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INTRODUCTION AND OBJECTIVES:Climacturia with or without stress urinary incontinence (SUI) is commonly encountered with erectile dysfunction (ED) after prostate cancer treatment. Previous work has s...

Surveillance is essential following endoscopic treatment for upper tract urothelial carcinoma. However unlike lower tract disease, surveillance cannot be performed in an outpatient basis. It is therefore critical to have a multidisciplinary approach to ensure follow-up. Conservative treatment which involves multiple invasive procedures can be cumbersome, for the patient and constant physician–patient dialogue must be maintained. We will outline the optimal approach in explaining to a patient and their families, what surveillance entails. Our surveillance protocol involves flexible cystoscopy, CT or MR urogram, and upper endoscopy in first 3 months. This is followed by repeat ureteroscopy, cytologies, cystoscopies, and imaging in 3–6 month intervals.

Ureteroscopic resection of upper tract is indicated by patient preference, medical comorbidities, and location/size of tumor. The literature on ureteral recurrence reports a recurrence rate of 48% for low grade and 60% for high grade, but the real recurrence rate is likely to be higher. Risk factors for recurrence include size >2 cm, grade, prior history of urothelial cell carcinoma and stage. The most important factor appears to be grade. Patients who failed conservative therapy and had a delayed radical nephroureterectomy had similar disease-specific survival and pathological stage to those who choose immediate radical nephroureterectomy. In our experience, ureteral tumors are best treated with ureteraoresectoscope. One must be careful with resecting near vessels such as the iliacs in the mid-ureter. In many cases, the resection will need to be staged secondary to the bulky nature of the tumor. If the lesion appears to be extensive or high grade, we instill Mitomycin C at the end of the procedure.

A survey of literature on UTUC shows a mix set of results on efficacy and outcome of conservative treatment. There are no standardized templates for ureteroscopic or percutaneous resection techniques nor the adjuvant treatment options. The assumptions of what institutes a diagnosis or success after treatment also remain unclear. The conservative management of UTUC is a work in progress requiring a multicenter prospective evaluation to provide more clear parameters to follow.

Endourologic management of upper tract urothelial carcinoma has become the preferred treatment in selected groups of patients. However, recurrence is high and there is a large interest in utilizing adjuvant topical agents as used in the lower tract. Many agents have been studied, but they are less efficacious than they are in the lower tract. This is likely due to incomplete staging, difficult delivery, and incomplete resection. There is evidence that primary BCG for isolated carcinoma in situ has some efficacy, but the evidence is not robust. There is mixed evidence for the use of adjuvant BCG, Mitomycin C, and Adriamycin. In our institution (ME), we utilize adjuvant Mitomycin C for a 6-week course in the office following resection. The future of adjuvant therapy likely lies in products such as MitoGel© that coat the upper tract.

This chapter describes in details all the aspects of percutaneous management of renal pelvis tumors. These tumors are mostly low grade and bulky and the resection is with the intent of complete, curative and sometimes palliative purposes. Majority of these patients have compromised renal function or have significant co morbidities. The technical aspects of resection, follow up biopsy and surveillance are described with video samples of different stages. There will also be description of intracavitary treatment.

Objective To, first, propose a novel scoring system to standardize reporting for percutaneous nephrolithotomy because the instruments currently available to predict the percutaneous nephrolithotomy outcomes are cumbersome, not validated, and of limited clinical utility; and, second, assess and predict the stone-free rates and perioperative parameters applying S.T.O.N.E. nephrolithometry. Materials and Methods Five reproducible variables available from preoperative noncontrast-enhanced computed tomography were measured: stone size (S), tract length (T), obstruction (O), number of involved calices (N), and essence or stone density (E). Results A total of 117 patients were included. The mean score was 7.7 (range 4-11). The stone-free rate after the first procedure was 80%. There were 18 complications (21%). The most frequent complications were postoperative sepsis and bleeding. The S.T.O.N.E. score correlated with the postoperative stone-free status ( P = .001). The patients rendered stone free had statistically significant lower scores than the patients with residual stones (6.8 vs 9.7, P = .002). Additionally, the score correlated with the estimated blood loss ( P = .005), operative time ( P = .001), and length of hospital stay ( P = .001). Conclusion The novel scoring system we have presented was found to predict treatment success and the risk of perioperative complications after percutaneous nephrolithotomy. Reproducible, standardized parameters obtained from computed tomography imaging can be used for preoperative patient counseling, surgical planning, and evaluation of surgical outcomes across institutions and within medical studies.

