Racial disparity in the utilization of immunotherapy for advanced prostate cancer

PURPOSE

To identify whether there was a disparity in the utilization of immunotherapy in the treatment of black patients with metastatic castration resistant prostate cancer (mCRPC).

METHODS

Using the National Cancer Database, we identified patients between 2010- 2015 with likely minimally/asymptomatic mCRPC. We analyzed annual trends for chemotherapy and immunotherapy use and compared utilization by demographic and clinical features. Multivariable analysis was performed to determine predictors of receiving immunotherapy vs chemotherapy.

RESULTS

We identified 1301 patients with likely mCRPC. The majority were non Hispanic White (NHW - 63 %) and 23 % were non-Hispanic Black (NHB). Overall, there was increased utilization of immunotherapy in mCRPC from 2010 onwards, with the peak occurring in 2014 (4.6 %). Chemotherapy use increased significantly, peaking in 2014 to 26.1 %. However, the increased utilization of immunotherapy in the mCRPC was mainly seen in White patients: from 50 % to 74.2 % of the cohort. Conversely, there was a decrease in utilization of immunotherapy among Black mCPRC patients: from 50 % to 25.8 %. On multivariable analysis, there was no statistically significant difference between treatment types by race.

CONCLUSION

FDA approval of Sipuleucel-T for mCRPC led to increased utilization of immunotherapy shortly thereafter, but this was mainly noted in white patients. Black patients comparatively did not exhibit increased utilization of this novel agent after 2010. Further studies are necessary to help understand barriers to access to new treatment in mCRPC and eliminate the burden of disease in minority populations."

The Development of an Artificial Intelligence Model Based Solely on Computer Tomography Successfully Predicts Which Patients Will Pass Obstructing Ureteral Calculi

OBJECTIVE

To improve upon prior attempts to predict which patients will pass their obstructing ureteral stones, we developed a machine learning algorithm to predict the passage of obstructing ureteral stones using only the CT scan at a patient's initial presentation.

METHODS

We obtained Institutional Review Board approval to conduct a retrospective study by extracting data from all patients with an obstructing 3-10 mm ureteral stone. We included patients with sufficient data to be categorized as having either passed or failed to pass an obstructing ureteral stone. We developed a 3D-convolutional neural network (CNN) model using a dynamic learning rate, the Adam optimizer, and early stopping with 10-fold cross-validation. Using this model, we calculated the area under the curve (AUC) and developed a model confusion matrix, which we compared with a model based only on the largest dimension of the stone.

RESULTS

A total of 138 patients met inclusion criteria and had adequate images that could be preprocessed and included in the study. Seventy patients failed to pass their ureteral stones, and 68 patients passed their stones. For the 3D-CNN model, the mean AUC was 0.95 with an overall mean sensitivity of 95% and mean specificity of 77%, which outperformed the model based on stone-size.

CONCLUSION

The 3D-CNN model predicts which patients will pass their obstructing ureteral stones based on CT scan alone and does not require any further measurements. This can provide useful clinical information which may help obviate the need for a delay in care for patients who inevitably require surgical intervention.

Safe transition to opioid-free pathway after robotic-assisted laparoscopic prostatectomy

To determine whether local anesthetic infiltration and non-narcotic pain medications can safely reduce or eliminate opioid use following robotic-assisted laparoscopic prostatectomy while maintaining adequate pain control. After initiation of this quality-improvement project, patients undergoing robotic-assisted laparoscopic prostatectomy had surgeon-administered local anesthesia around all incisions into each successive layer from peritoneum to skin, with the majority infiltrated into the transversus abdominis muscle plane and posterior rectus sheath of the midline extraction incision. Post-operatively patients received scheduled acetaminophen plus ketorolac, renal function permitting. A retrospective review was performed for all cases over 19 months, spanning project implementation. 157 cases (76 in opioid-free pathway, 81 in standard pathway) were included. Five patients (6.6%) in the opioid-free pathway required post-operative opioids while inpatient, versus 61 (75.3%) in the standard pathway, p < .001. Mean patient-reported pain score on each post-operative day was lower in the opioid-free pathway compared to the standard pathway [day 0: 2.4 (SD 2.6) vs. 3.9 (SD 2.7), p < .001; day 1: 1.4 [SD 1.6] vs. 3.3 (SD 2.2), p < .001; day 2 0.9 (SD 1.5) vs. 2.6 (SD 1.9), p < .001]. Fewer post-operative complications were seen in the opioid-free pathway versus standard [0 vs. 5 (6.2%), p = 0.028], and there was no statistically significant difference in number of emergency room visits or readmissions within 3 weeks of surgery. The use of surgeon-administered local anesthetic plus scheduled non-narcotic analgesics can safely and significantly reduce opioid use after robotic-assisted laparoscopic prostatectomy while improving pain control.

