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Diphallia, Double Bladder, and Two Hemiscrotums: A Case Report [Case Report]

Dunn, Debra; Fine, Ronnie G
Complete diphallia, a rare urogenital congenital anomaly in which a male is born with two fully formed phalluses, occurs in one out of every five to six million live births. The condition is characterized by two separate phalluses, each of which comprise a pair of corpora cavernosa and one corpus spongiosum with an orthotopic urethra. Approximately 100 cases have been reported worldwide, and it is thought that each case is unique. This article discusses diphallia, urethral duplication, and bladder duplication and concludes with a case study involving a three-year-old male born to consanguineous parents from a small, remote community in Ecuador who underwent surgery for correction of a complete coronal penile and bladder duplication. After consultation, the patient was scheduled for a right penectomy and cystoplasty.
PMID: 31135983
ISSN: 1878-0369
CID: 5014952

Robot-assisted Laparoscopic Urachal Excision in Children

Ahmed, Haris; Howe, Adam S; Dyer, Lori L; Fine, Ronnie G; Gitlin, Jordan S; Schlussel, Richard N; Zelkovic, Paul F; Palmer, Lane S
OBJECTIVE:To report the first exclusively pediatric series of robot-assisted urachal remnant excisions in children. METHODS:We reviewed the medical records of all children who underwent robot-assisted excision of urachal remnants from 2010 to 2016. For the procedure, a 3-port approach was performed in all cases. Excision of the urachus was performed, along with partial cystectomy if there was clear or suspected bladder involvement. Outcomes and complications were reviewed. RESULTS:Sixteen cases of robotic urachal excision were performed during the study period in patients aged 0.8-16.5 years. Complete excision was accomplished in all cases with no conversions. Partial cystectomy was performed in 11 cases, in which a urinary catheter was left for 1 day in all cases (no catheter was left in the absence of partial cystectomy). The only complication was a bladder leak requiring open surgical repair. There were no bowel injuries or hernias. The median operative time was 107 minutes. The length of stay was 2 days with partial cystectomy and 1 day without partial cystectomy. All patients were well at follow-up. CONCLUSION:We report the largest known series of robot-assisted urachal remnant excisions in children, demonstrating this minimally invasive approach to be safe and effective.
PMID: 28431995
ISSN: 1527-9995
CID: 3939912

A Unique Case of Pentaorchidism [Case Report]

Myers, Amanda; Morganstern, Bradley; Fine, Ronnie
Polyorchidism is a rare congenital anomaly with less than 200 case reports in literature. Triorchidism, the condition of having 3 testicles, is the most common presentation. We present an unusual case of a patient who was diagnosed with 5 testicles by magnetic resonance imaging. To the best of our knowledge, this rare presentation has not previously been reported in the medical literature.
PMID: 28336287
ISSN: 1527-9995
CID: 5014942

Barriers to use of semen analysis in the adolescent with a varicocele: Survey of patient, parental, and practitioner attitudes

Fine, Ronnie G; Gitlin, Jordan; Reda, Edward F; Palmer, Lane S
BACKGROUND:The American Society for Reproductive Medicine Practice Committee recommends obtaining a semen analysis (SA) in pediatric patients presenting with a varicocele in the absence of significant testicular atrophy. Among infertile adults with a varicocele, surgery is indicated in the presence of abnormal semen analysis regardless of testicular atrophy. Despite these two statements, semen analysis is not widely utilized by pediatric urologists in the USA managing a patient with a varicocele. OBJECTIVE:We explored the attitudes of patients, parents, and practitioners toward SA to identify potential barriers to the use of SA in the evaluation of the adolescent varicocele. STUDY DESIGN/METHODS:We conducted a survey of Society for Pediatric Urology members regarding their management of adolescent varicoceles, with focus on the utilization of SA. The survey consisted of 14 multiple choice questions and two open-ended questions regarding use of SA in practice, barriers to its use, indications for varicocelectomy, and demographics. We also surveyed patients presenting for initial evaluation of a varicocele, as well as their parents, regarding their knowledge about SA and their attitude towards obtaining it. Statistical analysis was performed (p < 0.05 significant). RESULTS:The practitioner survey response rate was 53% (168). Only 13.1% routinely incorporated SA in their practice, with 48% of all responders having some degree of discomfort asking for a SA. Of practitioners who cited discomfort, 90% never order a SA for patients with varicoceles. From the 46% of physicians who ordered a SA, we noted significant practice variability (see Figure). The patient/parent survey demonstrated that this population was uncomfortable with the notion of obtaining a SA, with most patients/parents citing lack of knowledge about SA as the main barrier. Patient and parent knowledge was found to correlate. DISCUSSION/CONCLUSIONS:This study uniquely addresses an issue that has not been discussed in the adolescent varicocele literature to date. It can increase awareness of the option of incorporating SA data in management of the adolescent who presents with a varicocele. CONCLUSION/CONCLUSIONS:Recognizing and then breaking through the barriers to obtaining a SA, would improve patient care, providing a direct assessment of the impact of a varicocele on fertility potential and thus best determining which patients require surveillance versus surgical intervention. This study suggested that the barriers to SA are surmountable.
PMID: 26342542
ISSN: 1873-4898
CID: 5014932