Objectives Laparoscopic retroperitoneal lymph node dissection (L-RPLND) was introduced over 20 years ago as a less invasive alternative to open node dissection. In this review we summarise the indications, surgical technique and outcomes of L-RPLND in the treatment of testicular cancer. Methods We searched MEDLINE using the terms ‘laparoscopy’, ‘laparoscopic’, ‘retroperitoneal lymph node dissection’, ‘RPLND’ and ‘testicular neoplasms’. Articles were selected on the basis of their relevance, study design and content, with an emphasis on more recent data. Results We found 14 pertinent studies, which included >1300 patients who received either L-RPLND (515) or open RPLND (788). L-RPLND was associated with longer mean operative times (204 vs. 186 min), but shorter hospital stays (3.3 vs. 6.6 days) and lower complication rates (15.6% vs. 33%). Oncological outcomes were similar between L-RPLND and open RPLND, with local relapse rates of 1.3% and 1.4%, incidence of distal progression of 3.3% and 6.1%, biochemical failure in 0.9% and 1.1% and cure rates of 100% and 99.6%, respectively. Conclusion There are no randomised controlled studies comparing L-RPLND with open RPLND. A review of case and comparative series showed similar perioperative and oncological outcomes. Patients undergoing L-RPLND on average have shorter hospital stays, a quicker return to normal activity and improved cosmesis.

To evaluate perspectives of urologists viewing live case demonstrations (LCD) and taped case demonstrations (TCD).A 15-question anonymous survey was distributed to attendees of the live surgery session at the American Urological Association 2012 national meeting (Atlanta) and the second International Challenges in Endourology meeting (Paris).Of 1000 surveys distributed, 253 were returned completed (response rate 25%). Nearly half of respondents were in the academic practice setting and nearly 75% were beyond training. Just over 30% had performed a LCD previously. The perceived benefit of an LCD was greater than unedited and edited videos (chi-squared P = 0.014 and P0.001, respectively). Nearly no one selected 'not helpful' and a few selected 'minimally helpful' for any of the three forms of demonstration. Most respondents identified that opportunity to ask questions (61%) and having access to the full unedited version (72%), two features inherent to LCD, improved upon the educational benefit of edited videos. Most (78%) identified LCD as ethical. However, those that did not perceived lower educational benefit from LCD (P = 0.019). A slim majority (58%) would allow themselves or a family member to be a patient of a LCD and the vast majority (86%) plan to transfer knowledge gained at the LCD session into their practice.Urologists who attended these LCD sessions identified LCDs as beneficial and applicable to their practice. LCDs are preferred over videos. The large majority considers LCD ethical, although not as many would volunteer themselves for LCD. Further studies are necessary to determine if there is actual benefit from LCD over TCD to patient care.

OBJECTIVES Sonography is a noninvasive, office-based diagnostic tool often used for evaluation of subfertile men. Previous studies have suggested that a resistive index (RI) greater than 0.6 is associated with impaired spermatogenesis. We sought to validate this threshold in a urologic patient population presenting for infertility evaluation. METHODS We retrospectively reviewed 99 consecutive patients seen for nonobstructive male infertility at our institution. Patient demographics, semen analysis parameters, hormone profiles, lipid profiles, and penile and scrotal sonographic measurements were recorded. The RI was calculated from measurements of the peak systolic velocity and end-diastolic velocity. Ninety-one patients fit the inclusion criteria and were subsequently divided into 2 groups based on RI: group 1 with RI values of 0.6 or less (n = 49) and group 2 with RI values greater than 0.6 (n = 42). RESULTS Variables that were significantly different between the groups included age, total sperm count, percent motile sperm, total motile sperm, follicle-stimulating hormone, high-density lipoprotein, and testis volume. On the other hand, body mass index, forward progression, World Health Organization score, total testosterone, free testosterone, estradiol, total cholesterol, low-density lipoprotein, and triglycerides were not significantly different between the groups. A receiver operating characteristic curve revealed an area under the curve of 0.64 (confidence interval, 0.52-0.75; P = .025). At the threshold of greater than 0.6, the RI had specificity of 63.27% and a 1.56 likelihood ratio to predict total motile sperm less than 20 × 10(6) at spermatogenesis. CONCLUSIONS An intratesticular RI greater than 0.6 is associated with impaired spermatogenesis. This finding supports the use of testicular spectral Doppler sonography as a noninvasive tool for evaluation of testicular function.

