Urology (Gold Journal) In Press

Malignant mesothelioma of the tunica vaginalis testis is a rare, but often fatal, malignancy that usually appears during the fourth decade and has a strong relationship with occupational exposure to asbestos and long-lasting hydrocele. We present a case involving a 36-year-old man without a history of hydrocele, trauma, or exposure to asbestos who developed malignant mesothelioma.

Objective: To compare a consecutive prospective cohort of patients who underwent robotic partial nephrectomy (RPN) with near infrared fluorescence (NIRF) imaging with indocyanine green dye (ICG) with a previous consecutive patient cohort. Methods: A total of 47 consecutive patients with renal masses suspicious for malignancy undergoing RPN were given 5-7.5 mg of ICG before hilar clamping or tumor excision. This cohort of patients was compared with 47 immediate previous consecutive patients who had undergone RPN without NIRF real-time imaging using ICG. The intraoperative, perioperative, and postoperative parameters were collected in an institutional review board-approved prospective database. Results: The preoperative demographics and tumor complexity according to the nephrometry or preoperative aspects and dimensions used for an anatomic (PADUA) scores were similar. The mean warm ischemia time was significantly decreased in the ICG group (15 vs 17 minutes, P = .01). The median hospital stay was 2 days in both groups. No significant difference was seen in the positive margin rate (ICG, 6% vs control, 8.5%; P = .69) or observed Clavien grade III-IV complications in these 2 cohorts (ICG, 4% vs control, 15%; P = .07). No adverse events were associated with ICG dye administration. Differential ICG uptake was observed with selective clamping or in patients with cystic tumors, hypofluorescent tumors with exophytic components, and angiomyelolipomas, but these benefits could not be quantified. NIRF-ICG was transiently helpful to identify the vascular anatomy and not helpful at all for endophytic tumors. Conclusion: RPN using NIRF-ICG can be performed safely and effectively. A decreased warm ischemia time in the ICG cohort was observed without specific measured advantages. Differential ICG uptake by different tumors did not lead to significant differences in the positive margin rate.

The authors present their experience using ICG with NIRF during RPN. ICG-NIRF has received considerable attention during the past 18 months, with a litany of anecdotal, single-institution publications evaluating the feasibility and utility of ICG-NIRF during open and minimally invasive nephron-sparing surgery. As the authors astutely point out, no comparative outcomes are available that determine what, if any, benefit ICG-NIRF might offer in this setting. The authors performed a retrospective cohort study that evaluated the role of ICG-NIRF during RPN with the explicit goal of answering this question.

We read with great interest the editorial by Dr. White commenting on our report “Is Near Infrared Fluorescence Imaging Using Indocyanine Green Dye Useful in Robotic Partial Nephrectomy: A Prospective Comparative Study of 94 Patients.” Several important points were raised, and these we believe deserve further attention.

Objective: To determine the effect of antenatally detected caliectasis on the postnatal surgical intervention rate. Methods: From 2006 to 2010, 56 patients with an anteroposterior diameter (APD) of 7-20 mm on the prenatal ultrasound scan performed in the third trimester of pregnancy were included in the present study. In these 56 patients, other anomalies (vesicoureteral reflux, posterior urethral valves, duplex system, megaureter) were excluded, and the postnatal clinical and radiologic follow-up data were available. The mean follow-up was 12.82 ± 10.72 months. These 56 patients were divided into 2 groups: those with (n = 32) and without (n = 24) caliectasis. In the caliectasis group, the mean follow-up was 13.6 ± 12.09 months and was 11.7 ± 8.70 months in the group without caliectasis. The statistical correlation between the postnatal operation rates and the presence of caliectasis (APD range 7-20 mm in third trimester) was investigated using the chi-square test. Results: In the study group (n = 56) with an APD range of 7-20 mm in the third trimester, postnatal surgical treatment (pyeloplasty) was performed in 12 (37.5%) and 3 (12.5%) of the children with and without caliectasis, respectively (P = .037). The risk of postnatal surgical treatment increased threefold in patients with an APD of 7-20 mm and a diagnosis of caliectasis (relative risk 3.0, 95% confidence interval 1.07-8.40). Conclusion: In our study, the presence of concomitant caliectasis within the APD range of 7-20 mm on the third trimester ultrasound scan increased the risk of surgical treatment threefold. During prenatal counseling, the presence of caliectasis requires more rigorous follow-up.

