Ryan Flannigan

Renal struvite stones—pathogenesis, microbiology, and management strategies

Infection stones—which account for 10–15% of all urinary calculi—are thought to form in the presence of urease-producing bacteria. These calculi can cause significant morbidity and mortality if left untreated or treated inadequately; optimal treatment involves complete stone eradication in conjunction with antibiotic therapy. The three key principles of treating struvite stones are: removal of all stone fragments, the use of antibiotics to treat the infection, and prevention of recurrence. Several methods to remove stone fragments have been described in the literature, including the use of urease inhibitors, acidification therapy, dissolution therapy, extracorporeal shockwave lithotripsy, ureteroscopy, percutaneous nephrolithotomy (PCNL), and anatrophic nephrolithotomy. PCNL is considered to be the gold-standard approach to treating struvite calculi, but adjuncts might be used when deemed necessary. When selecting antibiotics to treat infection, it is necessary to acquire a stone culture or, at the very least, urine culture from the renal pelvis at time of surgery, as midstream urine cultures do not always reflect the causative organism.

Testosterone Therapy in Patients with Treated and Untreated Prostate Cancer: Impact on Oncologic Outcomes

PURPOSEnTestosterone deficiency and prostate cancer have an increasing prevalence with age. However, because of the relationship between prostate cancer and androgen receptor activation, testosterone therapy among patients with known prostate cancer has been approached with caution.nnnMATERIALS AND METHODSnWe identified a cohort of 82 hypogonadal men with prostate cancer who were treated with testosterone therapy. They included 50xa0men treated with radiation therapy, 22 treated with radical prostatectomy, 8 onxa0active surveillance, 1 treated with cryotherapy and 1 who underwent high intensity focused ultrasound. We monitored prostate specific antigen, testosterone, hemoglobin, biochemical recurrence and prostate specific antigen velocity.nnnRESULTSnMedian patient age was 75.5 years and median followup was 41 months. We found an increase in testosterone (p <0.001) and prostate specific antigen (pxa0= 0.001) in the entire cohort. Prostate specific antigen increased in patients on active surveillance. However, no patients were upgraded to higher Gleason score on subsequent biopsies and none have yet gone on to definitive treatment. We did not note any biochemical recurrence among patients treated with radical prostatectomy but 3 (6%) treated with radiation therapy experienced biochemical recurrence. It is unclear whether these cases were related to testosterone therapy or reflected the natural biology of the disease. We calculated mean prostate specific antigen velocity as 0.001, 0.12 and 1.1 μg/l per year in the radical prostatectomy, radiation therapy and active surveillance groups, respectively.nnnCONCLUSIONSnIn the absence of randomized, placebo controlled trials our study supports the hypothesis that testosterone therapy may be oncologically safe in hypogonadal men after definitive treatment or in those on active surveillance for prostate cancer.

45,X/46,XY mixed gonadal dysgenesis: A case of successful sperm extraction

Infertility is common among couples, about one third of cases are the result of solely male factors, and rarely abnormalities of genetic karyotypes are the root cause. Individuals with a 45X,/46,XY mosaiscism are rare in the literature and very few have fertile potential. We discuss a case of a 27-year-old male with known mixed gonadal dysgenesis, 50:50 split mosaiscism of 45,X/46,XY, presenting for evaluation of 1.5 year history of infertility. He demonstrated low volume non-obstructive azoospermia. Upon testicular biopsy, spermatozoa were extracted. These sperm were subjected to aneuploidy studies demonstrating 95.95% euploidy. The sperm were further assessed and placed in cryopreservation after being deemed sufficient for potential intracytoplasmic sperm injection. This is a unique case of viable sperm in a man with mixed gonadal dysgenesis, 45,X/46,XY mosaiscism.

Persistent Sexual Dysfunction with Finasteride 1 mg Taken for Hair Loss

To examine the risk of persistent sexual dysfunction (PSD) with finasteride 1 mg.

Management of post-radiation therapy complications among prostate cancer patients: A case series.

INTRODUCTIONnTreating prostate cancer with radiation therapy (RT) is a viable option, albeit with its own profile of complications. We describe a unique Canadian report of a single surgeon (RJB) experience in the management of complex post-prostate cancer RT complications.nnnMETHODSnWe retrospectively analyzed patients who had previously received external beam radiation (XRT) or brachytherapy (BT) for prostate cancer referred to a single surgeon for persistent urologic related difficulties between 2005 and 2010. We used the Radiation Therapy Oncology Group (RTOG) morbidity grading system to assign each patient a 1 to 5 grade for their greatest complication.nnnRESULTSnIn total, 15 patients were identified with a total of 43 RT-related complications. Of these 43 complications, 19 presented with obstruction, 8 with radiation failure or new bladder cancer, 6 with hematuria, 5 with intractable incontinence, and 5 with urinary tract infections. These patients required several investigations prior to treatment. Treatment of these complications used surgical, local and medical approaches. In the end, 1 patient had total incontinence, 3 improved their incontinence, 3 had self-catheterization and dilation, 1 voided well, 3 underwent cystectomy with ileo-conduits, 2 had chronic hematuria, and 2 passed away.nnnCONCLUSIONnThese patients are heavily investigated and require significant resources, including patient visits, diagnostics and treatment modalities to optimize their condition. Cure is not always possible, but the aim to improve quality of life should guide management.

