Hidden trauma: shedding light on the relationship between gun violence and infertility.

Objective: To study the existing data on the relationship between penetrating abdominopelvic injuries and fertility guidance on managing fertility concerns of these patients using a case report and scoping review. Design: Case report and scoping review. Setting: Not applicable. Patients: People who have experienced abdominopelvic trauma from gun violence or in the course of combat. Interventions: None. Main Outcome Measures: We extracted case report data from electronic health records. We performed a scoping review using PubMed and Scopus. Search terms were related to penetrating abdominopelvic trauma, gunshot wounds (GSW), war, and fertility/infertility. We evaluated the study year, age and race, mechanism of injury, fertility outcomes, and how fertility concerns were addressed with patients who experienced penetrating abdominopelvic trauma. Results: In the case report, the couple had 10 years of infertility. The male partner experienced an abdominopelvic GSW before attempting to conceive. After evaluation, he was diagnosed with retrograde ejaculation. He recalled being advised that his GSW might affect his future fertility. The couple has discontinued care.For the scoping review, 879 sources were identified and 25 studies were included in the review. Among the studies conducted in the United States, most patients included were African American.Eighty-eight percent (n = 22) of the sources acknowledged the importance of fertility or used fertility-related outcome measures. One study commented on how to address fertility concerns with victims of abdominopelvic penetrating trauma. Conclusions: There is a paucity of data on the intersection of penetrating abdominopelvic injuries and fertility or guidance on how to discuss fertility issues with patients.

Association between Industry Payments and Published Position on Use of Devices for the Treatment of Lower Urinary Tract Symptoms.

OBJECTIVE: To determine the impact of industry payments to authors of opinion articles on the Urolift and Rezum devices. We also examined the extent to which authors omitted acknowledgements of financial conflicts-of-interest. METHODS: We searched Google Scholar for all articles that cite either of the respective pivotal trials for these devices. 2 blinded urologists coded the articles as favorable or neutral. A separate blinded researcher recorded industry payments from the manufacturers using the Open Payments Program database. RESULTS: We identified 29 articles written by 27 unique authors from an initial screening list of 235 articles. Of these articles, 15 (52%) were coded as positive and 14 (48%) were coded as neutral. 20 (74%) authors have accepted payments from the manufacturer of the device. Since 2014, these authors have collectively received $270,000 from NeoTract and $314,000 from Boston Scientific. Of the 20 authors with payments, 9 (45%) received more than $10,000 from either manufacturer. Of authors with payments, 65% (13/20) contributed to only positive articles. Authors who received payments had more than 4 times the number of article contributions than did authors without payments (42 vs 10). Authors of at least one favorable article were more likely to have received payments from the device manufacturers than authors of neutral articles (P = .014, Chi-squared test). Most (80%, 16/20) authors with payments did not report a relevant conflict-of-interest within any of their articles. CONCLUSION: These data suggest a relationship between payments from a manufacturer and positive published position on that company's device. There may be a critical lack of published editorial pieces by authors without financial conflicts of interest.

Persistent Opioid Usage After Urologic Intervention and the Impact of Tramadol.

OBJECTIVE: To determine if patients who receive tramadol are as likely to develop persistent usage compared to other opioids after urologic surgery and procedures. METHODS: We identified adults 18 to 64 years old who underwent a urologic procedure in the years 2014 to 2017 using the Truven MarketScan database and subsequently filled an opioid prescription within two weeks of discharge. Patients were excluded if they had any previous opioid prescriptions in the year before surgery. A multivariate logistic regression model was constructed to estimate influence of type of opioid on discharge and various comorbidities on persistent use to determine if persistent use was related to the choice of discharge opioid. We also compared these rates to a 1:3 comorbidities matched, non-surgical cohort of patients from the general population. RESULTS: Overall, 115,687 patients were included. After 1 year, 14.8% of the urologic surgery cohort had persistent opioid usage compared to 10.8% in the opioid naïve matched non-surgical cohort (OR = 1.37; 95% CI 1.35-1.39). Discharge with tramadol was associated with a higher odd of persistent usage compared to class II opioids controlling for type of urologic surgery, age, gender, and pain related comorbidities (OR = 1.23 95% CI 1.13-1.35). The odds of persistent usage varied slightly by type of urologic procedure, but all were higher than matched non-surgical cohort. CONCLUSION: Patients developed persistent opiate usage after urologic surgery compared to a comorbidity matched non-surgical cohort. In this model, tramadol specifically was associated with higher odds of novel persistent opioid usage compared to other opioids. Urologists should not consider tramadol to be a safer choice with regard to developing persistent usage and consider prospective validation of these results.

Virtual grand rounds as a novel means for applicants and programs to connect in the era of COVID-19.

BACKGROUND: COVID-19 has disrupted the 2020-2021 residency application cycle with the cancellation of away rotations and in-person interviews. This study seeks to investigate the feasibility and utility of video conferencing technology (VCT) as an opportunity for applicants to interact with faculty from outside programs. METHODS: 18 prospective urology applicants were randomized to 6 urology programs to give a virtual grand rounds (VGR) talk. Presentations were recorded and analyzed to determine audience engagement. Students were surveyed regarding perceived utility of VGR. Faculty were surveyed to determine system usability of VCT and ability to evaluate the applicant. RESULTS: 17 students completed the survey, reporting a 100% satisfaction rate with VGR. A majority felt this was a useful way to learn about outside programs. 85 physicians completed the faculty survey, with nearly half feeling confident in their ability to evaluate the applicant. Video transcription data shows sessions were interactive with minimal distractions. CONCLUSIONS: VGR can be a useful means for medical students to express interest in programs as well as an additional marker for faculty to evaluate applicants.