Durability of Digital Flexible Ureteroscope in University Hospital and Ambulatory Surgical Center: Is It Time to Rethink?

Introduction and Objectives: Published literature on damages to a digital flexible ureteroscope (DFU) examines a limited number of ureteroscopes and shows wide variation in its durability. The aim of this study was to compare the primary damage location, causes of DFU damages, and the durability of Karl Storz Flex-Xc digital ureteroscope between University Hospital (UH) and Ambulatory Care Surgery Center (ASC). We also evaluated the available literature on the durability of DFU. Methods: Each damaged DFU prospectively underwent a manufacturer's evaluation to determine the reason for return and primary site of damage. Hospital data on the number of ureteroscopic procedures and damaged DFUs over 3 years were retrospectively reviewed. The possible reason for the damage was classified as either intraoperative or between the procedures. The durability of DFUs, type, and cause of damage were compared between the UH and nonteaching ASC. A chi-square test was utilized for categorical variables. When cell frequencies were <5, Fisher's exact test was used. Results: During the study period, 1211 ureteroscopies were performed and 143 ureteroscopes were returned to the manufacturer. The mean number of uses was 7.45 at the UH and 16.5 at the ASC. The location and cause of damage were similar at both locations. The most common locations of primary damage were at the angle cover (70.6%) and instrument channel (19.2%). Most damage occurred during the handling of the ureteroscopes between surgical procedures (78%). On review of the literature, we found that DFUs were 6 times more durable in a nonteaching hospital. Conclusions: The DFU was more than two times as durable in the ASC as in the UH. Most incidents occurred during handling between surgical procedures. Future research is needed to examine the impact of training and certification of support staff on durability of DFUs.

Robotic Pyelolithotomy for the Intact Removal of a Complete Staghorn Calculus: A Feasible Approach Even After a Previous Open Pyelolithotomy

OBJECTIVE

To describe the steps and technique of a robotic pyelolithotomy for complete removal of a left staghorn stone after a previous open pyelolithotomy.

METHODS

The patient is placed in a left modified flank position with 4 laparoscopic ports placed: 12mm port for camera paramedian to the left of the midline, 8mm robotic port left lower quadrant at the level of the umbilicus, 8mm robotic port midclavicular line 2 finger breaths below the costal margin, 12mm Airseal assistant port paramedian infraumbilical. The white line of Toldt was incised and the colon was mobilized medially. Anterior Gerota's fascia was opened and tacked to the lateral abdominal wall exposing renal pelvis and parenchyma. An intraoperative ultrasound confirmed the underlying stone. A V-shaped Gil-Vernet pyelolithotomy incision was made and Prograsp forceps were used to manipulate the stone out of the renal pelvis. The collecting system was inspected and irrigated using the robotic lens. The pyelotomy was closed with 4-0 Monocryl suture on a TF needle in 2 lengths of suture, superiorly and inferiorly. Gerota's fascia was closed over the renal pelvis and the kidney was re-retroperitonealized by tacking the colon to the white line of Toldt. The specimen was retrieved through a mini-Pfannenstiel incision via a specimen bag. The patient was discharged on postoperative day 1 and seen in clinic 5 weeks later for stent removal.

CONCLUSIONS

Robotic pyelolithotomy is a minimally invasive alternative that can be offered to patients with complete staghorn stones even after major open stone surgery. However case selection for this approach relies on the stone burden primarily in a dilated renal pelvis with limited calyceal projections. It is imperative to review preoperative imaging to understand the calyceal anatomy and the rotation required to free the stone from the collecting system.

