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OBJECTIVE: To expand the diagnostic armamentarium for medullary sponge kidney (MSK), we evaluate the use of high-resolution multidetector computed tomography (MDCT) for MSK diagnosis and compare to the standard intravenous urography (IVU). Despite a significant prevalence amongst stone formers, diagnosis of this well described condition has declined. IVU, the gold standard in MSK diagnosis, has largely been replaced by CT, which has previously been shown unable to demonstrate signs of MSK. METHODS AND MATERIALS: Patients with known history of MSK based on IVU underwent limited MDCT urogram. Control group patients, without MSK, also had MDCT urograms performed for other clinically indicated conditions. Studies were scored by board-certified radiologists on a 0-2 scale based on the likelihood of MSK. IVU studies, when available, were similarly graded. RESULTS: MDCT was diagnostic of MSK in 9 out of the 10 patients with known history of MSK. No false positives were present in our series. The one case of MSK not detected on MDCT was graded as a "1" on its respective IVU. Sensitivity and specificity were 90 and 100%, respectively, when compared with IVU. CONCLUSION: Concordance with IVU findings, despite a small reduction in sensitivity, indicates MDCT to be a suitable, and more readily available replacement for IVU in the diagnosis of MSK.
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OBJECTIVE: Extracapsular extension (ECE) of prostate cancer is a poor prognostic factor associated with progression, recurrence after treatment, and increased prostate cancer-related mortality. Accurate staging prior to radical prostatectomy is crucial in avoidance of positive margins and when planning nerve-sparing procedures. Multi-parametric magnetic resonance imaging (mpMRI) of the prostate has shown promise in this regard, but is hampered by poor sensitivity. We sought to identify additional clinical variables associated with pathologic ECE and determine our institutional accuracy in the detection of ECE amongst patients who went on to radical prostatectomy. METHODS: mpMRI studies performed between the years 2012 and 2014 were cross-referenced with radical prostatectomy specimens. Predictive properties of ECE as well as additional clinical and biochemical variables to identify pathology-proven prostate cancer ECE were analyzed. RESULTS: The prevalence of ECE was 32.4%, and the overall accuracy of mpMRI for ECE was 84.1%. Overall mpMRI sensitivity, specificity, positive predictive value, and negative predictive value for detection of ECE were 58.3%, 97.8%, 93.3%, and 81.5%, respectively. Specific mpMRI characteristics predictive of pathologic ECE included primary lesion size ((20.73 ± 9.09) mm, mean ± SD, p < 0.001), T2 PIRADS score (p = 0.009), overall primary lesion score (p < 0.001), overall study suspicion score (p = 0.003), and MRI evidence of seminal vesicle invasion (SVI) (p = 0.001). CONCLUSION: While mpMRI is an accurate preoperative assessment tool for the detection of ECE, its overall sensitivity is poor, likely related to the low detection rate of standard protocol MRI for microscopic extraprostatic disease. The additional mpMRI findings described may also be considered in surgical margin planning prior to radical prostatectomy.
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As the number of Americans aged 65 years and older continues to rise, there is projected to be a corresponding increase in demand for major surgeries within this population. Consequently, it is important to utilize accurate preoperative risk stratification techniques that are applicable to elderly individuals. Currently, commonly used preoperative risk assessments are subjective and often do not account for elderly-specific syndromes that may pose a hazard for geriatric patients if not addressed. Failure to accurately risk-stratify these patients may increase the risk of postoperative complications, morbidity, and mortality. Therefore, we aimed to identify and discuss the more objective and better-validated measurements indicative of poor surgical outcomes in the elderly with special focus on frailty, patient optimization, functional status, and cognitive ability.
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Splenic injuries related to percutaneous nephrostolithotomy (PCNL) are infrequent. Herein, we report a combined splenic and pleural injury incurred during PCNL along with radiographic images documenting the complication. A review of management techniques for similar injuries is included.
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In recent years, laparoscopy and robot-assisted procedures have become more commonplace in urology. Incorporation of these techniques into clinical practice requires extensive knowledge of the surgical approaches and complex instrumentation unique to minimally invasive surgery. In this review, focus will be directed to laparoscopic trocars including differing subtypes, placement in select urologic procedures, and proper use with emphasis on the avoidance of complications. Differing methods for the development of pneumoperitoneum and the associated risks of each will be discussed. The aim of this article is to provide a complete review of laparoscopic trocar use for the practicing urologist.
