Wei Phin Tan

Periprostatic Fat: A Risk Factor for Prostate Cancer?

OBJECTIVEnTo evaluate whether periprostatic fat volume and periprostatic fat ratio as determined by multiparametric magnetic resonance imaging (mpMRI) correlate with the presence of high-grade prostate cancer.nnnMATERIALS AND METHODSnA total of 295 consecutive patients (median age: 64, range: 38-84) underwent mpMRI of the prostate gland between August 2013 and February 2015. All patients underwent a 3 Tesla mpMRI. Using DynaCAD (Invivo, Gainesville, FL), we calculated the prostate volume and volume of the periprostatic fat seen on mpMRI. The periprostatic fat ratio was calculated using the formula periprostatic fat volume/prostate volume.nnnRESULTSnA higher periprostatic fat volume (Pu2009<.001) and a higher periprostatic fat ratio (Pu2009<.001) were significantly associated with a higher Gleason score. Periprostatic fat ratio is a better predictor of higher Gleason score compared with periprostatic fat volume (Pu2009<u2009.001). There was no correlation observed between periprostatic fat ratio and prostate-specific antigen (median: 7.34, range: 0.36-59.7, Pu2009=u2009.274), age (median: 64, range: 38-84, Pu2009=u2009.665), or body mass index (median: 28.33, range: 17.99-45.44, Pu2009=u2009.310). Patients with a higher periprostatic fat ratio were more likely to undergo intervention for prostate cancer.nnnCONCLUSIONnA higher periprostatic fat ratio is significantly associated with a higher Gleason score. Periprostatic fat ratio is a better predictor of higher Gleason score compared with periprostatic fat volume and may be an important risk factor in diagnosing patients with higher grade prostate cancer.

Central zone lesions on magnetic resonance imaging: Should we be concerned?

INTRODUCTION AND OBJECTIVEnThe Prostate Imaging Reporting and Data System (PI-RADS) score was developed to evaluate lesions in the peripheral and transition zone on multiparametric magnetic resonance imaging (mpMRI) of the prostate. We aim to determine if the PI-RADS scoring system can be used to evaluate central zone lesions on mpMRI.nnnMATERIALS AND METHODSnA retrospective review of 73 patients who underwent mpMRI/ultrasound (US) fusion-guided biopsy of 143 suspicious lesions between February 2014 and October 2015 was performed. All patients underwent a 3T mpMRI. Indications for mpMRI included an abnormal digital rectal examination, PSA velocity >0.75ng/dl/y, and patients on active surveillance. The mpMRI sequence involved T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast enhancement. Using 3-dimensional model software (Invivo Corporation, Gainesville, FL, USA), a minimum of 3 magnetic resonance imaging (MRI)/US fusion-guided biopsy samples were taken from each prostate lesion seen on mpMRI irrespective of PI-RADS score, using local anesthesia in an outpatient clinic setting.nnnRESULTSnA total of 73 patients underwent MRI/US fusion-guided biopsy of 85 peripheral zone lesions, 31 transitional zone lesions, and 27 central zone lesions. Only 2 (7%) of central zone lesions were positive for prostate cancer. Both patients had lesions which were graded as PI-RADS 3. Both the patients had multifocal lesions that encompassed≥50% of the central and transition zones on the sagittal view MRI images. Both patients previously had transrectal US-guided biopsy of the prostate which was negative for cancer. Both patients underwent a robotic-assisted laparoscopic prostatectomy, each revealing high-grade cancer.nnnCONCLUSIONSnLesions involving only the central gland/zone seen on MRI are less concerning for malignancy and should not be given equal weight as peripheral zone lesions. In this series, no lesions involving solely the central gland/zone, regardless of PI-RADS score, was positive for malignancy on MRI/US fusion-guided biopsy. Consideration of a modified PI-RADS scoring system should be given to help identify central zone lesions with malignant potential.

