Patients with cystic fibrosis (CF) commonly suffer chronic respiratory infections, although systemic dissemination is relatively rare. Acute bacterial prostatitis presents dramatically and is believed to be mostly caused by local migration (with or without instrumentation) of the lower urinary tract and presents with a predictable microbial etiology. We report a case of a 26-year-old man presenting with acute Pseudomonas aeruginosa bacterial prostatitis due to hematogenous propagation from a chronic pulmonary infection.

Introduction

Many efforts are used to improve surgical techniques and graft materials for urethral reconstruction. We developed an endothelialized tubular structure for urethral reconstruction.

Methods:

Two tubular models were created in vitro. Human fibroblasts were cultured for 4 weeks to form fibroblast sheets. Then, endothelial cells (ECs) were seeded on the fibroblast sheets and wrapped around a tubular support to form a cylinder for the endothelialized tubular urethral model (ET). No ECs were added in the standard tubular model (T). After 21 days of maturation, urothelial cells were seeded into the lumen of both models. Constructs were placed under perfusion in a bioreactor for 1 week. At several times, histology and immunohistochemistry were performed on grafted nude mice to evaluate the impact of ECs on vascularization.

Results:

Both models produced an extracellular matrix, without exogenous material, and developed a pseudostratified urothelium. Seven days after the graft, mouse red blood cells were present only in the outer layers in T model, but in the full thickness of ET model. After 14 days, erythrocytes were present in both models, but in a greater proportion in ET model. At day 28, both models were well-vascularized, with capillary-like structures in the whole thickness of the tubes.

Conclusion:

Incorporating endothelial cells was associated with an earlier vascularization of the grafts, which could decrease the necrosis of the transplanted tissue. As those models can be elaborated with the patient’s cells, this tubular urethral graft would be unique in its autologous property.

Introduction

There are two prevailing perceptions among urology residents (1) fellowship training is becoming a requirement after residency, and (2) there are few job opportunities after graduation. In this study, we examine postgraduate training patterns and employment choices of urology residents.

Methods:

All Canadian urology program directors provided a summary of fellowship training and employment of Canadian residents graduating between 1998 and 2009. Logistic regression models were used to detect linear trends.

Results:

In total, 258 Canadian urology residents graduated over the study period, with a median of 22 (interquartile range 21–22) graduating per year. Of these, 72% completed a fellowship. Of these fellowships, 62% included protected research time. The most common subspecialty area was minimally invasive surgery (MIS)/endourology (39% of fellowships). There was a significant increase in fellowship training over time (p < 0.0001); this was mostly due to an increase in MIS/endourology fellowships. The number of urologists obtaining graduate degrees after medical school has increased significantly over the study period. Almost all graduates are employed. Of the employed graduates in total, 34% are academic urologists. Among all graduates, 50% are practicing within 100 km of their residency site, 16% are practicing in the United States and 22% are in rural practice. There has been no significant change over time in the proportion of residents practicing within 100 km of their training program, practicing rurally, leaving their province of training, practicing in the United States, or choosing academic practice.

Conclusions:

Fellowship training, especially in MIS/endourology, has become significantly more common. Graduate degrees are more frequently being obtained. We did not find evidence that there has been a significant change in a urology resident’s ultimate ability to obtain employment upon graduation.

Background

In this paper, we identify and analyze the top 100 cited articles in urology since 1965 and assess changes in the top 100 since 2007.

Methods:

We selected highest impact journals in both urological and general medicine journals from the 2011 edition of Journal Citation Reports: Science edition. We identified and analyzed the 100 most cited articles using the Science Citation Index Expanded (1965-present).

Results:

The top 100 articles were cited a mean of 892 times (range: 529–2088) and published between 1966 and 2009, with 21 published since 2000. In 2012, 19 new articles appeared in the updated top 100 cited articles. Also, 16 journals were represented, led by the New England Journal of Medicine (n=36), the Journal of Urology (n=16) and the Lancet (n=12). In total, 81 articles were published from North America (USA=77, Canada=4). From the United States, the following institutes were among the top 5 represented: Johns Hopkins University (n=12), Harvard University, Memorial Sloan Kettering Cancer Centre, National Institute of Health and Washington University (all 5). Only one institute outside the United States published more than one article in the top 100 (Institut Gustave Roussy, France). Nine urologists were first authors of 2 or more articles. Oncology (n=54) and transplantation (n=22) were the most common subspecialties represented.

