Management of hydrocele in adolescent patients

Hydrocele is defined as an abnormal collection of serous fluid in the potential space between the parietal and visceral layers of the tunica vaginalis. In the majority of affected adolescents, hydrocele is acquired and is idiopathic in origin. The pathogenesis of idiopathic hydrocele is thought to be an imbalance in the normal process of fluid production and reabsorption. The diagnosis is usually clinical. Taking a thorough history is essential to rule out any fluctuation in size, which is an indication of a patent processus vaginalis. Scrotal ultrasonography is mandatory in nonpalpable testicles to rule out a subtending testicular solid mass requiring inguinal exploration. Otherwise, open hydrocelectomy via a scrotal incision is the standard treatment of idiopathic hydroceles. The second most common cause of hydrocele in adolescents is varicocelectomy. The risk of hydrocele formation is higher with non-artery-sparing procedures or those performed without microsurgical aid, and in surgery requiring cord dissection. If hydrocele occurs after varicocelectomy, initial management should include observation with or without hydrocele aspiration. Large persistent hydroceles are best served by open hydrocelectomy

The Balance between Open and Robotic Training among Graduating Urology Residents-Does Surgical Technique Need Monitoring?

A minimum number of index procedures is required for graduation. Without thresholds for surgical technique, it is unclear if robotic and open learning is balanced. We assessed the distribution of robotic and open surgeries performed by residents upon graduation. Voluntary Accreditation Council for Graduate Medical Education resident case logs from 11 institutions were de-identified and trends in robotic and open major surgeries were compared using Wilcoxon rank sum and 2-sample t-tests. A total of 89,199 major cases were recorded by 209 graduates from 2011 to 2017. The median proportion of robotic cases increased from 2011 to 2017 in reconstruction (4.7% to 15.2%), oncology (27.5% to 54.2%) and pediatrics (0% to 10.9%) (all values p <0.001). Robotic and open cases remained most divergent in reconstruction, with a median of 12 robotic (IQR 9-19) to 70 open cases (IQR 55-106) being performed by residents in 2017. Similar observations occurred in pediatrics. In oncology the number of robotic procedures superseded that of open in 2016 and rose to a median of 148 robotic (IQR 108-214) to 121 open cases (IQR 90-169) in 2017, with the driver being robotic prostatectomy. Substantial differences in surgical technique were observed between institutions and among graduates from the same institution. Although robotic volume is increasing, the balance of surgical technique and the pace of change differ in reconstruction, oncology and pediatrics, as well as among individual institutions and graduates themselves. This raises questions about whether more specific guidelines are needed to ensure equity and standardization in training

Female sexuality in chronic pelvic pain

BPS/IC is a chronic disorder characterized by chronic pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder accompanied by at least one urinary symptom such as persistent urge to void or urinary frequency. Sexual dysfunction symptoms have been reported for women with BPS/IC, including lack of libido and of sexual interest, pain during intercourse, and vulvodynia. The exact prevalence of sexual dysfunction among women with BPS/IC is unknown, but it seems to range between 13 and 87 %, and worse sexual functioning has been observed among patients with BPS/IC than among the general population or age-matched control patients. Alteration in arousal, lubrication, and orgasm, together with dyspareunia and vulvodynia, is the most frequently reported sexual dysfunction in women affected by BPS/IC. From a neurophysiological point of view, chronic inflammation induces pain following chronic changes in neurotransmission, mechanisms of pain control, and tissue responses. Endometriosis is a common cause of chronic pelvic pain in women and is diagnosed in up to 80 % of BPS/IC. The baseline evaluation includes history and physical and laboratory examination in order to assess the presence of BPS/IC and exclude other diseases with similar symptoms, such as vaginismus, vulvar vestibulitis, vulvodynia, atrophic tissue or impaired lubrication, adnexal pathology, chronic cervicitis, pelvic inflammatory disease, and urethra disorders. Any eventual confusable disease should be diagnosed and excluded. Condition-specific symptom questionnaires, psychosocial parameters, and QoL questionnaires should be used to adequately assess patients with BPS/IC. Treatment should be approached in many directions, including psychological and social aspects. Patients should be educated that BPS/IC is a chronic condition associated with relapsing and remitting phases with a gradual progression to a more severe condition along time. Changes in diet and lifestyle can help reduce symptoms and bladder retraining by reducing voiding frequency in some patients with the disease. When the patients’ symptoms do not respond to nonpharmacological treatment, it is necessary to move toward pharmacological interventions. A combination of oral and intravesical therapies together with lifestyle intervention and physical therapy can gradually improve pain and urinary symptoms in patients affected by BPS/IC, although an evidence-based management approach has not yet been developed