Prashanth Kanagarajah

Contemporary Revision Penile Prosthesis Surgery Is Not Associated with a High Risk of Implant Colonization or Infection: A Single-Surgeon Series

INTRODUCTION Revision penile prosthesis surgery has traditionally been associated with a greater risk of postoperative infection than primary implant placement. This has been attributed to the high prevalence of asymptomatic bacteria found surrounding the implant at the time of revision surgery. AIM To validate whether contemporary revision surgery remains associated with a high risk of asymptomatic colonization and postoperative infection. METHODS A comprehensive, prospective database consisting of consecutive patients undergoing primary and revision penile prosthesis surgery at our center was analyzed. MAIN OUTCOME MEASURES The infection risk in primary and revision implant surgery was compared. The prevalence of asymptomatic implant colonization during revision surgery, and whether this was associated with clinical infection was evaluated. The spectrum of bacterial species causing infection in this contemporary single-surgeon series was described. RESULTS One hundred seventeen primary and 72 revision implant recipients were studied. Infection developed in four (3.4%) patients undergoing primary implants, two (4.3%) patients undergoing removal and replacement for mechanical malfunction, and three (12%) patients undergoing rerouting for extrusion (P = 0.26). Intraoperative cultures were positive in 5 (9.8%) of 51 revision patients, none of whom developed infections. Organisms causing infection included Staphylococcus aureus and Enterobacter aerogenes. Unexpectedly, an adjuvant, alcohol-based skin prep in our last 83 patients reduced the infection risk to 1.2%. CONCLUSIONS In our series, the infection risk associated with revision of malfunctioning devices was no greater than primary implant placement. Rerouting was associated with a higher infection risk, likely due to technical factors, and not implant colonization. Less than 10% of our revision implants were colonized, and this had no bearing on the development of a postoperative infection. S. epidermidis was not the most common organism implicated in device infections. Finally, our experience with an adjuvant, alcohol-based skin prep warrants further randomized prospective evaluation.

Predictors of Response to Intradetrusor Botulinum Toxin-A Injections in Patients with Idiopathic Overactive Bladder

Objectives. To evaluate whether there are any demographic or urodynamic differences in patients with idiopathic overactive bladder (I-OAB) that respond and do not respond to intradetrusor injections of botulinum toxin-A (BTX-A). Methods. This represents a secondary analysis of data collected from an investigator initiated randomized trial designed to evaluate clinical differences in outcomes for 100 versus 150 U BTX-A in patients with I-OAB. Preinjection demographic and urodynamic data were collected. Patients were evaluated 12 weeks after injection and were determined to be responders or nonresponders as defined by our criteria. Statistical comparisons were made between groups. Results. In patients with overactive bladder without incontinence (OAB-Dry), there were no variables that could be used to predict response to BTX-A. On univariate analysis, younger patients with overactive bladder with incontinence (OAB-Wet) were more likely to respond to BTX-A than older patients. However, this relationship was no longer statistically significant on multivariate analysis. Conclusions. We were unable to identify any preinjection demographic or urodynamic parameters that could aid in predicting which patients will achieve clinical response to BTX-A. Future studies are necessary to further evaluate this question.

Current concepts in the management of adrenal incidentalomas

Adrenal tumors are among the commonest incidental findings discovered. The increased incidence of diagnosing adrenal incidentalomas is due to the widespread availability and use of noninvasive imaging studies. Extensive research has been conducted to define a cost-effective diagnostic and therapeutic protocol to guide physicians in managing incidental adrenal lesions. However, there is little consensus on the optimal management strategy. Published literature to date, describes a wide spectrum of treatment options ranging from excision of all adrenal lesions regardless of the size and functional status to extensive hormonal and radiological evaluation to avoid surgery. In this review, we present a comprehensive overview of the presentation, evaluation and management of adrenal incidentalomas. Additionally, we propose a management algorithm to optimally manage these tumors.

Repeat intradetrusor injections of onabotulinum toxin a for refractory idiopathic overactive bladder patients: a single-center experience.

Objectives: The objective of the study was to evaluate the safety and efficacy of repeat intradetrusor onabotulinum toxin A injection in patients with idiopathic overactive bladder refractory to anticholinergic medications. Furthermore, 2 doses, 100 and 150 U, were compared. Methods: We prospectively enrolled 60 patients in our investigator-initiated, single-center randomized trial. Thirty patients were randomized to each dosage arm. Total study duration was 3 years. Patients were eligible to receive 6 onabotulinum toxin A injections. Subjects completed a 3-day voiding diary and Urogenital Distress Inventory 6 (UDI-6) questionnaire and graded their quality of life on a visual analog scale (VAS) before study enrollment and at week 6 after every injection. The outcome was based on the amount of improvement noted on the UDI-6 and VAS scores at 6 weeks post every injection as compared with study enrollment. Results: There were 9 men and 51 women. The mean UDI-6 and VAS scores improved significantly (P = 0.0001) at week 6 after initial onabotulinum toxin A injection, and no change was seen when comparing repeat injections; 20% and 10% of the patients randomized to 150 and 100 U required performing clean intermittent catheterization, respectively. The mean UDI-6 scores after repeat onabotulinum toxin A injections did not differ significantly between 100 and 150 U. Conclusions: Repeat injections of onabotulinum toxin A are capable of significantly improving UDI-6 scores and quality of life in refractory patients with idiopathic overactive bladder. There was no evidence of decreased efficacy after repeat injections. Lower clean intermittent catheterization rates were noted in patients randomized to 100 U as compared with 150 U. Both doses, 100 and 150 U, were equally efficacious.