Conclusion:

It is important to acknowledge the top cited articles as they mark key topics and advances in urology. There has been a 19% change in the top 100 cited articles in the past 5 years. Oncology and transplantation remain the most highly cited topics.

Intravesical foreign bodies are an uncommon, but significant, cause of urologic consultation. We present 3 patients who all inserted magnetic beads per urethra into the urinary bladder, which subsequently became retained. Endoscopic attempts were unsuccessfully tried in the first 2 cases, necessitating open cystotomy to remove the beads. The third went straight to open removal. Given the failure of minimally invasive techniques, we believe that open removal should be the first-line treatment for these types of foreign bodies.

Résumé

Nous rapportons un nouveau cas d’éléphantiasis pénoscrotal idiopathique chez un adulte de 31 ans. La masse scrotale atteignait les genoux, avec lésions de grattage traitées et guéries à l’éosine aqueuse associée à une antibiothérapie par voie parentérale. Une exérèse de la masse scrotale a été effectuée, suivie d’une plastie de peau scrotale postérosupérieure associée à une circoncision partielle. Le résultat esthétique et fonctionnel à long terme fut excellent, avec une peau pénienne assouplie et élastique.

Introduction

The objective was to determine the prevalence of, and factors that predict, detrusor underactivity (DU) in patients presenting with incontinence or lower urinary tract symptoms (LUTS) following radical prostatectomy (RP). We also determined the prevalence of bladder outlet obstruction (BOO) and detrusor overactivity (DO) in this population.

Methods:

Patients who underwent urodynamics post-RP were identified. Detrusor underactivity was defined as a maximum flow rate (Qmax) of ≤15 mL/s and detrusor pressure (Pdet) Qmax <20 cmH20 or maximum Pdet <20 cmH20 during attempted voiding. Abdominal voiding (AV) was defined as sustained increase in abdominal pressure during voiding. Bladder outlet obstruction and DO were identified using the Abrams-Griffiths nomogram and the International Continence Society criteria. Univariate logistic regression was used to determine factors predicting DU. The following factors were analyzed: age, year of RP, procedure type (minimally-invasive surgery [MIS] or open), postoperative radiation, nerve-sparing, clinical stage, biopsy Gleason grade and interval between RP and evaluation.

Results:

Between 2005 and 2008, 264 patients underwent urodynamics post-RP. Detrusor underactivity was observed in 108 patients (41%; 95% CI 35%, 47%), of whom 48% demonstrated AV. Overall, BOO and DO were present in 17% (95% CI 12%, 22%) and 27% (95% CI 22%, 33%), respectively. On univariate analysis, only MIS RP was predictive of DU (univariate odds ratio 2.05 for MIS vs. open; p = 0.009).

Conclusions:

Detrusor underactivity and AV are common in patients presenting for evaluation of incontinence or LUTS following RP. The etiology of DU in this setting is likely related to the surgical approach. Because DU may affect the success of male incontinence treatment with the male sling or artificial urinary sphincter, it is useful to document its presence prior to treatment. More studies are needed to elucidate the influence of DU on treatment success for male urinary incontinence following RP.

Purpose

Small renal masses are increasingly being discovered incidentally on imaging for another reason. The standard of care of these masses involves excision by open or laparoscopic techniques. Recently, ablative techniques, such as radiofrequency ablation (RFA) and cryoablation, have taken a more prominent role in the treatment algorithm of these masses. We evaluate the effectiveness and safety of cryoablation to treat renal tumours.

Methods:

A review of the literature was conducted. There was no language restriction. Studies were obtained from the following sources: the Cochrane Library, PUBMED, EMBASE and LILACS.

Results:

There was no clinical trial identified in the literature. Thus, we described the results from 23 case series and retrospective studies with a reasonable sample size (number of reported patients in each study ≥30), with a total of 2104 analyzed tumours from 2038 patients. There was wide variability in the outcomes reported, but success rates were generally good. Follow-up was generally short, but some series reported outcomes at 5 years. The most common complications reported were hemorrhage (some of the patients requiring transfusion), perinephric hematoma and urine leaks.

Conclusion:

Cryoablation presents a feasible treatment for patients with small renal masses. Only short-term data are available and, as such, meaningful conclusions regarding long-term cancer control cannot be made. More rigorous studies are needed.

The overall 5-year survival of patients with urothelial carcinoma of the bladder (UC) is about 78%; however, there are some rare subtypes. One of these is the lipoid cell subtype, which bears a very poor prognosis. Another rare disease entity with a poor prognosis is metastasis to the lower gastrointestinal tract in the form of secondary linitis plastica of the rectum. We describe an extremely rare and unique case of rectal linitis plastica secondary to the rare lipoid cell variant of UC.