A Single Dose of Intraoperative Antibiotics Is Sufficient to Prevent Urinary Tract Infection During Ureteroscopy

BACKGROUNDnAmerican Urology Association (AUA) Best Practice Guidelines for ureteroscopic stone treatment recommend antibiotic coverage for <24 hours following the procedure. The purpose of this study was to evaluate if the addition of postoperative antibiotics reduces urinary tract infections (UTIs) following ureteroscopic stone treatment beyond the recommended preoperative dose.nnnMETHODSnA retrospective review was performed of consecutive patients at two institutions, University of British Columbia and Massachusetts General Hospital, Harvard. All patients received a single dose of antibiotics before ureteroscopic stone treatment. A subset of patients was also given postoperative antibiotics. The rate of UTI was compared in patients receiving only preoperative antibiotics (group 1) vs those who received pre- and postoperative antibiotics (group 2).nnnRESULTSnEighty-one patients underwent ureteroscopy for renal calculi. Mean time to follow up was 42 ± 88 days. Eight (9.9%) patients in total (two from group 1 and six from group 2, p = 0.1457) developed UTIs postoperatively. In group 1, both patients presented with pyelonephritis (n = 2); those patients with infections in group 2 presented with urosepsis (n = 2) and cystitis (n = 2) and two patients had asymptomatic bacteriuria. Risk factors such as preoperative stenting, nephrostomy tubes, and foley catheters neither differed between groups nor did they predispose patients to postoperative infections.nnnCONCLUSIONSnThe postoperative UTI rate in this study (9.9%) is consistent with previous reports. Our data suggest that a single preoperative dose of antibiotics is sufficient, and additional postoperative antibiotics do not decrease infection rates after ureteroscopic stone treatment. Risk for selection bias is a potential limitation.

Organ procurement surgery as a means of increasing open surgical experience during urology residency

INTRODUCTIONnThe introduction and advancement of minimally invasive surgery (MIS) has resulted in a reciprocal decline in exposure to open surgery during urology residency training. We propose organ procurement surgery as a potential vehicle to facilitate an increase in open surgical experience among trainees. We define the surgical case volume for organ procurement surgeries currently performed by urology residents in Canada, and determine what capacity exists for expansion.nnnMETHODSnData on organ procurement surgeries were extracted for Canadian urology residents case-logs between 2005 and 2009. Case-logs were anonymously analyzed through the voluntary self-reporting program T-Res (Resilience Software Inc.). National deceased organ donor data were obtained from the Canadian Institute for Health Information.nnnRESULTSnThe graduating Canadian urology resident has performed an average of 0.95 organ procurement surgeries during 5 years of training. An average of 469.6 procurement surgeries were performed yearly in Canada between 2005 and 2009. The theoretical capacity exists for each graduating resident to perform an additional 16.3 organ procurements during residency.nnnCONCLUSIONSnWith the establishment of MIS as standard of care for many urologic surgeries, the decrease in open operative experience is concerning. Innovative ways to enrich open surgical experience may be required, and increased formal incorporation of organ procurements into urology residency training curriculum may help fill the void.

Microdissection testicular sperm extraction

Microdissection testicular sperm extraction (microTESE) is considered the gold standard method for surgical sperm retrieval among patients with non-obstructive azoospermia (NOA). In this review, we will discuss the optimal evaluation of NOA patients and strategies to medically optimize NOA patients prior to microTESE. In addition, we will also discuss technical principles and pearls to maximize the chances of successful sperm retrieval, sperm retrieval rates (SRR) based upon testicular histology, predictors of successful sperm retrieval, gonadal recovery following microTESE, and potential complications.

Case report and literature review of a rare diagnosis of ossifying renal tumor of infancy

One must entertain a broad differential diagnosis for infants presenting with gross hematuria. Initial workup includes urine analysis, serum laboratory values and abdominal ultrasound. We describe an infant presenting with gross hematuria found to have a calcified renal mass upon initial ultrasound and subsequent computed tomography scan. We considered a differential diagnosis of, but not exclusive to, staghorn calculi, nephroblastoma, Wilms tumour, mesoblastic nephroma and ossifying renal tumour of infancy (ORTI). A nephrectomy was performed, and the pathology report identified the calcified mass as an ORTI.

Standardized follow-up program may reduce emergency room and urgent care visits for patients undergoing radical prostatectomy

INTRODUCTIONnThe objective of the current study was to determine the impact of a standardized follow-up program on the morbidity and rates of hospital visits following radical prostatectomy (RP) in a tertiary, non-teaching urologic centre.nnnMETHODSnPatients who underwent a RP in 2008 were retrospectively evaluated in this study. Postoperative morbidity for the entire cohort was assessed using the Modified Clavien Scale (MCS). Those patients readmitted to hospital or who visited an urban or rural emergency department (ED) within 90 days of surgery were further evaluated to determine the reason for readmission.nnnRESULTSnAt our centre, 321 patients underwent RP in 2008 by 11 surgeons. Of the 321 patients, 77 (24.0%) visited an ED within 90 days, and 14 were readmitted to hospital, with an additional patient readmitted directly (with a total 15 readmissions, 4.7% overall). No patients died within the study period. In 2009 we launched a pilot study wherein 115 RP patients received scheduled and on-demand follow-up care by a dedicated nurse between May and November. We found that 90-day readmission rates among this cohort dropped to 5% and 2.6% for ED visits and hospital readmission, respectively.nnnCONCLUSIONSnAt our tertiary non-teaching centre, a significant number of patients presented back to hospital within 90 days following RP. Most of these patients (80.8%) were managed entirely through an outpatient ED, and many visits were for routine postoperative care. Only 18.2% (4.7% of the 321 prostatectomy patients) were readmitted to hospital. These data point to a need for enhanced postoperative support of patients to reduce costly and often unnecessary visits to acute care EDs. This conclusion is supported by our early experience. Limitations include retrospective design, and variability in practice of surgeons in this study.