Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:Describe the ACGME's changes to the PGY-1 year in urology and discuss the benefits and challenges faced by training programs. RECENT FINDINGS/RESULTS:There are no publications detailing the integration of the PGY-1 year in urology; however, response of other surgical subspecialties to their own integration has been studied. Benefits of integration include earlier exposure to techniques and knowledge specific to urology, potentially leading to increased preparedness for next steps in training and exams. Program directors have more flexibility to select rotations relevant to urology. Resident wellness may be improved as interns are incorporated into the department earlier and can help distribute the workload for senior residents. Challenges include decreased exposure to basic surgical knowledge and skills, decreased camaraderie with general surgery colleagues, and difficulties associated with evaluating interns who are spending limited time with urology departments. Overall, the change seems to have a positive impact on urological training.

Mucinous cystadenocarcinomas of the urachus are rare. Mucinous benign or premalignant tumors are even rarer, yet pose a challenge in diagnosis and management. We report a case of a 66-year-old man with lower abdominal pain who had a large cystic tumor at the dome of the bladder. En-bloc resection of the tumor with partial cystectomy revealed mucinous cystadenocarcinoma in situ. We reviewed the characteristics of all seven previously reported cases. These tumors are pre-malignant and can cause significant morbidity and mortality. They need to be treated similar to conventional mucinous cystadenocarcinoma by wide surgical resection and partial cystectomy.

OBJECTIVE: The purpose of our study was to determine the findings at both static and dynamic MRI in women with a clinically suspected urethral abnormality. MATERIALS AND METHODS: MRI of the urethra was performed in 84 women with lower urinary tract symptoms using multiplanar T2-weighted turbo spin-echo and unenhanced and contrast-enhanced gradient-echo sequences. A dynamic true fast imaging with steady-state free precession sequence was performed during straining in the sagittal plane. Images were evaluated by two radiologists for urethral pathology and pelvic organ prolapse. MRI findings were correlated with clinical symptoms using the Fisher's exact and Mann-Whitney tests. RESULTS: Urethral abnormalities were found in 10 of 84 patients (11.9%), including two urethral diverticula, five Skene's gland cysts or abscesses, and three periurethral cysts. Thirty-three patients (39.3%) were diagnosed with pelvic organ prolapse, of whom 29 (87.9%) were diagnosed exclusively on dynamic imaging. In 29 of 33 patients with prolapse (87.9%), the urethra was structurally normal. MRI showed 13 cystoceles and 17 cases of urethral hypermobility not detected on physical examination. Patients with a greater number of vaginal deliveries, stress urinary incontinence, frequency of voiding, and voiding difficulty were statistically more likely to have anterior compartment prolapse (p < 0.05). CONCLUSION: Including a dynamic sequence permits both structural and functional evaluation of the urethra, which may be of added value in women with lower urinary tract symptoms. Dynamic MRI allows detection of pelvic organ prolapse that may not be evident on conventional static sequences

PURPOSE: We evaluated the effect of warm ischemia time on early postoperative renal function following laparoscopic partial nephrectomy. MATERIALS AND METHODS: Of 453 patients who were surgically treated for renal tumors between May 2001 and September 2007, and who were identified in our database 128 underwent laparoscopic partial nephrectomy. Of these 128 patients 101 who were evaluable had complete demographic, operative, preoperative and early postoperative data available. Renal function was estimated using the glomerular filtration rate. Warm ischemia time was stratified into 4 interval groups and also analyzed based on different time cutoffs. Ultimately we also tested the relationship between postoperative renal failure, and preoperative factors and warm ischemia time. RESULTS: Warm ischemia time interval analysis was not significant. However, when analyzing the effect of warm ischemia time cutoffs, patients with warm ischemia time greater than 40 minutes had a significantly greater decrease in the glomerular filtration rate (p = 0.03) and a lower glomerular filtration rate postoperatively. The incidence of renal function impairment was more than 2-fold higher in those with a warm ischemia time of greater than 40 minutes than in the other groups (p = 0.077). Warm ischemia time was significant on univariate analysis when only patients with a preoperative glomerular filtration rate of 60 ml per minute per 1.73 m(2) or greater were analyzed. However, this did not hold as an independent predictor of postoperative renal function impairment on multivariate analysis. The preoperative glomerular filtration rate was the only independent predictor of postoperative renal function impairment. CONCLUSIONS: A warm ischemia time of 40 minutes appears to be an appropriate cutoff, after which a significantly greater decrease in renal function occurs after laparoscopic partial nephrectomy. The preoperative glomerular filtration rate was the only independent predictor of an increased risk of renal insufficiency following laparoscopic partial nephrectomy

PURPOSE: We describe the literature base pertaining to adrenalectomy at radical nephrectomy and present a pragmatic approach based on primary tumor and disease characteristics. MATERIALS AND METHODS: Literature searches were performed via the National Center for Biotechnology Information databases using various keywords. Articles that pertained to the concomitant use of adrenalectomy with radical nephrectomy were surveyed. RESULTS: The incidence of solitary, synchronous, ipsilateral adrenal involvement, ie that which is potentially curable with ipsilateral adrenalectomy along with nephrectomy, is much lower than previously thought at 1% to 5%. Evidence to date supports increased size and T stage, multifocality, upper pole location and venous thrombosis as risk factors for adrenal involvement. Cross-sectional imaging is now accurate at demonstrating the absence of adrenal involvement but still carries a significant risk of false-positives. The morbidity of adrenalectomy is minimal except in those patients with metachronous contralateral adrenal metastasis in whom the impact of adrenal insufficiency can be devastating. Disease specific and overall survival of those undergoing radical nephrectomy, with or without adrenalectomy, are similar. The survival of patients with widespread metastatic disease is historically poor regardless of whether adrenalectomy is performed. There is evidence for a survival advantage in patients with isolated adrenal metastasis, although this group comprises no more than 2% of those undergoing surgery for renal tumors. CONCLUSIONS: The apparent benefit of ipsilateral adrenalectomy does not support it as a standard practice in all patients with normal imaging. However, it should be considered in select cases in which there are risk factors for adrenal involvement

