Todd Yecies

Direction of Rotation in Testicular Torsion and Identification of Predictors of Testicular Salvage

OBJECTIVES To identify the rate at which testicular torsion occurs in a lateral direction and identify any predictors of direction of testicular rotation and orchiectomy. MATERIALS AND METHODS We performed a retrospective review of 104 cases of emergent scrotal exploration performed for testicular torsion by 3 pediatric urologists from 2003 to 2017. Patients with neonatal torsion, negative scrotal exploration, or exploration for presumed intermittent testicular torsion were excluded. Univariable logistic regression was performed to assess if any factors predicted direction of testicular rotation. Univariable and multivariable logistic regression was used to identify predictors of testicular salvage. RESULTS Of 104 cases of acute testicular torsion, information regarding the direction of testicular rotation was available in 81 patients. Lateral testicular rotation occurred in 38 cases (46%). No factors were found to be predictive of direction of torsion. Orchiectomy for testicular nonviability was performed in 50 of 104 cases (48%). On univariable analysis, younger age (p = .002), absence of gastrointestinal symptoms (P = .02), time to exploration (P < .001), testicular size differential on ultrasound (p = .002), absence of hydrocele (P = .01), abnormal ultrasound echotexture (P < .001), and degree of torsion (P = .04) were associated with orchiectomy. With the exception of absence of gastrointestinal symptoms, all predictors of orchiectomy remained statistically significant on multivariable analysis. CONCLUSION Testicular rotation occurs in a lateral direction in 46% of cases. Lateral manual detorsion should be performed only with awareness of the potential for increasing the degree of testicular rotation. New independent predictors of testicular salvage were identified.

Biopsy Perineural Invasion in Prostate Cancer Patients Who Are Candidates for Active Surveillance by Strict and Expanded Criteria

OBJECTIVE To evaluate the association of biopsy perineural invasion (PNI) with adverse pathologic findings on radical prostatectomy in patients who would have been candidates for active surveillance (AS). METHODS Using a prospectively populated database of 3084 men who underwent open radical prostatectomy, candidates for AS by strict (Johns Hopkins) and expanded (University of Toronto) criteria were identified. The presence of adverse pathologic features at radical prostatectomy was compared between those men with and without biopsy PNI. RESULTS Of 596 men who met strict criteria for AS, 16 (3%) had biopsy PNI. In the strict AS cohort, there were no differences in adverse pathologic features at radical prostatectomy between those with and without PNI. Of 1197 men who were candidates for AS by expanded criteria, 102 (9%) had biopsy PNI. Men with biopsy PNI in the expanded AS cohort were more likely to have extraprostatic extension (P < .001) and pathologic upgrading (P = .01) at prostatectomy. In addition, those with PNI had larger dominant nodules (P < .001), and cancer comprised a greater percentage of their prostate glands (P < .001). There was no difference in the proportion with a positive margin between the 2 groups (P = .77). CONCLUSION Biopsy PNI was rare in patients who met strict criteria for AS. Among those men who met expanded criteria, PNI was associated with adverse pathologic findings upon prostatectomy. The presence of biopsy PNI may have a role in further risk stratifying patients who meet expanded criteria for AS.

Spontaneous Bacterial Peritonitis Caused by Listeria monocytogenes Associated with Ascitic Fluid Lymphocytosis: A Case Report and Review of Current Empiric Therapy.

Spontaneous bacterial peritonitis (SBP) is a potentially deadly complication of ascites. We describe a case of SBP caused by Listeria monocytogenes in a patient with alcoholic cirrhosis. This was associated with the unusual finding of ascitic fluid lymphocytosis, which previously had only been associated with tuberculoid or malignant ascites. Given increasing rates of cefotaxime-resistant SBP alongside the possibility of Listeriosis, the use of cefotaxime as first-line therapy in SBP should be reevaluated.

Cowper's Gland Syringocele

Cowpers gland syringoceles are rare cystic dilations of the Cowpers gland duct. They are typically diagnosed in childhood but occasionally occur in adults. We report the case of a 28-year-old man who presented with a painful perineal and inferior scrotal mass and was found to have a large Cowpers gland syringocele extending into the scrotum associated with a scrotal abscess. Treatment consisted of surgical excision. The magnetic resonance imaging findings of this case are described.