The authors present their experience with prenatally detected caliectasis as a predictor of postnatal surgical intervention. Patients with an APD of 7-20 mm in the third trimester were divided into 2 groups: those with caliectasis and those without. Those with caliectasis were more likely to undergo postnatal surgical intervention.

Laparoscopic radical nephrectomy should be executed under the most fundamental principle of early ligature of the renal artery to prevent diffusion of cancerous cells. This is extremely true in the treatment of large renal tumors touching the main renal vasculature. Obviously, the concomitance of a duplicated inferior vena cava (IVC) with associated aberrant tributaries will significantly increase the surgical difficulty and the procedural risk of vascular injury. Herein we describe a transperitoneal left laparoscopic radical nephrectomy for a large hilar left renal tumor in the presence of a duplicated IVC with complicated anomalous tributaries by a transmesocolic approach.

Objective: To assess the role and prognostic significance of angiostatin, basic fibroblast growth factor (bFGF), and tyrosine endothelial kinase (TEK/Tie2) in transitional cell bladder carcinoma. Materials and Methods: Angiostatin, bFGF, and TEK serum concentrations were measured in 82 bladder cancer patients and 20 age-matched healthy controls using enzyme-linked immunosorbent assay. Results were compared with clinicopathologic and follow-up data with the Mann-Whitney U test and Kaplan-Meier, univariate and multivariate Cox regression analyses. Results: We found significantly decreased angiostatin and TEK serum levels and mildly elevated bFGF concentrations in samples of bladder cancer patients compared with controls (P < .001, P < .001, and P = .083, respectively). Furthermore, high TEK serum levels were correlated with poor disease-specific and metastasis-free survival in muscle-invasive bladder cancer (P = .013, P = .018), whereas angiostatin and bFGF concentrations did not show any correlation with patients' prognosis. Multivariate analysis revealed high TEK levels (<1.60 ng/mL) as borderline significant independent risk-factor of disease-specific survival (HR 1.83, 95% CI 0.97-3.44, P = .061) and metastasis-free survival (HR 2.65, 95% CI 0.93-7.55, P = .069). Conclusion: The characteristic differences in the circulating levels of angiostatin, TEK, and bFGF between patients and controls, suggest the presence of a tumor-induced proangiogenic milieu in bladder cancer. Serum TEK levels may contribute to a more reliable preoperative risk stratification in muscle-invasive bladder cancer and therefore may help to optimize therapeutic decisions.

Reninoma is an extremely rare, renin-secreting, benign kidney tumor that can cause hypertension. We present a case of hypertension secondary to reninoma treated with laparoscopic nephron-sparing surgery in a 15-year-old girl and review some relevant published literature. Laparoscopic retroperitoneal nephron-sparing surgery was performed and the tumor was removed intact. The histopathologic examination showed the characteristic of reninoma with positive CD34 staining immunohistochemically. The patient's blood pressure and level of serum potassium remained normal at 1-month follow-up examination.

Objective: To investigate the effect of hyperglycemia on the expression of the aquaporin (AQP) isoforms in the diabetic rat vagina. Methods: Female Sprague-Dawley rats (230-240 g, n = 45) were divided into control (n = 10) and experimental (n = 35) groups. Diabetes in the experimental group was induced by intraperitoneal injection of streptozotocin (STZ, 65 mg/kg). STZ-induced diabetic rats were left untreated or given subcutaneous injections of insulin (3 U/d). After 2 and 4 weeks, the blood glucose was measured, and the vaginal blood flow was assessed by Doppler flowmetry. The expression and cellular localization of AQP1 and AQP2 in the rat vagina were determined by Western blot and immunohistochemistry. Results: The vaginal blood flow (mL/min/100 g tissue) after pelvic nerve stimulation was significantly lower in the STZ-induced diabetic rats (21.9 ± 6.5 at 2 weeks and 21 ± 2.8 at 4 weeks) compared with the control group (55.5 ± 8.9 at 2 weeks and 52.9 ± 6.5 at 4 weeks; P < .05). In contrast, the vaginal blood flow response was significantly greater in the insulin-treated diabetic groups (47.7 ± 8.7 at 2 weeks and 47.7 ± 8.4 at 4 weeks) and comparable to that of the control group. The protein expression of AQP2 was significantly lower in the STZ-induced diabetic rats and was restored to the control level after insulin treatment. However, no change was seen in AQP1 expression. Thus, hyperglycemia might cause downregulation of AQP2 expression in the diabetic rat vagina. Conclusion: These results suggest that decreased vaginal lubrication in diabetic women might result from changes in aquaporin expression, in addition to a reduction in the vaginal blood flow response.