Perinephric Fat Stranding Is Associated with Elevated Creatinine Among Patients with Acutely Obstructing Ureterolithiasis

INTRODUCTION

Pyelovenous/pyelolymphatic backflow from acute ureteral obstruction, manifesting radiologically as perinephric fat stranding (PFS), may result in elevated serum creatinine. Among patients with acutely obstructing ureterolithiasis, we evaluated the relationship between degree of PFS and changes in serum creatinine from baseline.

METHODS

Our tertiary care center's radiology dictation system (Fluency Discovery, M Modal) was queried for noncontrast abdominopelvic CT studies obtained in the Emergency Department for patients with obstructing ureteral calculi from 7/2015 to 4/2016. A single radiologist blinded to clinical data reviewed all CT scans and coded stone size, location, severity of hydronephrosis, and degree of PFS (none, mild, moderate, severe). For patients who met imaging criteria, a retrospective chart review was performed.

RESULTS

We evaluated 148 patients with mean age of 46 years (SD 14.6), 56.0% (n = 83) were male. On univariate analysis, moderate-severe perinephric stranding was associated with elevated creatinine from baseline (OR 2.93, p = 0.03). Mean creatinine increased as the severity of stranding increased (none Cr = 0.978 mg/dL, mild Cr = 0.983 mg/dL, moderate Cr = 1.165 mg/dL, severe Cr = 1.370 mg/dL; p < 0.01). An increase in creatinine from baseline was not associated with greater severity of hydronephrosis (OR 0.504, p = 0.189). There was no association between degree of PFS and severity of hydronephrosis, positive urine culture, stone location, or symptom duration (p > 0.05). On regression analysis controlling for positive urine culture and degree of hydronephrosis, there remained an association between elevated serum creatinine from baseline and moderate-severe PFS (OR 9.0, p = 0.01).

CONCLUSIONS

Among patients with acute obstructive ureterolithiasis, moderate-severe PFS was associated with elevated serum creatinine from baseline. This elevated creatinine was not explained by the obstructed kidney alone, as there was no association between the severity of hydronephrosis and increased creatinine. Pyelovenous/pyelolymphatic backflow resulting in PFS may be a contributing factor to elevated serum creatinine in this setting.

Lowering positive margin rates at radical prostatectomy by color coding of biopsy specimens to permit individualized preservation of the neurovascular bundles: is it feasible? a pilot investigation

Objective:

To evaluate whether color-coding of prostate core biopsy specimens aids in preservation of the neurovascular bundles from an oncological perspective.

Materials and Methods:

MRI guided transrectal ultrasound and biopsy of the prostate were performed in 51 consecutive patients suspected of being at high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor.

Results:

Of the 51 patients undergoing prostate biopsy, 30 (58.8%) were found to have cancer of the prostate: grade group 1 in 13.7%, 2 in 25.5%, 3 in 7.8%, 4 in 7.8% and 5 in 3.9% of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. Five patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic extension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy.

Conclusion:

Color-coding of prostate biopsy core specimens may assist in tailoring the approach for preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modification of the prostate biopsy protocol is valuable in larger groups of patients.

Multi-parametric MRI guided dose escalated radiotherapy for treatment of localized prostate cancer (PCa): Initial toxicity results of a prospective phase II trial