Risk of Radiation from Computerized Tomography Urography in the Evaluation of Asymptomatic Microscopic Hematuria

Purpose The AUA (American Urological Association) guidelines for asymptomatic microscopic hematuria recommend that patients undergo computerized tomography urography, which is associated with high doses of ionizing radiation. To our knowledge the associated risk of secondary malignancy and mortality remains unknown. We modeled the risk of malignancy and associated mortality due to ionizing radiation from computerized tomography urography relative to the additional diagnostic benefit offered over renal ultrasound. Materials and Methods We performed a PubMed® based literature search to identify model inputs. We obtained estimates of age and gender specific radiation induced secondary malignancy and mortality rates from the BEIR (Biologic Effects of Ionizing Radiation) VII Phase 2 report with dose extrapolation using the linear no threshold model. Results Patients with asymptomatic microscopic hematuria had a 0.053% and 0.48% prevalence of upper tract urothelial carcinoma and renal cell carcinoma, respectively. Ultrasound had 77% sensitivity for upper tract urothelial carcinoma and 82% sensitivity for renal cell carcinoma. The effective radiation dose of computerized tomography urography was 31.7 mSv. Based on these inputs a population of 100,000 patients with asymptomatic microscopic hematuria would include 53.1 and 478 patients with upper tract urothelial carcinoma and renal cell carcinoma, respectively. On ultrasound alone 98.2 cases of upper urinary tract malignancy would be missed. An additional 149 cases of secondary malignancy would be caused by computerized tomography urography associated radiation with 101 fatalities. A total of 1,018.3 computerized tomography urography studies would need to be performed to detect an additional case of upper tract malignancy. Conclusions Based on current risk models computerized tomography urography for asymptomatic microscopic hematuria may be associated with a small but significant risk of secondary malignancy relative to the additional diagnostic benefit offered

Spinal interneuronal mechanisms underlying pudendal and tibial neuromodulation of bladder function in cats

Abstract This study examined the mechanisms underlying pudendal and tibial neuromodulation of bladder function at the single neuron level in the spinal cord. A microelectrode was inserted into the S2 spinal cord of anesthetized cats to record single neuron activity induced by bladder distention over a range of constant intravesical pressures (10–40 cmH2O). Pudendal nerve stimulation (PNS) or tibial nerve stimulation (TNS) was applied at 5 Hz frequency and 0.2 ms pulse width and at multiples of the threshold (T) intensities for inducing anal or toe twitches. A total of 14 spinal neurons from 11 cats were investigated. Both PNS and TNS at 2 T intensity significantly (p < .05) reduced by 40–50% the frequency of firing induced by bladder distention at 20–40 cmH2O in the same spinal neurons. This reduction was not changed by blocking opioid receptors with naloxone (1 mg/kg, i.v.). Activation of pudendal afferents by repeatedly stroking (3–5 times per second) the genital skin using a cotton swab also inhibited the neuron activity induced by bladder distention. Prolonged (30 min) TNS at 4 T intensity produced a short lasting (10–18 min) post‐stimulation inhibition that reduced by 40–50% bladder‐related neuron activity at different bladder pressures. These results indicate that PNS and TNS inhibition of reflex bladder activity may be mediated in part by convergence of inhibitory inputs onto the same population of bladder‐related interneurons in laminae V‐VII of the S2 spinal cord and that an opioid receptor mechanism is not involved in the inhibition. HighlightsBladder distention induces single neuron activity in the S2 spinal cord.Spinal neurons are a site of convergence of pudendal and tibial bladder inhibition.Tibial nerve stimulation induces a short‐lasting post‐stimulation inhibition.Opioid receptors play no role in pudendal or tibial inhibition at the spinal level.

Appearance of Pyelitis Emphysematosa on Computed Tomography

Pyelitis emphysematosa is a gas-forming infection characterized by gas located within the wall of the collecting system and renal pelvis. There are only 2 reported cases of pyelitis emphysematosa in the literature, neither of which occurred in the era of cross-sectional imaging. Here we present a case of pyelitis emphysematosa occurring in an elderly female with congenital left renal atrophy and chronic right hydronephrosis secondary to ureteropelvic junction obstruction.

MP08-07 SINGLE PULSE-PER-SECOND SETTING SIGNIFICANTLY REDUCES FLUOROSCOPY TIME DURING URETEROSCOPY

METHODS: Nine female participants with OAB underwent an extended urodynamics procedure (Laborie Aquarius XT) while ultrasound images of the bladder were obtained using a 3D 6MHz transabdominal probe (GE Voluson E8). The bladder was filled with saline at a rate of 10% bladder capacity (based on an initial clinical fill) per minute while ultrasound images were captured once per minute. Bladder volume was estimated from 2D cross-sectional images in the sagittal and transverse planes assuming an ellipsoid geometry (Eqn 1, Vspheroid), assuming a shape in between an ellipsoid and a cube (Eqn 2, VBih by Bih et. al. 1998), and from the 3D ultrasound data obtained by tracing the bladder outline in six planes with GE’s 4D View software (V3D, Fig. 1 panel A).