Objective: To perform a contemporary comparative cost-analysis of robotic-assisted laparoscopic radical prostatectomy (RARP) and open radical retropubic prostatectomy (RRP). Methods: All patients undergoing RARP (n = 115) or RRP (n = 358) by 1 of 4 surgeons at a single institution during a 15-month period were retrospectively reviewed. The hospital length of stay (LOS), operative time, hospital charges, reimbursement, and direct and indirect hospital costs were analyzed and compared. Results: The mean LOS between patients undergoing RARP (1.2 ± 0.6 days) and RRP (1.4 ± 0.8 days) was not significantly different. The operating room supply costs per case were almost 7 times greater for RARP ($2852 ± $528) than for RRP ($417 ± $59; P < .05). The ancillary, cardiology, imaging, administrative, laboratory, and pharmacy costs were not significantly different between the 2 approaches. The mean total costs per case for RARP exceeded the total costs for RRP by 62% ($14 006 ± $1641 vs $8686 ± $1989; P < .05). Payment to the hospital from all sources was nearly equivalent: $10 011 for RRP and $9993 for RARP. Therefore, the average profit for each RRP was $1325 and each RARP lost $4013. Conclusion: In the present single-institution analysis, the total actual costs associated with RARP were significantly greater than those for RRP and were attributable to the robotic equipment and supplies.

Objective: To prospectively test the hypothesis that end-fire transrectal ultrasound prostate biopsy probes have greater cancer detection rates than side-fire probes. Retrospective studies have suggested that such probes might have greater cancer detection rates. Methods: The present prospective randomized multicenter trial aimed to compare the prostate cancer detection rates of the end-fire versus side-fire probe configuration during transrectal ultrasound-guided 12-core prostate biopsy. Patients were randomized according to age, prostate-specific antigen level and prostate volume. An interim analysis was planned after the inclusion of 300 patients. Results: At the interim analysis after the inclusion of 297 patients, no differences were found in the mean prostate-specific antigen level (P = .412), mean age (P = .519), mean prostate volume (P = .730), and positive digital rectal examination findings (P = .295). The prostate cancer detection rate did not differ between the end-fire and side-fire probe (34.3% vs 34.4%, P = .972). On multivariate analysis, suspicious digital rectal examination findings (relative risk 8.185, P < .001), prostate-specific antigen level (relative risk 1.051, P = .041), and prostate volume (relative risk 0.973, P < .001), but not probe configuration (relative risk 0.942, P = .831), were independent predictive factors for the detection of prostate cancer. The interim analysis committee suggested that, because no difference of 5 absolute percent was achieved after 300 patients, no additional recruitment was necessary. Therefore, the study was terminated early. Conclusion: The results of the present study have shown that the transrectal ultrasound probe configuration does not affect the prostate cancer detection rate during transrectal ultrasound-guided prostate biopsy.

Since the time we observed and then reported that PCa detection was significantly greater when biopsy had been performed using end-fire probes, we have emphasized in our courses and resident/fellow teaching that the side-fire probe tends to aim the biopsy needle tangentially, often missing cancer in the anterior prostate and “very apex.” To overcome this, when using the side-fire probe since that time, we intentionally torque the probe to ensure that these areas are included in the biopsy sample.