Objective:

Dismembered pyeloplasty through dorsal lumbotomy to correct ureteropelvic junction obstruction is mainly successfully performed in children under 5 years old for technical reasons. We compared children who underwent dorsal lumbotomy by age group (<5 vs. ≥5 years old) to determine if the surgical success and long-term results were comparable.

Materials and Methods:

We retrospectively reviewed the charts of 134 children undergoing a pyeloplasty. Group 1 consisted of children <5 years old (n = 90) and Group 2 consisted of children ≥5 years old. Patients’ characteristics, as well as hospital stay, narcotic use, radiologic follow-up and success rate, were compared. Success was defined by absence of symptoms and ≥50% reduction in renal pelvis anteroposterior diameter and/or scintigraphic normalization of the drainage T1/2 when obtained. Univariate analysis was performed to compare the groups.

Results:

Mean age (years) and weight (kg) at surgery for Groups 1 and 2 were 1/8 kg and 11/35 kg, respectively. Mean operative time was 98 minutes versus 120 minutes, respectively; mean hospital stay was 2.5 days for both groups and analgesia requirement was 50% higher in Group 2. A Pippi-Salle stent was used in 90% (n = 120) of cases. Mean follow-up was 26 months and the success rate was 89% and 90% for Groups 1 and 2, respectively.

Conclusion:

Our study showed comparable success rates. We can infer that, as a technique, dismembered pyeloplasty is effective and safe in the younger and older children.

Objective:

Cancer Care Ontario has published an evidence-based guideline on their website “Guideline for Optimization of Surgical and Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management: Surgical and Pathological Guidelines.” The evidentiary base for this guideline was recently published in CUAJ. The CCO guideline proposes the following: a positive surgical margin (PSM) rate of <25% for organ-confined disease (pT2), a perioperative mortality of <1%, a rate of rectal injury <1%, and a blood transfusion rate <10% in non-anemic patients. The objective of this study was to review the radical prostatectomy practice at the Grey Bruce Health Services, an Ontario community hospital, and to compare our performance in relation to the Cancer Care Ontario guideline and the literature.

Methods:

We conducted a retrospective review of all radical prostatectomies performed at the Grey Bruce Health Services from January 1, 2006 to December 31, 2007. The following data were obtained from clinical records and pathology reports: patient age, pre-biopsy prostate-specific antigen, biopsy Gleason score, resected prostate gland weight, radical prostatectomy Gleason score, surgical margin status, pathological tumour stage (pT), lymph node dissection status, perioperative incidence of transfusion of blood products and if the patient was anemic (hemoglobin <140 g/L) preoperatively, incidence of rectal injury, and perioperative mortality within 30 days following surgery.

Results:

Using the method proposed by D’Amico, most patients undergoing radical prostatectomy were intermediate risk (62%), with a minority of low-risk (24%) and high-risk (14%) patients. The overall PSM rate was 37%. The rate of PSMs in organ-confined disease (pT2) was 26%. There was a statistically significant trend between increasing D’Amico risk category and increasing rate of PSM (Cochran-Armitage trend test, p = 0.023). There was a strong correlation between the pathological tumour stage and the rate of PSM (Cochran-Armitage trend test, p = 0.0003). The rate of blood transfusion in non-anemic patients was 6%. There was 1 patient (0.8%) who experienced a rectal injury. There were no perioperative deaths in our study group.

Conclusion:

Our results show that a community hospital group can appropriately select patients to undergo radical prostatectomy, as well as achieve an acceptable rate of PSMs. We believe that ongoing critical appraisal and reflective practice are essential to improving surgical outcomes and providing quality care.

Background:

Donation after cardiac death (DCD) has led to an increase of up to 40% in the number of kidney transplants in some programs. Unfortunately, the increase in warm ischemic time results in higher rates of delayed graft function (DGF). The purpose of our study was to examine our initial 5-year experience with DCD kidney transplantation and to determine the factors involved in early postoperative function and function at 1 year.

Methods:

This retrospective study included a review of the recipient and donor charts of 63 DCD kidneys retrieved and transplanted by the London Multi-Organ Transplant Program between July 2006 and October 2011. Comparisons were carried out between our early (n=31, July 2006 to January 2009) and our recent experience (n=32, March 2009 to October 2011). DGF and creatinine clearance at 3, 7 and 365 days were examined with regression analyses.

