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Gout is a metabolic disorder characterized by hyperuricemia and deposition of monosodium urate crystals in the joint spaces and other extraarticular locations. We report the case of a 40-year-old male who presented for consultation regarding gouty tophi on the phallus, an unusual location for tophi deposition, which was resolved with surgical removal. We provide a brief review of the pathophysiology of gout and its treatment modalities, both medical and surgical.

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Blastomyces dermatitidis is an environmental fungus endemic to parts of Eastern North America that notably causes pulmonary infection in humans and other animals with the potential for extrapulmonary spread, particularly in immunocompromised hosts. However, it rarely presents with genitourinary (GU) tract involvement. Herein, we present a unique case of a 37-year-old immunocompetent male with genitourinary blastomycosis with the initial presentation of a scrotal abscess.

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PURPOSE OF REVIEW: To evaluate recent literature regarding the role of robotic technology in the treatment of nephrolithiasis with particular attention to complex technical procedures. RECENT FINDINGS: Robotic platforms including single-port robotics have been widely adopted in urological practice for the treatment of both malignant and benign conditions and has led to an expansion of the utilization of robot-assisted surgery to tackle challenging clinical scenarios such as bladder neck reconstruction, upper urinary tract reconstruction, and more recently complex stone disease. Presently, the American Urological Association guidelines on the surgical management of stones advise against using robotic, open, or laparoscopic techniques as a first-line approach for most patients with stone disease with the exception for patients with anatomical abnormalities, large or complex stones, or patients requiring a concomitant reconstructive operation. Clinicians have demonstrated the safety and feasibility of surgical robotics in the treatment of stone disease for a variety of operations including robotic pyeloplasty, pyelolithotomy, ureterolithotomy, and surgical interventions in urinary diversions as well as novel technologies for robotic ureteroscopy and percutaneous access. Numerous clinicians have demonstrated the safety and feasibility of using robot-assisted surgery to treat nephrolithiasis, mainly in complex renal anatomy. Further research is necessary to identify the best candidates for utilization of robotics in complex stone disease, and further technological developments will continue to further advance the use of these platforms in the treatment of nephrolithiasis.

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Robotic-assisted laparoscopic radical prostatectomy represents one of the most common operations in urologic oncology and involves several critical technical steps including pelvic lymph node dissection, cavernous nerve sparing and vesicourethral anastomosis. The quality of performing these steps is linked to functional and oncological outcomes. Indocyanine green [ICG] is a non-radioactive, water-soluble compound which allows for enhanced visualization with near-infrared fluorescence of both anatomical structures and vasculature during complex abdominal operations such as prostatectomy. During the last decade, several investigators have examined the value and role of ICG fluorescence during prostatectomy. In this review, we sought to evaluate the body of evidence for fluorescence-guided robotic prostatectomy as well as assess potential future areas of investigation with this technology.

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BACKGROUND: Colonoscopy is the procedure of choice for both the diagnosis and treatment of large intestine and distal ilium in patients complaining of bowel symptoms, anemia resulting from malabsorption, radiographic colon abnormalities, screening for colorectal carcinoma, after polypectomy and cancer resection surveillance, ulcerative colitis surveillance, and those with suspicion of neoplastic masses. Inspection of the whole colonic and distal portion of terminal ilial mucosa is usually feasible during colonoscopy. Quality examination of the large bowel includes intubation of the complete colon and mucosal visualization. The investigators demonstrate that terminal ilium intubation is possible in endoscopy practice and yields additional clinical details. Furthermore, it may be used as an indicator of colonoscopy completion. OBJECTIVES: This study estimated the rate of cecal and ilial intubation by a single well-trained endoscopist and compared it with the results of a heterogeneous group of endoscopists. PATIENTS AND METHODS: This retrospective comparative study estimates the rate of cecal and ilial intubation in a private endoscopy center in which all the endoscopic procedures were conducted by a single consultant gastroenterologist, and compared it with the rates of a governmental center with by five colonoscopy endoscopists (general surgeons, general physicians, trained endoscopists, and gastroenterologists). The study population included 442 patients (245 males [55.42%] and 197 females [44.58%], ranging from 14 to 85 years of age. RESULTS: Overall cecal and ilial intubation rates were 88% and 47.5%, respectively. The adjusted rates for cecal and ilial intubations were 94.2% and 50.8%, respectively, after considering cases of anatomic colonic obstruction and when the clinical indications do not justify total colonic intubation. These figures were superior in comparison to the results of a multi-operator study in which the cecal- and the ilial intubation rates were 51.81% and 30.69%, respectively. CONCLUSION: Cecal and ilial intubation are important quality indicators for colonoscopy, and in this study, they were found to be superior in qualified gastroenterologists than in general surgeons and physicians. This outcome points to the importance of providing endoscopy units in Iraq, with qualified well-trained endoscopy personnel.

