Samuel Deem

Transient paralysis after robotic prostatectomy

Laparoscopic radical prostatectomy (LARP) has been accepted as first line therapy for clinically localized prostate cancer. Complications have been low and outcomes are comparable to that of open surgery with potential benefits including shorter hospital stay, less pain and quicker return to normal activity. Unexplained paralysis following LARP is a rare entity with no reported cases in the current literature. We report a case of complete motor paralysis following LARP. An extensive multidisciplinary evaluation did not definitively establish a diagnosis. Aggressive multimodality treatment led to a complete recovery. Our understanding of this phenomena with the possible etiology and treatment is discussed.

Percutaneous Nephrolithotomy Versus Extracorporeal Shock Wave Lithotripsy for Moderate Sized Kidney Stones

OBJECTIVE To compare the outcomes of percutaneous nephrolithotomy (PNL) and extracorporeal shock wave lithotripsy (ESWL) for moderate sized (1-2 cm) upper and middle pole renal calculi in regards to stone clearance rate, morbidity, and quality of life. METHODS All patients diagnosed with moderate sized upper and middle pole kidney stones by computed tomography (CT) were offered enrollment. They were randomized to receive either ESWL or PNL. The SF-8 quality of life survey was administered preoperatively and at 1 week and 3 months postoperatively. Abdominal radiograph at 1 week and CT scan at 3 months were used to determine stone-free status. All complications and outcomes were recorded. RESULTS PNL established a stone-free status of 95% and 85% at 1 week and 3 months, respectively, whereas ESWL established a stone-free status of 17% and 33% at 1 week and 3 months, respectively. Retreatment in ESWL was required in 67% of cases, with 0% retreatment in PNL. Stone location, stone density, and skin-to-stone distance had no impact on stone-free rates at both visits, irrespective of procedure. Patient-reported outcomes, including overall physical and mental health status, favored a better quality of life for patients who had PNL performed. CONCLUSION PNL more often establishes stone-free status, has a more similar complication profile, and has similar reported quality of life at 3 months when compared with ESWL for moderate-sized kidney stones. PNL should be offered as a treatment option to all patients with moderate-sized kidney stones in centers with experienced endourologists.

Calcifying nanoparticles associated encrusted urinary bladder cystitis

Encrusted cystitis is a subtype of chronic cystitis characterized by multiple calcifications in the form of plaques located in the interstitium of the urinary bladder mucosa and frequently associated with mucosal ulcers. It is a very rare disease of controversial etiology. Our transmission electron microscopy of the calcified plaques of encrusted cystitis has revealed that the smallest formed particles (elementary units) of these calcifications are electron-dense shells surrounding an electron lucent core, diagnostic of calcifying nanoparticles (previously called nanobacteria). We pioneer the notion that calcifying nanoparticles are the causative agents of encrusted urinary bladder cystitis.

Atypical presentation of priapism in a patient with acute iliocaval deep venous thrombosis secondary to May-Thurner syndrome.

We report on a 42-year-old male who presented with priapism, severe scrotal swelling, and left lower extremity pain and swelling. Initial management of priapism failed, and he was noted to have both cavernosal and glandular venous obstruction. Computed tomography (CT) was performed and identified extensive acute thrombosis involving the distal inferior vena cava and the left iliac veins. Pharmacomechanical thrombolysis (PMT) was started over the course of two days. At completion of thrombolysis, the culprit lesion in the left common iliac vein was treated with angioplasty and stenting. His postoperative course was uneventful, and his priapism as well as the scrotal and leg swelling improved. He was discharged home on full anticoagulation. To our knowledge, this is the first available description of this rare presentation along with a literature review of the underlying vascular etiology for priapism.

Are we fearful of tubeless percutaneous nephrolithotomy? Assessing the need for tube drainage following percutaneous nephrolithotomy

Objective: The objective was to demonstrate that percutaneous nephrolithotomy (PCNL) can be safely performed with a tubeless or totally tubeless drainage technique. Introduction: Standard PCNL includes nephrostomy tube placement designed to drain the kidney and operative tract at the conclusion of the procedure. Modern technique trend is tubeless PCNL and totally tubeless PCNL, which are performed without standard nephrostomy drainage. We aim to reinforce current literature in demonstrating that PCNL can be safely performed using a tubeless technique. With compounded supportive data, we can help generate a trend toward a more cost-effective procedure with improved pain profiles and patient satisfaction, as previously shown with the tubeless technique. Methods: Retrospective analysis of 165 patients who underwent PCNL treatment was performed. Of this group, 127 patients underwent traditional nephrostomy drainage following PCNL. A tubeless procedure was performed in the remaining 38 patients. Patients postoperative stone size and burden as well as complication profiles were analyzed. Largest stone size and total stone burden was similar between the groups. Results: Patient characteristics and demographic information were compared and no significant statistical difference was identified between the groups. Complication rates between the groups were compared and no statistical difference was noted. A total of 23 patients had at least one postoperative complication. Conclusion: Tubeless and totally tubeless PCNL demonstrates equivalent outcomes in the properly selected patient group when compared to PCNL performed with a nephrostomy tube. Although this is not the first study to demonstrate this, a large majority of urologists continue standard nephrostomy placement after PCNL. More studies are needed that demonstrate safety of this practice to shift the pendulum of care. Thus, tubeless and totally tubeless PCNL can be performed safely and effectively, which has previously been shown to improve cost, patient pain profiles, and length of hospitalization.

Ureteral Perigraft Fistula

Ureteral injury following aortic surgery occurs in less than 1% of all cases. Ureteral-arterial fistulae rarely occur in the current literature and only in case reports. This case involves a suspected ureteral aortic graft fistula presenting with acute hematuria with distant history of redo aortic bifemoral graft for aortoenteric fistula. Cystoscopy with retrograde pyelogram was performed and demonstrated what appeared to be a fistula between the left ureter and the aortic graft with a proximal hydroureter and hydronephrosis. After a detailed review of the films, we diagnosed a more benign ureteral perigraft fistula. Multidisciplinary management including urology and vascular surgery suggested conservative management. However, the patient later required more definitive therapy for his illness. This case demonstrates a ureteral perigraft fistula and displays how it appears radiographically. Here we present our experience with this new radiological diagnosis.

Primary Melanoma of the Urinary Tract

© 2015 American Osteopathic Association An 83-year-old woman with a painful distal urethral mass presented to the urology department. Results of a cystoscopy revealed a 4-cm dark pigmented lesion in the bladder (image A). The patient was evaluated for a primary skin lesion or other primary malignancies, which was found to be negative. She underwent distal urethrectomy and transurethral resection of the bladder tumor, and HMB-45 and S-100 staining revealed melanoma of the urinary tract (image B). After this diagnosis, the patient underwent bladder preservation therapy with external beam radiation and close surveillance. This treatment delayed disease progression for 20 months, at which point the patient developed metastatic disease and elected to receive hospice care. Primary melanoma originating from the urinary tract is an extremely rare occurrence and Primary Melanoma of the Urinary Tract