The Use of Botulinum Toxin A in Idiopathic Overactive Bladder Syndrome

Overactive bladder syndrome continues to be a significant burden for the general population. Current first-line medical therapy often includes antimuscarinic medications designed for overactive bladder. Poor efficacy and significant side effects of these antimuscarinic medications have left patients and physicians looking for alternative treatments. There is increasing evidence that intradetrusor injection of botulinum toxin A can effectively treat these patients. We present a current and extensive review of the literature covering the use of botulinum toxin A in patients with overactive bladder with or without idiopathic detrusor overactivity.

Anomalies of the inferior vena cava and renal veins and implications for renal surgery.

Abnormalities of the inferior vena cava (IVC) and renal veins are extremely rare. However, with the increasing use of computed tomography (CT), these anomalies are more frequently diagnosed. The majority of venous anomalies are asymptomatic and they include left sided IVC, duplicated IVC, absent IVC as well as retro-aortic and circumaortic renal veins. The embryological development of the IVC is complex and involves the development and regression of three sets of paired veins. During renal surgery, undiagnosed venous anomalies may lead to major complications. There may be significant hemorrhage or damage to vascular structures. In addition, aberrant vessels may be mistaken for lymphadenopathy and may be biopsied. In this review we discuss the embryology of the IVC and the possible anomalies of IVC and its tributaries paying particular attention to diagnosis and implications for renal surgery.

Evaluation of Current Synthetic Mesh Materials in Pelvic Organ Prolapse Repair

With increasing use of synthetic material in pelvic organ prolapse repair, the reporting and incidence of associated complications also have increased. The role of synthetic mesh in pelvic organ prolapse repair remains controversial and it is a therapeutic dilemma whether to continue its use in patients with poor native tissues, despite the recent public safety notification provided by the U.S. Food and Drug Administration. In this article, we review the biomaterials used in pelvic organ prolapse repair and discuss the outcomes and associated complications, paying emphasis to the benefits and the risks.

Small Cell Carcinoma Arising from the Bulbar Urethra: A Case Report and Literature Review

Primary neuroendocrine carcinomas of the genitourinary tract are rare and aggressive tumors carrying a bad prognosis. With squamous cell and transitional cell carcinoma being the most commonly reported urethral malignancies, primary small cell carcinoma (SCC) of the urethra is extremely rare. To date, only 5 cases have been reported in the literature. We present the first case of primary SCC occurring in the bulbar urethra in an 89-year-old male. We discuss the clinical, histological and immunohistochemical features of SCC of the urethra. Furthermore, we summarize the available literature and discuss the possible treatment options for this rare yet aggressive neoplasm.

Response by authors re: Differentiation of oncocytoma and renal cell carcinoma in small renal masses (<4 cm): the role of 4-phase computerized tomography

Throughout medicine, there is a recurrent paradigm of development of noninvasive/less invasive testing used to identify patients who may then be able to forgo relatively more invasive diagnostic testing and treatment. In the realm of cardiology, reconstructed advanced imaging has been extensively investigated as a substitute for cardiac catheterization [1]. In the realm of urology, we have long pursued use of PSA testing to identify men at risk for the prostate cancer and have used this to aid in the selection of patients to undergo prostate biopsy. More recently, further refinements in overall care to those patients diagnosed with prostate cancer, in response to potentially excessive diagnosis and treatment related morbidity, have been introduced with the development of active surveillance protocols to aid in the identification of patients with prostate cancer that may potentially be spared treatment-associated morbidity [2]. In the case of renal tumors, to date, only limited advancements have taken place in terms of preoperative characterization of renal masses. Due to lack of such advancements, notably in the case of small renal masses, we as urologists, in the majority of cases, essentially resort to excisional biopsy of these poorly characterized lesions, for lack of better preoperative characterization. Though partial nephrectomy has certainly undergone a number of refinements and technical advances, this procedure, even in centers of excellence, has well defined risk for morbidity [3]. The effects and nature of renal ischemia are also currently under investigation at a large number of institutions due to concerns over what long-term impact this may have for the patient [4, 5].

Feasibility of renal transplantation after unroofing of a large renal cyst in an expanded criteria donor

We present a case in which a deceased donor kidney with a large simple cyst was successfully unroofed and transplanted to a 61-year-old male. The donor was a 62-year-old male with a history of hypertension for 2 years; cerebral vascular accident was the cause of death. A large 8-cm cyst distorting the renal hilum was identified upon the procurement of the deceased donor kidney. Prior to transplantation, the large cyst was unroofed from the allograft; the frozen section confirmed a benign cyst and the transplant was performed. Postoperatively, the serum creatinine level was 1.4 mg/ml at 22-month follow-up and the patient was normotensive. Deceased donor kidneys with giant cysts distorting the renal hilum can be effectively transplanted.