The initial surge of interest in laparoendoscopic single-site (LESS) surgery is balanced by skepticism regarding its future. We sought to evaluate the perspectives of practicing urologists on the role of LESS in urologic training and practice.An anonymous questionnaire was electronically mailed to members of the Endourological Society and the American Urological Association. Questions were grouped in three domains: training background and LESS experience, perspectives on LESS training, and perspectives on LESS in a current urologic practice.Four hundred twenty-two surveys were completed. Respondents had a mean of 11.7 years in practice and 60.7% completed fellowship training. LESS was performed by 44.7% of respondents, however, of these respondents, 75% had only performed10 LESS cases. For timing of LESS training, 50% believed LESS should be taught during residency and 39% during fellowship. Hands-on workshops and courses were thought to be insufficient by a majority (56%) for learning the LESS techniques before use in practice, and 51% support a credentialing process for urologists performing LESS surgery. Assessing the role of LESS in urologic practice, in its current state, LESS was deemed to provide superior cosmesis (69%) more commonly believed by those with LESS experience 77% versus 63% (p=0.004), however, without yielding a quicker recovery (75%) or less postoperative pain (73%).LESS is viewed as an area with potential growth with benefits of superior cosmesis. LESS training should be more integrated into residency and fellowship training and establishing a credentialing process for LESS should be strongly considered by accrediting bodies.

Unlike traditional valved trocars, the valveless trocar maintains pneumoperitoneum during laparoscopy by forming a CO(2) curtain at the proximal end of the trocar. This gas barrier instantaneously maintains exact intraperitoneal pressure that yields to the transient physiological changes seen with breathing. Due to this different mechanism of action, pneumothorax development may be masked by the valveless trocar system.We retrospectively reviewed 850 transperitoneal laparoscopic kidney and adrenal surgeries in which a valveless trocar system was used to determine any record of pneumothorax detected intraoperatively or postoperatively. A patient with pneumothorax was considered a case and anesthetic parameters were reviewed. A matched control group was generated from patients treated with transperitoneal laparoscopic kidney and adrenal surgery using the valveless trocar with no complications.Pneumothorax was diagnosed in 10 patients (1.2%). Two cases were the result of intentional excision of the diaphragm, which were repaired intraoperatively, while 8 were not recognized until the postoperative period. Five of the patients (63%) with unintentional pneumothorax required chest tube placement for a mean of 2.4 days. The remaining 3 patients (37%) were treated conservatively and followed with serial chest x-rays. The only anesthetic variable that was significantly different between the groups was Δ end tidal CO(2) with greater fluctuations in end tidal CO(2) in the pneumothorax group than in controls (p = 0.03).Pneumothorax is a rare complication of laparoscopic urological surgery that is usually recognized intraoperatively through physiological changes. Valveless trocar systems mask these findings and can delay identification until the postoperative period.

great variability in the surveillance methods of these patients in urologic practices in the United States and around the world. The objective of this study was to evaluate the efficacy of annual renal tract ultrasound rather than regular urodynamic testing for urinary tract monitoring in our population of SCI patients managed with long-term intermittent catheterization. METHODS: Data was gathered retrospectively from the records of 48 SCI patients (40 males and 8 females) included in the study. After establishing a safe system with initial urodynamics, renal tract surveillance was done with annual ultrasonograpy. Urodynamics were repeated only when patients presented with new symptoms. The primary endpoint was the presence/absence of ultrasound abnormalities at last follow-up. Findings of dilation, calculi, and scarring were noted. RESULTS: Mean follow-up was 6.8 years. By final follow-up 7 (15%) subjects had moderate/minimal hydronephrosis. 3 cases were stable and 4 (8%) cases were new compared to initial assessment. No severe cases of hydronephrosis were noted. 5 (10%) subjects had renal/ureteral calculi; one case of calculi was stable compared to the initial exam. No new cases of renal cortical scarring/thinning were noted. CONCLUSIONS: There are no consensus guidelines for the routine monitoring of the urinary tract in SCI patients. Using routine renal tract ultrasonography, the abnormalities detected in our patients were early consequences of acute obstructive processes rather than late manifestations of detrusor changes, thus they could not have been prevented with more regular urodynamic testing. These results support the regular use of ultrasonography rather than urodynamics for urinary tract surveillance in SCI patients.