Tunneled buccal mucosa tube grafts for repair of proximal hypospadias

Fine, Ronnie; Reda, Edward F; Zelkovic, Paul; Gitlin, Jordan; Freyle, Jaime; Franco, Israel; Palmer, Lane S
PURPOSE/OBJECTIVE:Buccal mucosa is the favored graft material for patients with long urethral defects and a paucity of skin. Since 2007, we have used the novel tunneled buccal mucosa tube graft urethroplasty technique in these patients. We describe this operative technique and report our surgical and functional outcomes. MATERIALS AND METHODS/METHODS:Between 2007 and 2013, 37 males with proximal hypospadias underwent tunneled buccal mucosa tube graft urethroplasty. After the penile shaft was optimized at a prior stage a free buccal graft was tubularized and tunneled under the intact ventral shaft skin and into the glans. We retrospectively reviewed all charts to report our results. We assessed uroflowmetry and bladder ultrasound for post-void residual urine. RESULTS:The overall complications rate in 34 patients with more than 1-year followup was 32% (11), including fistula in 5, proximal stricture in 4 and meatal stenosis in 2. In the first 10 patients a total of 7 complications (70%) developed but there were only 4 complications in the next 24 (16%). Surgeon experience was the only significant predictor of complications (p = 0.003). We obtained uroflow and post-void residual urine data on 13 of 37 patients, of whom 9 achieved a normal flow pattern and post-void residual urine, and 4 had a blunted flow pattern. CONCLUSIONS:The novel technique of the tunneled buccal mucosa tube graft in patients with proximal hypospadias represents a good alternative for a long urethroplasty in patients with a paucity of skin. After the learning curve plateaus the rate and degree of complications decrease. Furthermore, voiding function is adequate, as assessed by uroflow studies and post-void residual urine measurement.
PMID: 25817150
ISSN: 1527-3792
CID: 5014452

Laparoscopic orchiopexy and varicocelectomy: is there really an advantage?

Fine, Ronnie G; Franco, Israel
The role of laparoscopy in the case of nonpalpable cryptorchidism is both diagnostic and therapeutic. Laparoscopic orchiopexy for nonpalpable testes in the pediatric population has become the preferred surgical approach among pediatric urologists over the last 20 years. In contrast, laparoscopic varicocelectomy is considered one of several possible approaches to the treatment of a varicocele in an adolescent; however, it has many challengers and it has not gained universal acceptance as the gold standard. This article reviews the published evidence regarding these surgical techniques.
PMID: 25455169
ISSN: 1558-318x
CID: 5014912

Bladder ganglioneuroma in a 5-year-old girl presenting with a urinary tract infection and hematuria: case report and review of the literature [Case Report]

Hartman, Christopher; Williamson, Alex K; Friedman, Ariella A; Palmer, Lane S; Fine, Ronnie G
Ganglioneuromas are rare benign tumors arising from neural crest cells of the autonomic nervous system. These tumors may rarely localize to the bladder, and few cases have been reported in the adult literature. To date, however, bladder ganglioneuromas have not been reported in the pediatric literature. We report the case of a 5-year-old girl who presented with hematuria and a urinary tract infection and on workup was found to have a large bladder mass. Transurethral resection and pathologic examination revealed the mass to be a ganglioneuroma. The case is presented followed by a brief review of the literature.
PMID: 25623721
ISSN: 1527-9995
CID: 5014922

