Faculty Bibliography

OBJECTIVES/OBJECTIVE:The aims of this study were to describe our technique of gel-infused translabial ultrasound (GITLUS) to assess the female urethra for stricture and to highlight its utility when compared with other diagnostic techniques. METHODS:Consecutive patients presenting with prior diagnosis and/or suspicion for female urethral stricture underwent evaluation with uroflowmetry, postvoid residual, video urodynamics, and cystoscopy at the surgeon's discretion. All patients underwent GITLUS; 8-MHz curvilinear and 6-MHz linear high-frequency transducers were used to image the urethra from meatus to bladder neck while instilling 20 mL of lidocaine jelly to distend the urethra. Stricture location, length, caliber, and presence of periurethral fibrosis were assessed. Two healthy volunteers underwent GITLUS to serve as a comparison. RESULTS:Eight patients with suspected stricture underwent GITLUS. In all cases, GITLUS identified and characterized stricture and demonstrated periurethral fibrosis. Two healthy volunteers underwent GITLUS, which demonstrated a patent urethra and no evidence of fibrosis. Cystoscopy and video urodynamics on patients with stricture did not perform as well at identifying and fully assessing strictures. Six patients underwent definitive surgical repair, and GITLUS findings were confirmed. One patient had a postoperative GITLUS demonstrating resolution of the stricture and periurethral fibrosis. CONCLUSIONS:Gel-infused translabial ultrasound is a novel and accurate technique that in this small series appeared to identify and further characterize female urethral stricture in cases where it was utilized. Further research is needed to determine its role in preoperative planning and in providing a definitive diagnosis of stricture when other studies are equivocal.

Testicular cancer represents approximately 1% of all cancers diagnosed in males. Testicular cancer is the most commonly diagnosed cancer in male adolescents and young adults between 15-35 years of age. Bilateral presentation is rare with a reported rate of 0.8% for every 1,000,000 men between the age 15-40 years from which 0.5% are synchronous and .2-3% are metachronous. We report a case of 42-year-old man with metachronous testicular seminoma within 8 years from the first testicular tumor. Patient was treated at the urology clinic with a left testicular mass causing painful swelling. He experienced discomfort in left side of testis before two weeks. He was on anti-inflammatory treatment by his GP doctor with recommendation to visit a urologist. It is the first time in our clinic of urology to treat a patient with metachronous testicle tumor. The follow-up of patients with testicular tumor is very important for early detection of metachronous testicular tumor. In routine, after surgery treatment the strict follow-up of patients continue in Oncologic Institute. In the first 5 years it is biannual, then yearly with tumor markers and images of thorax, abdomen and pelvis. In our case the patient continued the follow-up for two years until he stopped by himself.

OBJECTIVE: To describe the technique of ultrasound urethrogram for the diagnosis of anterior urethral stricture performed in an ambulatory setting without any adjunctive imaging. METHODS: Between September 2013 and September 2015, thirty-five consecutive adult men (>18 years old) presenting for anterior urethral reconstruction underwent outpatient ultrasound urethrogram prior to definitive management. No alternative imaging test was performed. Lengths of the strictures as determined by outpatient ultrasound urethrogram and via direct intra-operative measurements were compared by a paired t-test. RESULTS: Strictures were in the bulbar urethra in 24 men and the penile urethra in 11 men. The differences between the outpatient ultrasound urethrogram length measurements (mean=1.86 cm) and the intra-operative stricture length measurements (mean=2.02 cm) were not significantly different (p=0.10). Additionally, the correlation coefficient between these length measurements was 0.84 (p<0.001). CONCLUSIONS: Preoperative ultrasound urethrogram performed in the ambulatory setting for the diagnosis and characterization of anterior urethral strictures is safe and feasible. This outpatient imaging modality offers an alternative to retrograde urethrogram.