Renal fungus ball: a challenging clinical problem

Introduction We describe a case of renal pelvi-ureteric fungus ball managed with placement of two nephrostomy tubes and amphotericin B irrigation through a nephrostomy tube with the other to free drain. Case Report A 46-year-old man with uncontrolled Type 2 diabetes mellitus was referred to the urology clinic for workup of recurrent urinary tract infection. Urine culture grew Candida albicans. The patient was started on oral fluconazole therapy. Cystoscopy and cystogram revealed a grade 3 left vesicoureteral reflux and right retrograde pyelogram revealed a filling defect in the right renal pelvis extending into the proximal ureter with severe hydroureteronephrosis. Two nephrostomy tubes were placed (mid-pole and lower pole) to ensure that the system was not obstructed. Amphotericin B (50 mg/1000 ml normal saline) irrigation was then instilled through the mid-pole nephrostomy tube at a rate of 30 ml/h with the lower pole nephrostomy tube to free drain. An antegrade nephrostogram was performed after 5 days of amphotericin B instillation, showing complete resolution of the fungus ball. The patient is awaiting definitive minimally invasive management of the distal ureteral narrowing. Comments Renal and pelvi-ureteric fungus ball is a challenging clinical entity. It must be addressed promptly and efficiently to be successful. We describe a minimally invasive approach that was tolerated well and resulted in complete clearance of the fungus ball in a relatively short time frame.

Unfriendly Filter: An Unusual Cause of Hydronephrosis and Hematuria

A 67-year-old woman was referred to the urology clinic for abdominal pain and hematuria. Urine analysis showed microscopic hematuria. Computed tomography urogram revealed a misplaced inferior vena cava (IVC) filter in the right gonadal vein causing right hydronephrosis. Retrograde pyelography revealed a 3-cm ureteral narrowing at the level of the IVC filter. A double-J ureteral stent was placed in the right ureter prior to exploratory laparotomy, which revealed partial erosion of the IVC filter into the right ureter and a thrombosed right ovary. The patient underwent a right oophorectomy and removal of the misplaced IVC filter. Her postoperative course was uncomplicated.

Bear's Paw Sign: A Classic Presentation of Xanthogranulomatous Pyelonephritis

A 41-year-old woman with recurrent urinary tract infections presented with right flank pain, fever, and anorexia. Physical examination revealed right-sided flank pain and a right-sided unilateral renal mass. Computed tomography of the abdomen and pelvis revealed xanthogranulomatous pyelonephritis with perinephric extension. The bears paw sign was visualized. The classic radiology triad (unilateral large kidney, renal pelvis stone, and a nonfunctioning or poorly functioning kidney) was also found on computed tomographic imaging. She completed a course of antimicrobial therapy and underwent a nephrectomy. Her post-operative course was uneventful and she was discharged from the hospital on postoperative dayxa04.

Robotic assisted laparoscopic radical cystectomy with stentless intracorporeal modified Ves.Pa neobladder: early experience

AbstractThis study aimed at demonstrating the feasibility of robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder with stentless ureteroileal anastomosis. Pure intracorporeal robotic assisted laparoscopic technique has been recently developed with a select number of high-volume centers utilizing various operative and neobladder techniques. We reviewed the patient characteristics, operative details and perioperative courses in the two patients who have undergone robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder and one who has undergone the Hautmann W neobladder. These results were compared to other contemporary robotic neobladder series. We demonstrate technical success with similar operative and perioperative results with the modified Ves.Pa neobladder. The robotic pure intracorporeal modified Ves.Pa neobladder is a technically feasible operation and may be easier to perform compared to other neobladders. Initial experience suggests operative time and perioperative outcomes are similar to other robotic techniques.n

Well-Differentiated Papillary Mesothelioma of the Tunica Vaginalis

A 39-year-old man presented with painless scrotal swelling for 2 months. He denied any asbestos exposure but worked with wall and ceiling plaster. Physical exam revealed a large right scrotum which transilluminated. Scrotal ultrasonography revealed a large right hydrocele and a polypoidal mass along the anterior wall of the scrotum. Magnetic resonance imaging of the abdomen and computed tomography of the chest showed no metastases. He underwent a right inguinal scrotal exploration and wide excision of tunica vaginalis and a partial epididymectomy. Pathology revealed well-differentiated papillary mesothelioma of the tunica vaginalis. The patient had an uneventful recovery.