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INTRODUCTION: Crohn's disease (CD) is a chronic inflammatory disorder that may involve any part of the alimentary tract from mouth to anus and is characterized by periods of clinical remission alternating with periods of recurrence. Current clinical and endoscopic indices only measure disease activity at a specific time point. The recently published Lémann index (LI) is the first tool that aims to measure cumulative structural bowel damage and thus evaluates long-term disability. AIM OF STUDY: To measure the LI at initial presentation of CD in a sample of Iraqi patients attending the gastroenterology and hepatology teaching hospital (Baghdad). PATIENTS AND METHODS: This is a descriptive single-center study conducted in gastroenterology and hepatology teaching hospital and enrolled 30 patients with CD diagnosed from 2013 to 2015. They all underwent complete physical examination, abdominopelvic CT scan, upper endoscopy, and colonoscopy upon diagnosis for the purpose of assessing bowel damage by the LI. RESULTS: For the 30 patients included, median LI was 1.3 (range 0.2-12.6). CONCLUSIONS: The LI is now available and it enables, for the first time, assessment of bowel damage in CD.

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PURPOSE: The objective of this study was to assess the accuracy of cystoscopy and cystography, as compared to other diagnostic studies, in identifying vesicoenteric fistulae (VEF) in a contemporary series of patients with surgically confirmed VEF. METHODS: With institutional review board approval, we performed a single-center retrospective review of surgically confirmed VEF between 2002 and 2018. Demographic data, comorbidities, symptoms, and diagnostic evaluation were reviewed. The sensitivity, specificity, and accuracy of cystoscopy in diagnosis of VEF were compared to cross-sectional imaging. RESULTS: The study cohort consisted of 51 patients with surgically confirmed VEF secondary to diverticular disease. Diagnostic evaluation included cross-sectional imaging with CT (94%), colonoscopy (82%), cystoscopy (75%), cystography (53%), and barium enema (26%). Cystoscopic evaluation definitively demonstrated evidence of VEF in 34% of patients, while 55% of patients had nonspecific urothelial changes on cystoscopy without definitively demonstrating VEF. Comparatively, the sensitivity of VEF was 25% for cystography and 84% for CT. CONCLUSIONS: In clinical practice, the diagnostic work-up of VEF is variable. In the modern era of managed care, inclusion of cystoscopy and cystography in the evaluation of VEF does not contribute a substantial additive benefit over standard cross-sectional imaging. Cystoscopy and cystography could potentially be eliminated from the diagnostic evaluation of VEF, in the absence of a concern for malignancy, in an effort to minimize unnecessary invasive testing as well as health care expenditures.

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The authors present a rare case of primary diagnosis of metastatic, differentiated thyroid cancer presenting as a solitary, large renal mass. Renal cortical masses which represent metastatic primary malignancies are often small, multifocal, and in the setting of active malignancy. Surgical excision of this patient's renal mass demonstrated the unexpected diagnosis and subsequent endocrine surgical intervention.

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Cutaneous metastases of genitourinary malignancies are an extremely rare phenomenon. Few cases of skin metastasis from urothelial carcinoma of the bladder have been reported. We report a case of 71-year-old female with primary bladder transitional cell carcinoma who presented with the initial presentation of cutaneous skin lesions that covered the entire lower abdominal wall.

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Recreational use of synthetic cannabinoids (SCs), also known as "K2" or "Spice," is becoming a major public-health concern due to their potential for abuse and harmful consequences. New substances are constantly being added to the content of SCs. The dearth of information on these newly added contents as they are introduced into the black market hinders risk assessments of these compounds. We report a highly unusual case of gross hematuria in a 28-year-old male patient after SC use. He was found to have a supratherapeutic INR with no history of prior anticoagulation. His hematuria resolved after four units of fresh-frozen plasma were administered. We include a literature review of the clinical effects of SCs and their possible mechanism of gross hematuria and management.

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Ureteral injury is an uncommon but potentially morbid complication following any open or endoscopic pelvic procedure. Gynecologic surgeries alone make up 50 percent of nonurologic ureteral injuries leading to prolonged hospital stays, secondary interventions, and potential loss of renal function. The use of AmnioFix ® a processed dehydrated, immunologically privileged cellular amniotic membrane allograft has been well established in urologic and gynecologic procedures. These allografts contain human extracellular matrix components, growth factors, and cytokines that mediate inflammation and facilitate would healing. We report the first application of AmnioFix on a denuded ureter during a case of robotic-assisted excision of endometriosis. We include a literature review and discussion on the management outcomes of iatrogenic injury to the ureters.