PURPOSE OF REVIEW: This article discusses the new imaging techniques in diagnosis and treatment of benign prostatic hyperplasia by reviewing the most recent publications. RECENT FINDINGS: Imaging study for the evaluation of patients with lower urinary tract symptoms is not suggested by American Urology Association guidelines; however, European Association of Urology recommends the assessment of the upper urinary tract by modalities like ultrasound. Several new imaging indices like resistive index of capsular artery, presumed circle area ratio, prostatic urethral angle, intraprostatic protrusion, and detrusor wall thickness are used to find a noninvasive way for bladder outlet obstruction diagnosis. In addition to them, 3D transrectal ultrasound, near infrared spectroscopy, and MRI are used to add more practical findings in patient management. SUMMARY: Urologists have requested more imaging studies than expected for benign prostatic hyperplasia patients in recent years, and several studies have been done to find a noninvasive way to diagnose bladder outlet obstruction. However, none of them could play the urodynamic studies role in bladder outlet obstruction diagnosis.

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Some studies have evaluated preoperative and intraoperative examination for inguinal hernias and their repair, noting a decrease in the rate of post-prostatectomy hernias. However, this did not eradicate post-prostatectomy hernias, indicating that this method probably missed subclinical hernias. Other studies looked at prophylactic procedures to prevent the formation of inguinal hernias at the time of prostatectomy and showed a decrease in the rate of postoperative hernias. To our knowledge this is the only series evaluating a multi-modal approach with magnetic resonance imaging, ultrasonography and examination to identify all clinical and subclinical hernias and repair them at the time of prostatectomy. This approach only subjects those patients at risk for symptomatic hernias to an additional procedure and decreases the post-prostatectomy hernia rate to <1%. OBJECTIVE: * To assess if a comprehensive evaluation to diagnose clinical and subclinical hernias and repair of these hernias at the time of open radical retropubic prostatectomy (ORRP) decreases the incidence of clinical inguinal hernias (IHs) after ORRP. PATIENTS AND METHODS: * Between 1 July 2007 and 31 July 2010, 281 consecutive men underwent ORRP by a single surgeon. * Of these men, 207 (74%) underwent comprehensive preoperative screening for IH, which included physical examination, upstanding ultrasonography and magnetic resonance imaging. * Between 12 and 24 months after ORRP, 178 (86%) of these men completed a questionnaire designed to capture development of clinical IHs. RESULTS: * Of the 178 evaluable patients, 92 (52%) were diagnosed preoperatively with IH by at least one diagnostic modality. * Forty-one and 51 of the men had bilateral or unilateral IHs, respectively for a total of 133 IHs. * No preoperative factor was significantly associated with the presence of an IH before prostatectomy. * No groin subjected to IH repair (IHR) at the time of ORRP developed a clinical IH compared with four of the 21 patients with postoperative IHs who did not undergo repair of their preoperatively diagnosed IH at the time of ORRP (P= 0.024). * Only one (0.4%) clinical IH developed in a groin that had no evidence of IH by physical examination, upstanding ultrasonography and magnetic resonance imaging before prostatectomy. CONCLUSIONS: * Our comprehensive evaluation increases the detection of IHs before ORRP. * Repair of these IHs at the time of ORRP significantly decreases the risk of developing post-prostatectomy clinical IHs.

Study Type - Diagnostic (exploratory cohort)Level of Evidence 2b OBJECTIVE: To evaluate the role of magnetic resonance imaging (MRI) and up-standing ultrasonography (USUS) for the detection of inguinal hernias (IHs) before open radical retropubic prostatectomy (ORRP) and to assess factors associated with the presence of IHs in these men. PATIENTS AND METHODS: From 1 July 2007 to 1 February 2009, 164 men underwent preoperative evaluation for ORRP by one surgeon. Of these men 113 (69%) were evaluated for IHs by physical examination (PE), USUS and MRI. In all 226 groins were examined. Any IH diagnosed by any method was considered a true positive. The sensitivity, negative predictive value (NPV), and concordance were calculated for the three diagnostic methods. Possible predictive factors of IHs were evaluated. RESULTS: Of the 226 groins evaluated, 72 (32%) IHs were diagnosed. USUS had the greatest sensitivity (69.4%) and the highest NPV (87.5%). MRI had fair agreement with PE and USUS, while USUS and PE had moderate agreement with each other. No factor was associated with an increased likelihood of preoperative diagnosis of IH. CONCLUSIONS: This study was limited by the lack of a reference standard to diagnose IH. USUS was the most sensitive method for the detection of IH. We recommend that all men undergoing ORRP should be evaluated for IHs by PE and at least one imaging method and that IHs be repaired at the time of ORRP, obviating the need for a second surgical procedure