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Background: Multi-parametric MRI (mpMRI) of PCa uses advanced sequences to detect aggressive, high grade and bulky lesions. Given known advantages of hypofractionated radiotherapy (RT) to treat PCa (low a/b ratio), we conducted a phase II trial to escalate a high dose to mpMRI lesion(s) via Image-Guided (IG)-RT/Volumetric Arc Therapy (VMAT)/Stereotactic Body Radiotherapy (SBRT) technology. We present the acute toxicity results of this novel approach. Methods: 22 pts with mpMRI lesion(s) were prospectively treated to a course of IGRT/VMAT to the prostate & seminal vesicle +/- pelvic lymph nodes (PLN) to a dose of 45 Gy in 25 fractions followed by SBRT boost, 18 Gy in 3 fraction to the prostate with a simultaneous integrated boost 21 Gy in 3 fractions (EQD2 = 85.2 Gy using a/b 3 or 93.4 Gy using a/b 1.5) to the mpMRI prostatic lesion(s). Placement of 3 polymer based fiducial markers visible in both CT and MRI for image co-registration and treatment guidance was performed. Genitourinary (GU) and gastrointestinal (GI) adverse events (AE) were scored using CTCAE v4. DSMC approved reporting of acute AE results prior to completion of trial accrual as an interim safety assessment prior to final trial accrual. Results: Median age was 66.5 years (range: 57-80). All patients had PI-RADS grade 3-5 mpMRI lesion(s); 41.0%, 45.4% and 13.6% having 1, 2 and 3 lesions respectively. Ten (45%) pts had Gleason Score (GS) 8-10 and 12 had GS 7 disease. Median PSA was 8.97 (range: 4.0-77.9). Eleven (50%), 10 (46%), and 1 (5%) pts had stage T1, T2, and T3 tumor, respectively. Nine pts received treatment to the PLN and 15 received androgen deprivation therapy. All patients completed the protocol treatment without reporting acute GI or GU AEs grade ≥3 during treatment or at follow up. Grade 2 GI (diarrhea) and GU toxicity (frequency) was seen in 2 (9%) and 9 (41%) pts, respectively, during treatment. Of the 16 pts (71%) with least 3 months follow-up all grade 2 GI and 55.5% GU toxicities had resolved. Conclusions: Early results of this prospective Phase II study suggest that high-dose RT for localized PCa via mpMRI-guided RT/VMAT and SBRT boost is tolerable with a favorable acute toxicity profile.

Perineal urethrostomy: Still Essential in the Armamentarium for Transurethral Surgery

A 69-year-old morbidly obese man presented with hematuria caused by a large anterior wall bladder tumor. The mass was inaccessible for resection by standard means due to the patient's obesity and phallic length. A perineal urethrostomy was required to enable complete resection. This age-old technique is revisited for the benefit of this generation's urologists.

Quantification of risk factors in 500 patients with postoperative urinary retention

INTRODUCTION

An Institutional Quality and Safety Initiative to reduce postoperative urinary retention (POUR) and improve patient safety indicators (PSIs) was undertaken after a nurse driven protocol for catheter removal lead to an increase in POUR. The aim of this study was to identify the number of risk factors present in patients with POUR while examining the prevalence of those risk factors individually.

MATERIALS AND METHODS

A retrospective review of our institution's surgical database was performed to identify 500 consecutive cases of POUR between July 1, 2013 and July 1, 2014. POUR was defined as the inability to void postoperatively with bladder scan volumes greater than 450 mL and subsequent need for catheterization with an output greater than 450 mL. These records were individually reviewed for 15 known independent risk factors for urinary retention. Patients with incomplete records or preoperative baseline urinary retention requiring catheterization were excluded.

RESULTS

Of the 500 consecutive patients with POUR, 288 (57.6%) were male and 212 (42.4%) were female. At the time of voiding trial, all 500 patients with POUR (100%) had at least one perioperative risk factor identified and over 75% had six or more (mean 6.88, median 7, range 1-12).

CONCLUSIONS

Multiple perioperative risk factors are present in the vast majority of patients with POUR. Many of the risk factors are modifiable and represent an opportunity for intervention. This could ultimately lead to a risk profile which could be used to optimize timing of postoperative voiding trials, thus improving patient care (improve PSIs and patient comfort, reduce trauma) while maintaining low rates of CAUTI.

Intentional Omission of Ureteral Stents During Robotic-assisted Intracorporeal Ureteroenteric Anastomosis: Is It Safe and Feasible?

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.

Totally intracorporeal robot-assisted laparoscopic reverse seven ileal ureteric reconstruction

We describe the first reported case of completely intracorporeal robot-assisted laparoscopic reverse seven ileal ureteric reconstruction. The patient was a woman with bilateral, long segment ureteric strictures secondary to pelvic surgery and radiation. This report demonstrates that robotic reconstruction is a viable option even in a complex patient with a hostile abdomen.

