Faculty Bibliography

CONTEXT/BACKGROUND:Radical prostatectomy (RP) is a major oncologic urological surgery that can have high morbidity if complications arise. Bladder-urethral urine anastomotic leaks (AL) are one of the most common complications and can greatly increase morbidity. To date, there are few resources to manage AL. One management technique is using a Foley catheter with an additional auxiliary drainage port, also known as a fenestrated catheter. This type of auxiliary drainage port allows a low-pressure drainage source that is located near the anastomosis to increase urine drainage from catheter rather than from the AL site. The optimal size and location of this additional drainage port is currently unknown. This experiment evaluated the optimal auxiliary drainage port size and an inexpensive technique to easily construct such a catheter. METHODS:Utilizing different size punch biopsies, auxiliary drainage ports were placed in different size Foley catheters and drainage rates and the structural integrity of the catheter was assessed. RESULTS:A 3.0 mm punch biopsy located 1.0 cm proximal to the Foley balloon in an 18 French (Fr) catheter was determined to be the optimal size. A 2.0 mm punch biopsy provided significantly less drainage. The 4.0 mm punch biopsy compromised the structural integrity of the catheter. CONCLUSIONS:Based on these experimental results, we recommend using a 3.0 mm punch biopsy in an 18 Fr catheter 1.0 cm. proximal to the balloon for an auxiliary drain site in Foley catheter when the anastomosis is not watertight or the surgeon has reason to believe the patient is at higher risk for an AL Factors such as history of pelvic radiation, abnormal anatomy, large prostate, post-surgical hematoma formation, obesity, previous prostatic surgery, difficult anastomosis, blood loss and postoperative urinary tract infection may make use of this type of device more attractive.

Pathologic complete response is an exceptionally rare occurrence in prostate cancer, especially in the setting of poorly differentiated cancer, with high risk and poor prognostic features. Patient reviewed and signed an informed consent. The case details were collected. Patient had PSA of 52.6 ng/dl and Gleason score 5 + 5 = 10 prostate adenocarcinoma with focal signet ring cell pattern. Genomic testing revealed pathogenic p53 and SPOP mutations. The patient received androgen deprivation therapy and six cycles of docetaxel. His PSA declined to undetectable, and radical prostatectomy (RP) showed no evidence of malignancy. The patient has discontinued all therapy and continues in remission 12 months after surgery.

PURPOSE:This prospective study was performed to compare the accuracy of femoral version measurements following repair of femoral shaft fractures using computed tomography (CT) scanograms with 10 % of the standard dose of ionizing radiation versus standard-dose scanograms. METHODS:CT scanogram protocols that used 90 and 10 % of the usual dose of ionizing radiation were developed. Ten patients with comminuted femoral shaft fractures repaired with either an intramedullary (IM) nail or plate were imaged with both high- and low-dose CT scanograms. Postoperative version of both femurs was measured and compared between the two dose scans using the Bonesetter application. This was a prospective blinded controlled study at a level 1 trauma centre. Statistical analysis was performed, including standard deviation (SD) and paired t test. Significance was set at p < 0.05. RESULTS:Comparison of femoral version measurements between the 90 and 10 % dose scanograms on the native and repaired sides were insignificant (p = 0.870 and p = 0.737, respectively). The difference between native and repaired femurs had an average error of 2.0 ± 1.1° for both the high- and low-dose scans and was insignificant (p = 0.742). CONCLUSIONS:Reducing the dose of ionizing radiation in a CT scanogram by 90 % has no significant effect on the accuracy of femoral version measurement. This simple change can significantly reduce patient radiation exposure while accurately measuring femoral version and length.

INTRODUCTION:Noncontrast CT is the standard of care to evaluate nephrolithiasis. We evaluated the performance of low-dose CT (LDCT) scan for evaluation of renal colic in the emergency room (ER). MATERIALS AND METHODS:Patients visiting the ER with suspected nephrolithiasis received a standard-dose CT (SDCT) and an LDCT. Two urologists read the LDCTs and later they read SDCTs. Stone information was recorded on a diagram of the renal system. Findings on SDCTs and LDCTs were correlated through side-by-side comparison of the diagrams. Later, the two urologists adjudicated all nonconcordance between SDCTs and LDCTs in an unblinded manner. RESULTS:Twenty-seven patients were included. SDCTs revealed 27 stones in 18 patients. Mean stone size was 3.81 mm. LDCTs revealed 27 stones in 18 patients with a mean stone size of 4.7 mm (p = 0.23). Overall sensitivity and specificity of LDCTs were 70% and 39%, respectively. There were eight false-positive and eight false-negative stones. All the false-positive stones on LDCTs were placed in the ureter, in which all of the corresponding SDCTs were visible calcifications outside the ureter. Of the eight false-negative stones on LDCTs, seven were visible calcifications on the SDCTs and the eighth stone was 1 mm and was not visible. CONCLUSION:LDCT may not perform well in the evaluation of suspected nephrolithiasis in the acute setting. LDCT scan accurately demonstrates calcifications; however, accurate placement of calcifications in or out of the urinary tract may be diminished due to impaired resolution of soft tissue structures.