Objective: To investigate the urinary metabolic excretion pattern among local stone formers given the great differences in the intrinsic and extrinsic risk factors as well as the urinary metabolic excretions compared with other populations. Methods: Thirty urinary stone formers out of an initial 62 recruited provided a complete 24-hour urine sample for metabolic evaluation. Student's t-test and Pearson correlation test were used for the statistical analysis. Results: Urinary volume (1719 ± 712 vs 1215 ± 575, P < .05) and oxalate excretion (0.386 ± 0.111 vs 0.306 ± 0.104, P < .05) were significantly higher among stone formers than controls. Other commonly studied urinary parameters and urinary melamine did not differ significantly between the 2 groups. Similarly, the calcium/citrate ratio was unable to discriminate the stone formers from their controls. Hypocitraturia was the most prevalent urinary abnormality found in stone formers and low urinary citrate excretion was a general phenomenon in both stone formers and controls. Comparing within the stone formers cohort, the recurrent stone formers had a significantly higher urinary saturation and calcium excretion than their first-time stone former counterparts. Conclusion: Elevated urinary oxalate level was the most important urinary risk factor among the local stone formers. A low urinary citrate excretion appeared to be a general phenomenon among the studied cohorts.

Objective: To investigate whether ischemic postconditioning effects on the development of tubulointerstitial fibrosis follow acute renal ischemia-reperfusion. Methods: Rat models of warm renal I/R were established by clamping left pedicles for 45 minutes after right nephrectomy, both with and without treatment with ischemic postconditioning, and then reperfused for up to 12 weeks. Hematoxylin–eosin (H&E) and Masson's trichrome staining were used to assess renal fibrosis. The expression spot and protein levels of α-smooth muscle actin (α-SMA), transforming growth factor–β1 (TGF-β1), and phospho-Smad2 were also analyzed. Results: Our data showed that patchy inflammation and tubulointerstitial fibrosis were found 12 weeks later in rats subjected to I/R alone or with postconditioning. Tubulointerstitial fibrosis worsened further in rats subjected to 45-minute ischemia-reperfusion, accompanied by the increased expressions of α-SMA, TGF-β1, and phospho-Smad2 at the end of 12 weeks. In contrast, the above histologic changes and molecular expressions were significantly attenuated in rats of ischemic postconditioning group. Conclusion: The results indicated that 45-minute I/R injury may cause tubulointerstitial fibrosis in the long term, and ischemic postconditioning has beneficial effects on renal fibrosis. Its mechanisms may involve inhibition of the TGF-β1/phospho-Smad2 pathway to exert protective effects.

Objective: To assess the outcomes of a modified technique for pediatric laparoscopic pyeloplasty (LP) performed without instrument trocars. Methods: A retrospective cohort study for all LPs performed without instrument trocars was performed. Patient demographics, surgical technique, complications, and clinical outcomes were reviewed. All patients undergoing this procedure had a single trocar placed to insufflate and introduce the laparoscope. Skin punctures were used without trocars to introduce 3-mm instrumentation for LP. Results: Nine patients with 10 procedures were identified. Median age was 8 months old (range 3-190). Median weight was 8.3 kg (range 5.9-70.5). Median operative time was 229 minutes (range 145-387). All procedures were performed without additional trocars. There were no open conversions. Median hospital stay was 1 day (range 1-4). Median narcotic use was 0.1 mg/kg/d of intravenous morphine equivalent. There were no intraoperative complications. Median follow-up was 36 months (range 18-45). Follow-up renal ultrasound evaluation has demonstrated improved hydronephrosis in all patients. No reoperative pyeloplasty was performed. Subjective assessment of cosmesis has shown excellent outcome with almost imperceptible evidence of operative intervention. Conclusion: LP without instrument trocars can be safely and effectively performed without compromise of the surgical procedure, with minimal use of narcotics, and with a short hospital stay. Intermediate-term follow-up indicates encouraging results for achieving scarless surgery.

Objective: To evaluate the use of automated volumetric assessment for stone surveillance and compare the results with manual linear measurement. Methods: We retrospectively reviewed patients seen in our stone clinic who had undergone 2 noncontrast computed tomography (NCCT) scans without stone intervention during the interval between scans. Thirty patients met our inclusion criteria and underwent longitudinal assessment for urolithiasis via NCCT (mean interval 583.2 days, range 122-2030). Fifty-two discrete calculi were analyzed. Three board certified radiologists measured maximal linear stone size in the axial plane using electronic calipers on soft tissue (ST) and bone windows (BWs). Automated stone volume was also obtained by each reader using a dedicated prototype software tool for stone evaluation. Results: Mean stone linear size and volume was 4.9 ± 2.8 mm (ST), 4.5 ± 2.6 mm (BW), and 116.2 ± 194.6 mm3 (window independent), respectively. Mean interobserver variability for linear size measurement was 16.4 ± 10.5% (ST) and 20.3 ± 13.8% (BW). Interobserver variability for volumetric measurement was 0%. Of the 52 persistent stones, the mean percent change in linear stone size between CT studies was 39.3 ± 46.7% (ST) and 42.9 ± 53.1% (BW) growth, compared with 171.4 ± 320.1% (window independent) growth for automated volume measurement over a mean of 583.2 days. However, discordant results for increased vs decreased interval size was seen between linear and volumetric assessment in 19/52 stones (36.5%). Conclusion: Automated volumetric measurement of renal calculi via NCCT is independent of specific reader and window settings. Volumetric assessment amplifies smaller linear changes over time, whereas as much as one third of cases show linear-volume measurement discordance. Volumetric assessment is therefore preferable, particularly for longitudinal surveillance of renal calculi.

