Faculty Bibliography

This 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.

Dermatillomania is a rare disease that seldom affects the genitals. Genital dermatillomania has not yet been recognized as a separate entity within the disease. The purpose of the report is to highlight a new facet of dermatillomania and inform urologists that dermatillomania could be a potential reason for genital ulcers. This report documents 2 cases of genital dermatillomania which vary in severity from mild (case 1), where the patient's ulcers healed after extensive counseling, to extremely dire (case 2), where the patient lost his penis after recurring ulcers and multiple reconstructive surgeries. Clinicians should be aware of the characteristics of dermatillomania to ensure that appropriate therapy can be promptly initiated to prevent morbidity.

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.

A 69-year-old man with a psoriatic arthritis treated with infliximab for 1 month presented to the urology clinic for lower urinary tract symptoms. He was found to have a new diagnosis of elevated creatinine. Computed tomography of the abdomen and pelvis revealed bilateral severe hydronephrosis with abnormal soft tissue thickening of the right renal pelvis and proximal ureter. Bilateral stents were placed after ureteroscopy demonstrated no abnormalities. A computed tomography-guided biopsy of the peri-ureteral lesions revealed fibroadipose tissue with sclerosis and extensive chronic inflammation consistent with retroperitoneal fibrosis. Infliximab was discontinued and the patient was started on corticosteroids. Follow-up magnetic resonance imaging of the abdomen and pelvis at 2 months revealed total resolution of soft tissue and inflammation along the proximal ureter bilaterally. Repeat imaging demonstrated no hydronephrosis after stents removal, and the patient's creatinine remains normal at 12 months follow-up.

INTRODUCTION/BACKGROUND: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/METHODS: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/CONCLUSIONS: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.

OBJECTIVE:To describe the surgical technique we used to perform a stentless intracorporeal ureteroenteric anastomosis and to determine the outcomes in this initial series. METHODS:We 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. RESULTS:A 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 quartile = 3 months, third quartile = 17 months). CONCLUSION:Robotic intracorporeal urinary diversion with intentional omission of ureteral stents is a safe and feasible option when establishing continuity of the genitourinary and gastrointestinal tracts.

INTRODUCTION AND OBJECTIVE:The 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. MATERIALS AND METHODS:A 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. RESULTS:A 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. CONCLUSIONS:Lesions 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.

OBJECTIVE:To 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. MATERIALS AND METHODS/METHODS:A 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. RESULTS:A higher periprostatic fat volume (P <.001) and a higher periprostatic fat ratio (P <.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 (P < .001). There was no correlation observed between periprostatic fat ratio and prostate-specific antigen (median: 7.34, range: 0.36-59.7, P = .274), age (median: 64, range: 38-84, P = .665), or body mass index (median: 28.33, range: 17.99-45.44, P = .310). Patients with a higher periprostatic fat ratio were more likely to undergo intervention for prostate cancer. CONCLUSION/CONCLUSIONS:A 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.