INTRODUCTION/BACKGROUND:Several clinical series of retrograde nephrostomy for percutaneous nephrolithotomy (PCNL) have been published over the past 30 years demonstrating good outcomes and safety. We previously reported our adaptation of the Lawson technique, wherein we deploy the puncture wire through a flexible ureteroscope. We herein aim to clarify the performance characteristics of this nephrostomy creation technique. MATERIALS AND METHODS/METHODS:Institutional Review Board approval and informed consent were obtained. A ureteroscopy-assisted retrograde nephrostomy (UARN) procedure was performed as described previously. Data were collected prospectively. Multiple patient and operative factors were evaluated for association with UARN success and nephrostomy creation time: body mass index (BMI), skin-to-stone distance, Guy's score, Clinical Research of the Endourological Society nephrolithometric score, hydronephrosis, stone burden, location of nephrostomy, exit from a stone-bearing calix, and use of holmium laser to access calix. RESULTS:Nephrostomy was successful in 49/52 UARN procedures (94%). Only single access was placed: upper-18, mid-27, and lower-7. Median BMI was 29 kg/m(2) and median time for nephrostomy creation was 39 minutes. Fluoroscopy time for the entire PCNL including nephrostomy creation was 84 and 16 seconds for case numbers 1-25 and 26-52, respectively. By stepwise linear regression, variables correlating with nephrostomy creation time were BMI (r(2)=0.219), stone burden (r(2)=0.094), use of holmium laser to access calix (r(2)=0.104), and total r(2) linear=0.416. CONCLUSIONS:UARN is an intuitive safe procedure that offers dramatic reductions in fluoroscopy times. UARN is best suited to cases requiring only one nephrostomy tract. Upper pole access is commonly performed with a subcostal technique to navigate the puncture wire below the ribs. Increasing BMI best predicts longer nephrostomy creation times; procedure failure was associated with BMI exceeding 40 kg/m(2). UARN is a robust technique for nephrostomy creation in appropriately selected patients.

We describe flexible ureteroscopy-directed retrograde nephrostomy access using a puncture wire to achieve renal access. This is a natural extension of modern retrograde intrarenal surgical techniques and a modernization of the original Lawson technique for retrograde nephrostomy tract creation. In appropriately selected patients, this approach is safe and permits reduced radiation exposure. We believe this technique is easy to learn and may overcome the difficult learning curve of antegrade nephrostomy techniques faced by urologists who have not undergone subspecialty training in endourology.

PURPOSE: The 4th annual meeting of the Society of Urologic Oncology (SUO) was held December 5-6, 2003 in Bethesda, Maryland. The meeting was attended by urologists, medical and radiation oncologists, and researchers whose focus is genitourinary (GU) malignancies. More than 500 participants registered for the meeting. MATERIALS AND METHODS: The agenda for the SUO meeting included more than 50 speakers and discussion panels, and addressed a broad range of topics in GU oncology. Transcripts of the proceedings and submitted slide presentations were reviewed for content following the meeting, and the highlights were summarized. These written materials can be accessed through the SUO web site at http://societyofurologiconcology.org. RESULTS: Reviewed session topics included epidemiology of GU malignancies, biomarkers for GU malignancies, cancer genomics, bladder cancer, testis cancer, minimally invasive treatments for GU malignancies, molecular therapeutics and advanced prostate cancer. Significant advances in these fields have directly impacted clinical care and improved patient outcomes across the many disciplines associated with treatment of GU cancers. CONCLUSIONS: The SUO meeting is unique in its multidisciplinary forum and focus on urological oncology. The 2003 meeting highlighted recent advances in epidemiology, clinical management and emerging molecular approaches in the diagnosis and treatment of urological malignancies with several state-of-the-art presentations

Cellular inactivation through killer immunoglobulin-like receptors (KIRs) may allow neoplastic cells to evade host natural killer (NK) cell-mediated immunity. Recently, alloreactive NK cells were shown to mediate antileukemic effects against acute myelogenous leukemia (AML) after mismatched transplantation, when KIR ligand incompatibility existed in the direction of graft-versus-host disease (GVHD). Therefore, we investigated whether solid tumor cells would have similar enhanced susceptibility to allogeneic KIR-incompatible NK cells compared with their KIR-matched autologous or allogeneic counterparts. NK populations enriched and cloned from the blood of cancer patients or healthy donors homozygous for HLA-C alleles in group 1 (C-G1) or group 2 (C-G2) were tested in vitro for cytotoxicity against Epstein-Barr virus-transformed lymphoblastic cell lines (EBV-LCLs), renal cell carcinoma (RCC), and melanoma (MEL) cells with or without a matching KIR-inhibitory HLA-C ligand. Allogeneic NK cells were more cytotoxic to tumor targets mismatched for KIR ligands than their KIR ligand-matched counterparts. Bulk NK populations (CD3(-)/CD2(+)/CD56(+)) expanded 10(4)-fold from patients homozygous for C-G1 or C-G2 had enhanced cytotoxicity against KIR ligand-mismatched tumor cells but only minimal cytotoxicity against KIR ligand-matched targets. Further, NK cell lines from C-G1 or C-G2 homozygous cancer patients or healthy donors expanded but failed to kill autologous or KIR-matched MEL and RCC cells yet had significant cytotoxicity (more than 50% lysis at 20:1 effector-target [E/T] ratio) against allogeneic KIR-mismatched tumor lines. These data suggest immunotherapeutic strategies that use KIR-incompatible allogeneic NK cells might have superior antineoplastic effects against solid tumors compared with approaches using autologous NK cells.

Prostate cancer detection is a rare occurrence in patients with Klinefelter syndrome, in whom chronically low circulating androgen levels are common findings. Administration of exogenous testosterone has increasingly been used to treat young adolescents diagnosed with Klinefelter syndrome and documented androgen deficiency. Although testosterone replacement in adult patients has been associated with prostatic enlargement, it remains unknown whether chronic supplementation of exogenous testosterone to pubescent males with hypogonadism results in early prostate carcinogenesis. We report a first case of prostate cancer in a patient with Klinefelter syndrome who had undergone long-term testosterone replacement therapy since childhood for chronically depressed levels of testosterone.