastatic RCC, chromophobe-type, lymph node. The surgical margins were negative for tumor. CONCLUSION We present a successful surgical outcome of a robotic retrocaval metastasectomy for recurrent RCC, chromophobe type. At the time of publication, the patient continues to remain cancer free. Incorporating the da Vinci robotic platform allows for excellent visualization and access to difficult surgical locations while providing patients with the least invasive approach. A high degree of robotic experience is necessary before attempting this procedure, given the adherence of the mass to the inferior vena cava and duodenum.