Xanthogranulomatous cystitis associated with inflammatory bowel disease

Xanthogranulomatous inflammation is a benign condition characterized by the presence of multinucleated giant cells, chronic inflammatory cells and lipid-laden macrophages, known as xanthoma cells. Only 22 cases of xanthogranulomatous cystitis (XGC) have been reported in the Japanese and English literature. In this report, we describe the twenty-third case of XGC and the third case associated with inflammatory bowel disease (IBD). A 50-year-old woman with quiescent Crohn's disease was incidentally found to have a bladder mass on ultrasound. The lesion was resected through a transurethral approach. Pathology demonstrated XGC. At 3 months post-resection, there was no evidence of recurrence adjacent to the previous resection scar.

Bovine serum albumin glutaraldehyde for completely sutureless laparoscopic heminephrectomy in a survival porcine model

INTRODUCTION

Laparoscopic partial nephrectomy (LPN) has not received widespread clinical application because of its technical challenge. Bovine serum albumin glutaraldehyde (BSAG) is a hemostatic agent that is independent of the clotting cascade. We evaluated the use of BSAG as the sole agent for parenchymal and collecting system closure during LPN in a survival porcine model.

METHODS

Eighteen pigs underwent hilar clamping and LPN by longitudinal excision of the lateral one-third of the right kidney. The opened collecting system was covered with oxidized cellulose to prevent BSAG seepage into the urinary tract. BSAG was allowed to set for 10 or 5 minutes. Twelve animals underwent survival LPN BSAG only closure; six control pigs were acutely studied using saline. Urinary extravasation was evaluated by injection of furosemide and indigo carmine, and then evaluating the renal surface and bladder catheter drainage for dye. A subjective bleeding score was assigned after hilum unclamping. At 6 weeks, BSAG kidneys were harvested for burst pressure testing and histopathological analysis.

RESULTS

All 12 pigs survived for 6 weeks. No pigs had urinary extravasation. Mean percentage of kidney removed by weight was 19%. Mean warm ischemia time was 29 minutes. Five pigs required a second BSAG application to achieve a bleeding score of 0. Mean arterial and collecting system burst pressures were 301.8 and 322.4 mm Hg, respectively. Mean postoperative creatinine increase was 0.07 mg/dL.

CONCLUSION

BSAG for completely sutureless LPN in a survival porcine model was feasible.

Evaluation of the outcomes of electrosurgical induced bowel injury treated with tissue glue/sealant versus sutured repair in a rabbit model

INTRODUCTION

Bowel injury is an uncommon, although potentially devastating, intraoperative laparoscopic complication. Questions have been raised about the possible use of a tissue adhesive to repair injured bowel. We compared glued repair and sutured repair of both large bowel (LB) and small bowel (SB) electrosurgical injuries in a rabbit model.

METHODS

Pneumoperitoneum was obtained, and four laparoscopic ports were placed in each of 48 New Zealand rabbits. The hook electrode was used in a specified manner to create an equal number of uniform full-thickness injuries to either the SB or the LB. Laparoscopic repair was performed with a 3-0 silk Lembert suture (LS), fibrin glue (FG), or BioGlue (BG), or repair was not performed (i.e., no repair, NR); the animals were monitored for 3 weeks. Adverse clinical outcomes and findings at laparotomy were recorded. Pathologic assessment included an objective scaled evaluation of the intensity of the inflammatory response and degree of healing.

RESULTS

In the SB injury group, deteriorating clinical condition necessitated early euthanasia in one animal repaired with FG, one animal repaired with BG, and two animals with NR. LS repair animals had no adverse clinical outcomes. The LB injury group had no adverse clinical outcomes regardless of the method of repair, including the control group. Of the animals that survived for 3 weeks, the animals repaired with BG had more intraabdominal adhesions (100%) than LS (33%), FG (55%), and NR (50%) (p = 0.001). The pathologic assessment revealed that BG induced a more intense inflammatory response (p < 0.05).