Study Type - Therapy (case series) Level of Evidence 4 OBJECTIVE To determine the mechanism for delayed healing of the urinary anastomosis after radical retropubic prostatectomy (RRP). PATIENTS AND METHODS The volumes of the para-anastomotic haematoma (PHV) and anastomotic extravasation were measured by ultrasonography in 95 men after RRP. The performance characteristics of PHV for predicting urinary extravasation were ascertained and compared with that of postoperative blood loss, measured as the difference between the haematocrit immediately after RRP and that at discharge. RESULTS The sensitivity and specificity of PHV for predicting urinary extravasation at a threshold of 37 mL was 100% and 96%, respectively. PHV was superior to postoperative blood loss in predicting anastomotic extravasation, as shown by an area under the receiver operating curve of 0.99 vs 0.91, respectively. CONCLUSIONS Our findings provide compelling evidence that delayed healing of the anastomosis after RRP is due to distraction forces secondary to a pelvic haematoma. The accuracy of PHV as a predictor of anastomotic extravasation suggests that this measurement might replace cystography for assessing anastomotic integrity after RRP

OBJECTIVE: Fluorocystography (FC) is the reference standard for assessing the integrity of the vesicourethral anastomosis after radical prostatectomy (RP). We describe a new technique, transperineal sonocystography (TPSC), as a cost-effective alternative and more informative than FC. METHODS: Between May 1, 2007, and October 1, 2008, 175 consecutive men underwent open or robotically assisted RP. Before Foley catheter removal, all men underwent both TPSC and FC, which were performed and interpreted by a single radiologist. Transperineal sonocystography was performed first with real-time imaging after gravity filling of the bladder with 150 mL of normal saline. Extravasation of saline was calculated by computer software after outlining the observed pooling of extravasated saline in the transverse and longitudinal views. Fluorocystography was performed after TPSC using our standard protocol, with qualitative classification of anastomotic leaks as none, slight, moderate, or severe. RESULTS: The mean extravasation volume +/- SEM was 16.3 +/- 2.9 mL. Of the 175 patients, 142 (81.2%) showed no anastomotic leaks on TPSC. Of the remaining 33 patients (18.8%), TPSC identified 20 (11.4%), 13 (7.4%), and 0 patients with slight, moderate, and severe leaks, respectively. Excellent concordance was shown between TPSC and FC. CONCLUSIONS: Transperineal sonocystography was equivalent to FC in detecting anastomotic leaks after RP. It provides a safe, inexpensive, and effective alternative to traditional FC for evaluating the integrity of the vesicourethral anastomosis after RP

PURPOSE: We describe our new technique of transabdominal sonocystography in men following radical prostatectomy. MATERIALS AND METHODS: From May 2007 to January 2008, 75 men underwent gravity transabdominal sonocystography and fluorocystography 8 days following open radical retropubic prostatectomy. Bladder volume after the instillation of 150 cc saline was determined by measuring bladder height, width and length in the longitudinal and transverse planes. Extravasation volume was calculated by subtracting the calculated bladder volume after filling from a volume of 165 ml, which represents the instilled saline volume of 150 ml plus 15 ml in the urinary catheter balloon. Extravasation was then qualitatively graded as none, slight, moderate or severe after instilling 150 cc contrast medium into the bladder. RESULTS: The correlation between fluorocystography and transabdominal sonocystography was ascertained by determining the mean extravasation volume corresponding to the qualitatively graded categories of extravasation determined fluoroscopically. Mean extravasation volume in cases with no, slight and moderate extravasation on fluoroscopic cystography was -3.72, 6.51 and 46.0 ml, respectively. At an extravasation volume of 20 ml the sensitivity and specificity of transabdominal sonography to differentiate no or slight vs moderate or severe fluoroscopic extravasation was 100%. CONCLUSIONS: The advantages of transabdominal sonocystography over fluorocystography are lower cost, lack of radiation exposure and the ability to perform the procedure at most urological outpatient facilities. Therefore, transabdominal sonocystography represents a good alternative to fluorocystography for assessing the integrity of the vesicourethral anastomosis following open radical retropubic prostatectomy