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Laparoscopía/métodos , Complicaciones Posoperatorias/prevención & control , Procedimientos Quirúrgicos Robotizados/métodos , Instrumentos Quirúrgicos , Procedimientos Quirúrgicos Urológicos/métodos , Adrenalectomía/efectos adversos , Adrenalectomía/instrumentación , Adrenalectomía/métodos , Puntos Anatómicos de Referencia , Anestésicos Locales/uso terapéutico , Antisepsia/métodos , Cistectomía/efectos adversos , Cistectomía/instrumentación , Cistectomía/métodos , Humanos , Enfermedad Iatrogénica/prevención & control , Hernia Incisional/prevención & control , Laparoscopía/efectos adversos , Laparoscopía/instrumentación , Escisión del Ganglio Linfático/efectos adversos , Escisión del Ganglio Linfático/instrumentación , Escisión del Ganglio Linfático/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos , Nefrectomía/efectos adversos , Nefrectomía/instrumentación , Nefrectomía/métodos , Neumoperitoneo Artificial/métodos , Prostatectomía/efectos adversos , Prostatectomía/instrumentación , Prostatectomía/métodos , Espacio Retroperitoneal/cirugía , Procedimientos Quirúrgicos Robotizados/efectos adversos , Procedimientos Quirúrgicos Robotizados/instrumentación , Uréter/cirugía , Procedimientos Quirúrgicos Urológicos/efectos adversos , Procedimientos Quirúrgicos Urológicos/instrumentación , Urología , Lesiones del Sistema Vascular/prevención & controlRESUMEN
PURPOSE: Infection of a penile prosthesis is a devastating complication that necessitates the removal of all device components. Many aspects of preoperative and intraoperative infection prophylaxis practices have been examined but the specific relevant factors remain unknown. We determined whether use of a mandatory checklist of perioperative practices believed to reduce the risk of prosthesis infection would impact patient safety. MATERIALS AND METHODS: We retrospectively reviewed men with erectile dysfunction who underwent penile prosthesis insertion. Only patients who had not previously undergone penile prosthesis surgery were included in the study. After an outbreak of infections, a mandatory checklist comprised of best infection prophylaxis practices was developed and was required for all subsequent implant surgeries. Patient cohorts were divided into 3 groups of baseline period, outbreak period and intervention period. Statistical analysis was performed using the chi-square test, Fisher's exact test and ANOVA. RESULTS: During the baseline period 2 of 68 (2.9%) inflatable penile prosthesis devices became infected. During the outbreak period 6 of 11 (54.5%) devices became infected, representing an incidence risk ratio 18.55 times that of the baseline period. After the implementation of the preoperative checklist the incidence risk ratio decreased to 0.0 in the intervention period with 0 of 52 devices (0%) becoming infected. CONCLUSIONS: After an outbreak of an unusually high number of penile prosthesis infections, implementation of a required checklist brought the rate down to zero. Although the specific factors that led to the infection outbreak and subsequent cessation of infections are unknown, we have shown that use of a checklist was associated with a dramatic impact on patient safety.
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Lista de Verificación , Prótesis de Pene/efectos adversos , Cuidados Preoperatorios , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
INTRODUCTION: Aggressive angiomyxoma (AAM) is a rare, benign mass with propensity for local invasion and recurrence after resection. Infrequently, this tumor can be found arising from the scrotum or cord structures in males. AIM/METHODS: A case report is presented followed by a review of relevant literature addressing the diagnosis, imaging, management and follow-up for aggressive angiomyxoma of the scrotum. RESULTS: Imaging can assist in further characterization of masses noted on physical exam. Scrotal sonography is typically the primary imaging modality utilized and magnetic resonance imaging is able to provide further anatomic detail. Treatment mainstay is surgical resection with necessary long term surveillance.
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Neoplasias de los Genitales Masculinos/patología , Mixoma/patología , Escroto/patología , Adulto , Femenino , Neoplasias de los Genitales Masculinos/diagnóstico por imagen , Neoplasias de los Genitales Masculinos/cirugía , Humanos , Imagen por Resonancia Magnética , Masculino , Mixoma/diagnóstico por imagen , Mixoma/cirugía , Escroto/diagnóstico por imagen , Ultrasonografía DopplerRESUMEN
Type III stress urinary incontinence (SUI) is generally defined as a condition that involves intrinsic sphincter deficiency (ISD). Although the clinical parameters for ISD are loosely defined as a Valsalva leak-point pressure <60 cmH(2)O or a maximal urethral closure pressure <20 cmH(2)O, consensus is lacking. As a result, studies evaluating the success of any treatment for ISD are difficult to interpret. Regardless, several studies over the past 20 years have evaluated a number of surgical and nonsurgical treatments specifically for SUI caused by ISD. Surgical options include retropubic suspension, needle suspensions, various types of suburethral slings and the artificial urinary sphincter, whereas nonsurgical options include urethral bulking agents. Assessing urethral function (specifically, leak-point pressure or maximal urethral closure pressure) and urethral hypermobility will enable treating physicians to determine the ideal solution for individual patients, especially as no standardized treatment for ISD exists.