CONCLUSION

In the rabbit, suture repair of an electrosurgical SB injury appears to have improved outcomes when compared with a glued repair. In contrast, LB injury responded well to any form of treatment. The data suggest that suture is superior to biological glues when dealing with a laparoscopic electrosurgical bowel injury.

The UCI Seldinger technique for percutaneous renal cryoablation: protecting the tract and achieving hemostasis

PURPOSE

To describe our Seldinger technique of percutaneous renal cryoablation that was devised to facilitate renal biopsy, cryoprobe placement, and instillation of adjunctive hemostatics while protecting surrounding tissues from cryoinjury.

PATIENTS AND METHODS

This approach was used to manage 13 renal masses in 12 adult patients. Under CT-fluoroscopic guidance, an access needle was inserted to abut the surface of the tumor, followed by an Amplatz super-stiff guidewire and a customized coaxial catheter system, which was used as a conduit for needle biopsy, cryoprobe insertion, and FloSeal instillation. In addition, a porcine model was used to compare the temperature readings adjacent to the sheathed and the unsheathed cryoprobe during percutaneous renal cryoablation.

RESULTS

In all patients, the use of this access approach was accomplished without incident. Two patients needed blood transfusions. No patient had significant skin, muscle, or nerve debility. At a mean follow-up of 11 months, none had evidence of persistent disease on CT or MRI contrast imaging. In the porcine model, the customized sheath protected the surrounding tissues from reaching temperatures below 5 degrees C while temperatures down to -15 degrees C were obtained when no insulating sheath was used.

CONCLUSIONS

A modified Seldinger technique enabled us to perform percutaneous renal cryotherapy through a single access channel, which facilitated access for biopsy, cryoprobe placement, and instillation of hemostatic agents. This approach may provide a protective barrier against cryogenic damage to neighboring tissues and could theoretically help minimize the chance of tract seeding.

Comparison of healing after cystotomy and repair with fibrin glue and sutured closure in the porcine model

PURPOSE

We compared healing after laparoscopic cystotomy using fibrin glue, sutures, or a combination to determine whether fibrin glue can obviate the need for sutures and whether there is any detriment when glue is used in the presence of sutures.

MATERIALS AND METHODS

In 24 Yorkshire pigs, a 3.5 cm vertical cystotomy was created laparoscopically and repaired as follows: Group 1--no closure; group 2--fibrin glue closure; group 3--suture repair; group 4--combined fibrin glue and suture repair. All animals had a Foley catheter for 1 week. In each group, three animals were harvested at 1 week (acute) and three animals were harvested at 6 weeks (chronic).

RESULTS

Acute: Group 1--all pigs had an unhealed defect that leaked when evaluated by cystography. Groups 2, 3, 4--mean leak pressures were 80, 97, and 60 cm H(2)O (P = 0.36), respectively. Mean bladder capacity was not significantly different between groups. Chronic: No leakage seen on a cystogram at 1 week; at 6 weeks, bladders were filled at > or =95 to 100 cm H(2)O without leakage. Histologically, there was more inflammation in the acute group v chronic group pigs. In the acute group pigs repaired with glue or suture + glue, there was more inflammation and less epithelial continuity than in the suture alone group. At 6 weeks, there was no difference between groups.

CONCLUSION

Fibrin glue provoked an intense inflammatory response that might have delayed healing acutely, resulting in a lower burst pressure in both scenarios in which it was used (i.e., alone or in combination with sutures). However, by 6 weeks, there did not seem to be any difference between groups either clinically or histopathologically.

Rapid communication: effects of Steris 1 sterilization and Cidex ortho-phthalaldehyde high-level disinfection on durability of new-generation flexible ureteroscopes

BACKGROUND AND PURPOSE

The effects of commonly used reprocessing methods on flexible ureteroscope longevity have never been examined. We prospectively studied the effects of Steris 1 sterilization and Cidex ortho-phthalaldehyde (OPA) high-level disinfection (HLD) on the image quality, physical structure, and deflective properties of two new flexible ureteroscopes.