Laparoendoscopic single-site radical nephrectomy for large renal masses

Rosoff, James S; Fine, Ronnie G; Velez, Marissa C; Del Pizzo, Joseph J
PURPOSE/OBJECTIVE:To report our operative experience and short-term outcomes for the laparoendoscopic single-site (LESS) management of large renal tumors and tumors of advanced stage. PATIENTS AND METHODS/METHODS:Ten consecutive patients underwent LESS-radical nephrectomy (RN) for large (≥ 7 cm) and/or locally advanced tumors (>T(2)). Intraoperative, postoperative, and short-term follow-up data were analyzed. RESULTS:Median surgical time was 146 minutes (range 73-164 min), and median estimated blood loss was 100 mL (range 25-400 mL). No procedure needed conversion to open RN or hand-assisted laparoscopic RN. The median hospital stay was 47 hours (range 42 hours-12 days). One (10%) patient had a minor complication (postoperative fever treated with antibiotics) and one (10%) patient had a major complication (small bowel obstruction necessitating reoperation). Of the 10 tumors, 2 were pathologic stage T(1b), 4 were pathologic stage T(2), and 4 were stage T(3a). At a median follow-up of 12.3 months (range 1-16 mos), six (60%) patients were alive without evidence of recurrence, and 4 (40%) patients were alive with disease. Of those four patients, all four had known metastatic disease before surgery. CONCLUSION/CONCLUSIONS:LESS-RN for large or advanced stage renal masses is a technically challenging operation. In experienced hands, however, it is a safe and feasible therapeutic option for the management of these tumors.
PMID: 22984849
ISSN: 1557-900x
CID: 5014892

Varicocele: standard and alternative indications for repair

Fine, Ronnie G; Poppas, Dix P
PURPOSE OF REVIEW/OBJECTIVE:This review provides timely and relevant information to address the indications for repair of the adolescent varicocele. In this review, we summarize the most recent available evidence and provide clinical guidelines. RECENT FINDINGS/RESULTS:The indications for adolescent varicocelectomy commonly include testicular hypotrophy and pain but become confusing and contradictory when discussing potential infertility as an indication for repair. The preponderance of patients with varicocele in the infertile population leads to the search for causality and reversibility. However, in the era of assisted reproduction, the question of early prevention of infertility is brought to the forefront of discussion. Recent attempts have been made to determine the patient parameters that predict future infertility. Current publications have focused on predictors for clinically significant varicoceles that would benefit from intervention, such as hormonal profile and peak retrograde flow. Contradictory evidence exists regarding the significance of testicular asymmetry in adolescence. SUMMARY/CONCLUSIONS:Substantial effort has been made to tease out the clinically significant adolescent varicocele. However, definitive evidence regarding fertility outcomes and adolescent varicocele repair remains limited and controversial. Large-scale, long-term follow-up studies are necessary to determine the true benefit of adolescent varicocele repair on decreasing the risk of fertility problems in adulthood.
PMID: 23026897
ISSN: 1473-6586
CID: 5014902

Pure primary prostatic osteosarcoma arising in a non-irradiated prostate [Case Report]

Rabbani, Farhang; Fine, Ronnie G; D'Adamo, David; Edgar, Mark; Akin, Oguz; Paty, Philip
A 68-year-old man who initially presented with hematuria was found on prostate biopsy to have sarcoma of the prostate with osteogenic features. Radiological examination revealed a locally advanced pelvic mass involving the prostate, seminal vesicles, and rectal wall without metastatic disease. The patient underwent total pelvic exenteration with intraoperative radiotherapy. The tumor was composed of two nodules measuring 7.5 and 4.5 cm involving the prostate, both seminal vesicles, the bladder, rectum, and perirectal fibroadipose tissue. The final diagnosis was osteogenic sarcoma of the prostate.
PMID: 19752624
ISSN: 1423-0399
CID: 5014882