Predictors of fluoroquinolone-resistant bacteria in the rectal vault of men undergoing prostate biopsy

ImportanceFluoroquinolone (FQ)-resistant rectal vault flora is associated with infectious complications in men undergoing transrectal ultrasound-guided prostate needle biopsyxa0(TRUS-PNB).ObjectiveTo determine the patient factors that predict FQ-resistant rectal cultures in men who are undergoing transrectal ultrasound-guided prostate needle biopsy.MethodsAn IRB approved retrospective review of 6183 consecutive men who had undergone a rectal swab culture in preparation for TRUS-PNB between January 2013 and December 2014 was performed. Multivariable logistic regression was used to determine the clinical and demographic factors associated with FQ-resistant Enterobacteriaceae in the rectal vault.ResultsOf the 6179 rectal swabs analyzed, 4842 (78%) were FQ-sensitive, and 1337 (22%) were FQ-resistant. On univariable analysis, increasing age, prior TRUS-PNB, higher number of biopsy cores obtained, diabetes mellitus, antimicrobial use within the past 6 months and non-Caucasian race were predictors of FQ-resistance (all pu2009<u20090.05). Men with FQ-resistantxa0cultures were more likely to have benign pathology on TRUS-PNB (pu2009=u20090.004). On multivariable analysis, increasing patient age (ORu2009=u20091.01/year [1.00–1.02]), use of antimicrobials in the last 6 months (ORu2009=u20092.85[2.18–3.72]), African American (ORu2009=u20091.99 [1.66–2.37]), Asian (ORu2009=u20093.39 [2.63–4.37]), and Hispanic (ORu2009=u20092.10 [1.72–2.55]) races were independently associated with FQ-resistant rectal cultures. The overall infectious rate was 1.1% (56/5214) and the sepsis rate was 0.46% (24/5214). The infection rate in the FQ-resistant group was 3.9% (43/1107) compared to FQ-sensitive group 0.3% (13/4107), pu2009<u20090.001.ConclusionIn this cohort, increasing age, recent antimicrobial-use, and non-Caucasian race were independent predictors of FQ-resistance in the rectal vault. As FQ-resistance is associated with infectious complications from transrectal ultrasound-guided prostate needle biopsy, understanding risk factors may assist infection control efforts.Key pointsQuestion: What are the factors that predict fluoroquinolone (FQ)-resistant rectal cultures in men undergoing transrectal ultrasound-guided prostate needle biopsy?Findings: Increasing age, recent antimicrobial-use, African American, Asian, and Hispanic race were independent predictors of FQ resistance in the rectal vault.Meaning: Older man, antimicrobial usage within 6 months, African American, Asian and Hispanic race werexa0 associated with men withxa0FQ-resistancexa0rectal flora and may benefit from alternative prophylaxis and monitoring strategies.

Intentional Omission of Ureteral Stents During Robotic-assisted Intracorporeal Ureteroenteric Anastomosis: Is It Safe and Feasible?

OBJECTIVEnTo describe the surgical technique we used to perform a stentless intracorporeal ureteroenteric anastomosis and to determine the outcomes in this initial series.nnnMETHODSnWe performed a retrospective review of a prospective database of all patients undergoing robotic-assisted intracorporeal urinary diversion with stentless ureteroenteric anastomosis between March 2014 and July 2016. Diversions were performed at the time of either robotic-assisted laparoscopic cystectomy for bladder cancer or urinary diversion for other indications.nnnRESULTSnA total of 10 patients underwent implantation of 20 ureters into the intestine via a robotic-assisted approach with intentional omission of stents. Median body mass index was 29.57 (first quartile 23.68, third quartile 34.69). Median American Society of Anesthesiologists score was 3 (range 2-3). Seven patients had intracorporeal ileal conduit reconstruction and 3 patients had an intracorporeal neobladder creation. There were no patients who developed a stricture of the ureter nor did any patient develop a leak at the ureteroenteric anastomosis. All patients had normal serum creatinine at least 4 weeks after surgery, and all patients had follow-up computed tomography of the kidneys, which were normal. The median follow-up was 8 months (first quartileu2009=u20093 months, third quartileu2009=u200917 months).nnnCONCLUSIONnRobotic intracorporeal urinary diversion with intentional omission of ureteral stents is a safe and feasible option when establishing continuity of the genitourinary and gastrointestinal tracts.

Schistosoma haematobium: A Delayed Cause of Hematuria

A 22-year-old African American man with recurrent episodes of gross hematuria for 6 months presented to the clinic for evaluation. A thorough history revealed that the patient emigrated from Mozambique to the United States 12 years ago. Urine culture was negative for a urinary tract infection. Cystoscopy revealed 4 lesions in the bladder. Biopsy of the bladder lesion revealed severe cystitis and Schistosoma haematobium. The patient later confirmed that he used to swim in rivers and streams back in Africa. He completed a course of praziquantel and his gross hematuria resolved.