Results:

DGF was seen in 65% of transplanted kidneys. Mean creatinine clearance (CrCl) at 1 year was 66.7 mL/min. Low pre-transplant recipient daily urine output was the most statistically significant predictor of DGF in multivariate analysis (p < 0.001). In comparisons between our early and more recent results, improvements were noted in time from asystole to flush (16.0 vs. 12.0 minutes, p = 0.003), while cold ischemic time increased (464 vs. 725 minutes, p = 0.006). Experience contributed to a significant reduction in hospital length of stay (16 vs. 13 days, p = 0.035) and improved early renal function (CrCl at 3 days 7.8 vs. 11.9 mL/min, p = 0.027). The use of machine cold perfusion and higher recipient preoperative daily urine output predicted improved early renal function, while increasing donor age predicted poorer function at 1 year.

Discussion:

Despite early DGF, our results justify the continued transplantation of kidneys from DCD donors.

Introduction:

We delineated Canadian regional differences in practice patterns in the management of upper tract urothelial carcinoma (UTUC) after nephroureterectomy and relate these to patient outcomes.

Methods:

A database was created with 1029 patients undergoing radical nephroureterectomy for UTUC between 1994 and 2009 at 10 Canadian centres. Demographic, clinical and pathological variables were collected from chart review. Practice pattern variables were defined as: open versus laparoscopic nephroureterectomy, management strategy for the distal ureter, performance of lymphadenectomy and administration of chemotherapy and/or radiation therapy. The outcome measures were overall (OS), disease-specific (DSS) and recurrence-free survival (RFS). The centres were divided into three regions (West, Central, East). Cox proportional multivariable linear regression analysis was used to determine the association between regional differences in practice patterns and clinical outcomes.

Results:

There was a significant difference in practice patterns between regions within Canada for: time from diagnosis to surgery (p = 0.001), type of surgery (open vs. laparoscopic, p < 0.01) and method of management of the distal ureter (p = 0.001). As well, there were significant differences in survival between regions across Canada: 5-year OS (West 70%, Central 81% and East 62%, p < 0.0001) and DSS (West=79%, Central=85%, East=75%, p = 0.007) were significantly different, but there was no difference in RFS (West 47%, Central 48%, East 46%, p = 0.88). Multivariable linear regression analysis demonstrated that the differences in survival were independent of region OS (p = 0.78), DSS (p = 0.30) or RFS (p = 0.43).

Conclusion:

There is significant disparity in practice patterns between regions within Canada, but these do not appear to have an effect on survival. We believe that the variability in practice is a reflection of the lack of standardized treatments for UTUC and underlines the need for multi-institutional studies in this disease.

Skeletal-related events (SREs) are a common complication of bone metastases, and have serious negative consequences for patients with castrate-resistant prostate cancer (CRPC). SREs can lead to severe pain, increased risk of death, increased health care costs and reduced quality of life. Until recently, zoledronic acid has been the sole standard of care for the prevention of SREs in men with CRPC with bone metastases. Denosumab, a receptor activator of nuclear factor kappa-B ligand (RANK-L) inhibitor, has been recently approved for use in Canada for this indication, thus presenting another option for these patients. Denosumab was shown to be superior to zoledronic acid in delaying the time to first or subsequent SREs in CRPC patients with bone metastases. This review discusses current and previous trials examining agents designed to prevent SREs in men with CRPC and bone metastases. It also discusses the practical aspects of administering a bone-targeted therapy, including choosing a bone-targeted therapy, monitoring at the onset and during therapy, switching from one therapy to another, and assessing potential complications.

Résumé

Le syndrome de levée d’obstacle est une polyurie massive faisant suite au traitement d’une insuffisance rénale obstructive. Les mécanismes physiopathologiques sont multiples : un état de surcharge hydrique qui dépend du caractère complet ou incomplet de l’obstacle, des anomalies tubulaires (atteinte de la capacité de dilution et de concentration des urines, diminution de la réabsorption du sodium, fuites de potassium, troubles de l’acidification des urines, insensibilité des cellules tubulaires à l’hormone antidiurétique), ainsi que des facteurs biochimiques et immunologiques sont mis en jeu. La levée d’un obstacle nécessite une surveillance clinique et biologique stricte (diurèse horaire, état hémodynamique, état d’hydratation, créatininémie, urémie, ionogramme sanguin). Le traitement a pour but d’éviter les troubles hémodynamiques et métaboliques graves, et repose sur le principe de la compensation des pertes hydroélectrolytiques.