OBJECTIVE: The objective of our study was to retrospectively compare the degree of pelvic organ prolapse shown on dynamic true fast imaging with steady-state precession (FISP) versus HASTE sequences in symptomatic patients. MATERIALS AND METHODS: Fifty-nine women (mean age, 57 years) with suspected pelvic floor dysfunction underwent MRI using both a sagittal true FISP sequence, acquired continuously during rest alternating with the Valsalva maneuver, and a sagittal HASTE sequence, acquired sequentially at rest and at maximal strain. Data sets were evaluated in random order by two radiologists in consensus using the pubococcygeal line (PCL) as a reference. Measurement of prolapse was based on a numeric grading system indicating severity as follows: no prolapse, 0; mild, 1; moderate, 2; or severe, 3. A comparison between sequences on a per-patient basis was performed using a Wilcoxon's analysis with p < 0.05 considered significant. RESULTS: Overall, 66.1% (39/59) of patients had more severe prolapse (>or= 1 degrees ) based on dynamic true FISP images, with 28.8% (17/59) of the cases of prolapse seen exclusively on true FISP images. Only 20.3% (12/59) of patients had greater degrees of prolapse on HASTE images than on true FISP images, with 10.2% (6/59) of the cases seen exclusively on HASTE images. A statistically significant increase in the severity of cystoceles (p < 0.01) and urethral hypermobility (p < 0.01)-with a trend toward more severe urethroceles (p < 0.07), vaginal prolapse (p < 0.09), and rectal descent (p < 0.06)-was shown on true FISP images. CONCLUSION: Overall, greater degrees of organ prolapse in all three compartments were found with a dynamic true FISP sequence compared with a sequential HASTE sequence. Near real-time continuous imaging with a dynamic true FISP sequence should be included in MR protocols to evaluate pelvic floor dysfunction in addition to dynamic multiplanar HASTE sequences

INTRODUCTION: The identification and isolation of vascular structures are crucial and technically demanding aspects of laparoscopic renal surgery. Doppler technology has been used for this purpose in laparoscopic varicocele repair, renal cryoablation, and adrenalectomy. However, it has not been formally described for use in laparoscopic radical nephrectomy, partial nephrectomy, or pyeloplasty. We report our initial experience with Doppler technology in 20 patients undergoing these procedures. TECHNICAL CONSIDERATIONS: A laparoscopic Doppler probe was used in laparoscopic radical nephrectomy (n = 6), partial nephrectomy (n = 8), nephroureterectomy (n = 3), and robotic-assisted pyeloplasty (n = 3). The Doppler system consisted of a disposable 8-MHz probe passed through a 5-mm port and a battery-powered transceiver. The probe was used to guide dissection/isolation of the renal hilum and aberrant vasculature in radical and partial nephrectomy, confirm parenchymal ischemia before resection in partial nephrectomy, and identify crossing vessels during pyeloplasty. Nine accessory vessels were detected in 6 (35%) of 17 patients undergoing radical/partial nephrectomy or nephroureterectomy. In 1 case of partial nephrectomy, persistent parenchymal flow despite renal artery clamping required clamp repositioning. In 1 case of pyeloplasty, the Doppler probe detected a crossing vessel despite negative preoperative imaging findings. Use of the probe altered management in 7 (35%) and saved time in 15 (75%) of 20 cases. No complications were associated with the use of the probe. CONCLUSIONS: Doppler ultrasound technology might have extended applications in laparoscopic renal surgery by facilitating the dissection and evaluation of vasculature. A prospective study with objective endpoints would be helpful in confirming the utility of this technology in these settings

OBJECTIVES: To evaluate our laparoscopic radical nephrectomy (LRN) series to determine whether any significant increases have occurred in operative morbidity when resecting large (7 cm or greater) renal masses. LRN is becoming the reference standard for treating suspicious renal masses not amenable to nephron-sparing surgery. METHODS: We retrospectively reviewed the charts of 164 consecutive patients who had undergone laparoscopic radical nephrectomy performed for suspicious renal masses by two surgeons from February 2000 and December 2006. After institutional review board approval, we reviewed the patient charts to determine whether patients with 7-cm or larger lesions had significant differences in age, body mass index, American Society of Anesthesiologists class, operative time, estimated blood loss, conversion rate, positive margin rate, postoperative creatinine, and hematocrit compared with patients with lesions smaller than 7 cm. RESULTS: The data from 164 patients were reviewed. Of these 164 patients, 124 had less than 7-cm masses and 40 had lesions 7 cm or larger. The mean tumor size in the less than 7-cm group was 4.2 cm (range 1.8 to 6.9) and was 9.2 cm (range 7 to 14) in the 7-cm or larger group. The patients with large tumors had a significantly longer operative time, greater estimated blood loss, and increase in postoperative serum creatinine than those with smaller tumors but all other perioperative variables were similar. Two conversions to open radical nephrectomy occurred in both groups. CONCLUSIONS: Our data have clearly shown that larger tumors can safely be resected with transperitoneal laparoscopic nephrectomy. Open nephrectomy for large tumors can be associated with increased morbidity and the use of LRN could minimize this increased risk. Urologists with laparoscopic experience should consider expanding their indication for LRN