Objective: To evaluate the efficacy of single tract percutaneous nephrolithotomy (sPCNL) and investigate the preoperative predictive factors associated with stone clearance after sPCNL. Methods: A retrospective review of 351 cases of sPCNL performed at a single institution by 1 of 2 endourologists between January 2000 and March 2010 was performed. The primary outcome evaluated was stone-free rate (SFR) as assessed immediately after either an initial procedure or a second-look nephroscopy performed on postoperative day 2. Preoperative patient and stone factors, including age, sex, body mass index (BMI), preoperative hematocrit and creatinine, previous surgeries, comorbidities, renal anomalies, stone size, shape, location, and history of any previous treatment to the active stone burden were included in the univariate analysis. Significant or clinically relevant factors on univariate analysis were included in a logistic regression the multivariate analysis. Results: SFR after either an initial procedure or a second-look nephroscopy was 76%. On univariate analysis, rising preoperative creatinine, hypertension, increasing stone diameter, complete staghorn stone, presence of stones in the upper pole and absence of prior SWL were associated with lower SFR. Stone size, presence of stones in the upper pole, and prior SWL for the active burden were independent predictors of SFR on multivariate analysis. Conclusion: sPCNL is an efficient procedure to clear renal stones, especially when used in conjunction with routine second-look nephroscopy. Increasing stone size and upper pole stones are associated with lower rates of stone clearance, whereas SWL performed before percutaneous nephrolithotomy (PCNL) is associated with improved stone clearance. The role of SWL before PCNL warrants further prospective investigation.

Squamous metaplasia is a proliferative lesion characterized by the replacement of the transitional epithelium with stratified squamous cells. In the urinary system, it is mostly seen in the bladder. It can be nonkeratinized or keratinized. We report the cases of 2 adolescent girls with keratinizing metaplasia, 1 of whom presented with difficulty with indwelling catheterization and 1 with final terminal hematuria. The predisposing factors were recurrent urinary tract infection and additional catheterization in 1 of the patients. The diagnosis was confirmed by histologic examination in both patients. We report on these cases to draw attention to this rare entity in children.

Objective: To investigate the role of fatty acid synthase (FASN) in bladder transitional cell carcinoma (BTCC). Methods: FASN expression was investigated in non–muscle-invasive BTCC tissue specimens by immunohistochemistry and BTCC cell lines by Western blot. After treatment with FASN-siRNA or FASN inhibitor cerulenin (Cer), the proliferation and apoptosis of BTCC cell lines 5637 and 253 J were determined by cell counting Kit-8 (CCK8) assay and flow cytometry respectively. The expression of p-AKT, cyclin D1 (CCND1), and apoptosis-related proteins were detected by Western blot. Results: High levels of FASN expression were observed in 59% (32/54) of non–muscle-invasive BTCC tissue specimens, and FASN expression was associated with histologic grade (P < .05) and recurrence (P < .05). FASN expression was high in 6 BTCC cell lines. FASN inhibitor Cer and FASN-siRNA produced the increased apoptosis and decreased proliferation of bladder cancer cells, and caused inactivity of AKT and downregulation of CCND1. Furthermore, treatment of BTCC cell lines with Cer resulted in apoptosis via the caspase-dependent pathway involving inactivation of antiapoptotic bcl-2 protein. Conclusion: Our data suggest that FASN plays an important role in BTCC development. Targeting FASN may be a new therapeutic strategy for BTCC.