INTRODUCTION AND OBJECTIVES: Percent positive cores (PPC) on a standard 12 core prostate biopsy has been previously demonstrated to correlate with pathologic tumor stage, Gleason score and tumor size. We sought to determine whether the highest quartile of PPC correlates with highest final tumor stage, Gleason score, and tumor volume compared to the remaining quartiles in a contemporary cohort of underserved urban patients. METHODS: Retrospective chart review was performed of 330 patients who underwent a robotic radical prostatectomy (RRP) at a single institution. Of these, 258 patients had biopsies done at our institution with at least 12 cores. Demographic, clinical and pathologic outcomes were recorded. Patients were divided into four quartiles, ANOVA and Chi-squared tests were used when appropriate. Spearman’s correlation was used to compare PPC to final tumor stage, Gleason score and tumor volume. RESULTS: There was no significant difference between the quartiles with respect to age, race or BMI. Mean pre-operative PSA, number of patients who received adjuvant hormone therapy or radiation therapy were similar between the groups. Overall, PPC was weakly correlated with final Gleason score and tumor stage (r 0.22, p 0.001, r 0.21, p 0.001 respectively) and strongly correlated with final tumor volume (r 0.47, p 0.001). The highest quartile (75 percentile PPC 42%) did not correlate with final tumor stage and tumor volume (r 0.12, p 0.34, r 0.001, p 0.96 respectively) and had a weak but not-significant correlation with final Gleason score (r 0.21, p 0.09). At an average follow up of 11.1 months, biochemical recurrence, or use of adjuvant therapy occurred no differently in the highest quartile compared to the remaining quartiles (p 0.37). CONCLUSIONS: Although overall PPC correlates with final Gleason score, stage and tumor volume, at the highest quartile this correlation no longer exists. Therefore, urologists should use caution when using PPC alone to classify a patient’s risk profile for treatment.

The R.E.N.A.L. nephrometry is a standardized scoring system that quantifies the complexity of kidney tumors. We evaluated our experience with laparoscopic cryoablation and determined the ability of nephrometry to predict complications.We reviewed the records of all patients who underwent laparoscopic cryoablation from July 2005 to February 2010 at 3 institutions. The composite R.E.N.A.L. score was determined using preoperative imaging, and tumors were categorized as low (4-6), moderate (7-9) or high complexity (10-12). Perioperative data were analyzed to determine the presence of complications. The distribution of surgical complications and tumor categories was compared using the chi-square and Student's t test. Logistic regression was used to analyze the association between nephrometry score and postoperative complications.A total of 210 patients underwent laparoscopic cryoablation, 77 of whom had available preoperative imaging. Mean patient age was 64.5 years and mean tumor size was 2.6 cm (range 1 to 4.5). Mean nephrometry score was 6.1 (range 4 to 12). Of the tumors 47 (61%) were categorized as low, 23 (30%) as moderate and 7 (9%) as high complexity lesions. Overall there were 15 (19.5%) complications, including 7 (9.5%) major and 8 (10%) minor complications. There was a significant difference in complication rates among the low (47 patients, 0%), moderate (23 patients, 35%) and high complexity (7 patients, 100%) groups, respectively (p0.001). On multivariate analysis nephrometry score was independently associated with a higher risk of postoperative complications (OR 2.23, 95% CI 1.05-2.11, p = 0.008).In a multi-institutional cohort of patients undergoing laparoscopic cryoablation, the R.E.N.A.L. nephrometry score is independently associated with the occurrence of complications. Therefore, nephrometry can be used to successfully stratify patients in terms of anticipated risk of complications which, in turn, may help with surgical decision making.