MATERIALS AND METHODS

Two identical "out-of-the-box" Storz 11278AU1 flexible ureteroscopes (Karl Storz Endoscopy, Tuttlingen, Germany) were sterilized individually using the Steris 1 system (Steris Mentor, Ohio) or disinfected with Cidex OPA (Advanced Sterilization Products, J&J, Irvine, CA) for 100 trials followed by a crossover to the other method for another 100 trials over a period of 1 year. After every five trials, optical quality, angle of deflection, and fiber damage were analyzed in the laboratory. Throughout the study, neither of these ureteroscopes was used clinically.

RESULTS

After 100 trials, ureteroscope 1, which was sterilized initially in the Steris system, had a 12-mm tear on its shaft (noted after the 17th trial), 297 damaged fibers, and a 37% drop in resolution (loss of 3.75 lines/mm). There was no change in deflection from baseline. In contrast, after 100 cycles, ureteroscope 2, which was subjected to HLD with Cidex OPA, had no visible external damage, a 0% change in resolution, 10 damaged fibers, and no change in deflection. After the crossover, ureteroscope 2 developed a semilunar defect that obscured the endoscopic view, whereas there was no further significant damage to ureteroscope 1.

CONCLUSION

After 100 cycles, the Steris 1 system rendered the flexible ureteroscope unusable, whereas HLD with Cidex OPA had minimal adverse impact.

Advances in Percutaneous Nephrostolithotomy

Percutaneous nephrolithotomy was first performed in 1976. In the past 30 years, many refinements to the procedure have been made and it has become the gold standard for the management of large and complex renal calculi. This article reviews advances made in the field and highlights the nuances of the technique. The large published series are reviewed and their results discussed.

Sperm Granuloma of the Inguinal Vas Deferens Mimicking Recurrent Incarcerated Inguinal Hernia

Masses of the spermatic cord are rare and can be neoplastic or inflammatory lesions. We present a case of a sperm granuloma of the inguinal vas deferens presenting as a recurrent incarcerated inguinal hernia in a 42-year-old man.

Rapid Communication: Transvaginal Single-Port NOTES Nephrectomy: Initial Laboratory Experience

BACKGROUND AND PURPOSE

Natural orifice translumenal endoscopic surgery (NOTES) using purpose-built equipment has never been applied to urologic surgery. Herein, we present our initial experience with a trans-vaginal single-port NOTES nephrectomy.

METHODS AND RESULTS

An acute experiment was performed in a female farm pig. A single 12-mm trocar was placed in the midline and the TransPort Multi-Lumen Operating Platform (USGI Medical, San Clemente, CA) was passed transvaginally. This flexible device has four working channels and can be locked into position, thereby creating a rigid multitasking platform that allows two-handed tissue manipulation. Dissection was performed using an endoscopic needle knife and a tissue grasper for retraction. Via the 12-mm port, the renal artery and vein were taken separately with a vascular EndoGIA and standard laparoscopic titanium clips, respectively. The kidney was placed in a 10-mm EndoPouch retriever and removed intact via the vagina. The total operative time was 300 minutes.

CONCLUSION

Transvaginal NOTES nephrectomy can be accomplished in a porcine model. Additional testing on survival animals is necessary to validate this approach.

Percutaneous Cryoablation of an Upper Pole Renal Mass: Use of Contralateral Single Lung Ventilation to Avoid Pleural and Pulmonary Puncture

A percutaneous approach to cryoablation of renal masses is not without a risk of complications. We describe a case in which selective, single lung intubation of an obese patient with an upper pole left renal mass allowed for percutaneous cryoablation with avoidance of pleural and pulmonary injury. We accomplished this by minimizing the ventilation-induced renal motion and collapsing the ipsilateral lung so that it remained out of harm's way.

Review of minimally invasive renal therapies: Needle-based and extracorporeal

Management of the small renal mass (< or = 3 cm) is a topic of significant debate among urologists worldwide. With the advent of needle-based therapies and, less frequently, reports of extracorporeal approaches, along with ongoing refinements in each technology, patients with such masses may have the option of being treated in a truly minimally invasive, or even noninvasive, manner. Herein we review the body of available clinical literature on these modalities with respect to patient selection, success and complication rates, follow-up information, energy delivery devices, and current probe configurations.