Perineal dermoid cyst in a young male.

Dermoid cysts, also known as mature cystic teratomas, are most frequently encountered in young women. While these lesions can be found throughout the body, they rarely involve the perineum. In order to better understand the clinical presentation, evaluation, and treatment of a perineal dermoid cysts, we present a 22-year-old male with a right buttock mass.

Artificial urinary sphincter longevity following transurethral resection of the prostate in the setting of prostate cancer.

PURPOSE: Refractory urinary incontinence after channel transurethral resection of the prostate (cTURP) (TURP in the setting of prostate cancer) is a rare occurrence treated with artificial urinary sphincter (AUS). We sought to characterize those patients receiving AUS after cTURP and understand device longevity. MATERIALS AND METHODS: We identified patients who underwent cTURP and AUS placement in SEER-Medicare from 2002 to 2014. We analyzed factors affecting device longevity using multivariable Cox proportional hazard models. We performed propensity matching to accurately compare patients receiving AUS after cTURP to those receiving AUS after radical prostatectomy (RP). RESULTS: For patients undergoing cTURP, 201 out of 56,957 ultimately underwent AUS placement (< 0.5%). AUS after cTURP incurred a 48.4% rate of reoperation versus 30.9% after RP. Importantly, patients undergoing cTURP were significantly older than those undergoing RP [75 vs. 71 years of age (p < 0.01)]. At 3 years after insertion, 28.2% of patients after RP required reoperation compared to 37.8% of patients post-cTURP (p < 0.01). There were no detectable differences in revision rates for those patients who underwent traditional vs. laser cTURP. Patients with a history of radiation therapy had significantly shorter device survival. Even after propensity matching, patients receiving AUS after cTURP incurred more short-term complications compared to AUS after RP. Differences in device longevity were diminished after propensity match. CONCLUSIONS: In the SEER-Medicare population, AUS after cTURP remains rare. While there is an increased risk of infectious complications, AUS after cTURP fared similarly to AUS after RP in terms of device longevity. A history of radiation therapy leads to worse outcome for all patients.

Evaluating the Role of Postoperative Oral Antibiotic Administration in Artificial Urinary Sphincter and Inflatable Penile Prosthesis Explantation: A Nationwide Analysis.

OBJECTIVE: To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown. MATERIALS AND METHODS: We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates. RESULTS: We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation. CONCLUSION: Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.

The Relationship Between Incontinence and Erectile Dysfunction After Robotic Prostatectomy: Are They Mutually Exclusive?

BACKGROUND: Urinary incontinence (UI) and erectile dysfunction (ED) remain the most common long-term complications of prostatectomy, with a significant impact on sexual health and quality of life. AIMS: To determine the relation between UI and moderate to severe ED and the risk factors for UI in patients undergoing robotic-assisted laparoscopic prostatectomy. METHODS: Patients in our institutional database who underwent robotic-assisted laparoscopic prostatectomy for prostate cancer (2006-2013) and who completed the University of California-Los Angeles Prostate Cancer Index and the Sexual Health Inventory for Men (SHIM) surveys at 12 months after prostatectomy were eligible for inclusion. Men who reported use of no urinary pads per day were considered continent, whereas men who used at least one pad per day were considered incontinent. Men with moderate to severe ED based on a SHIM score no higher than 11 were considered to have ED. Patients who had preoperative moderate to severe ED and/or UI based on these definitions were excluded from further analysis. OUTCOMES: A better understanding of what increases the risk for UI after a prostatectomy and how it can co-occur with ED. RESULTS: We analyzed 464 patients who met the inclusion criteria. After prostatectomy, 36% of patients had UI and 47% of patients had moderate to severe ED. Of all patients with ED, 45% (98 of 216) were incontinent compared with 27% (67 of 248) of patients without ED (P < .001). On multivariable analysis, older age at diagnosis (odds ratio [OR] = 1.05, P = .002) and ED (OR = 1.88, P = .005) were independent predictors for incontinence. The use of unilateral nerve sparing (OR = 1.03, P = .94) or no nerve sparing (OR = 0.53, P = .50) during surgery did not have an impact on postoperative incontinence. CLINICAL IMPLICATIONS: Understanding that ED is an independent predictor of UI after robotic-assisted laparoscopic prostatectomy has important clinical implications and suggests a common anatomic pathway. STRENGTHS AND LIMITATIONS: Our focus on different measurements of incontinence and their relation to ED and our use of validated questionnaires to define incontinence and ED were important strengths of this study. Limitations of our study include its retrospective nature and the fact that our results were drawn from a single-center database of a tertiary referral hospital. CONCLUSION: Our results show that the presence of moderate to severe ED after prostatectomy is an independent risk factor for incontinence, suggesting a possible common pathway for these two complications. Further studies to investigate the anatomic and clinical bases of this relation are warranted. Tsikis ST, Nottingham CU, Faris SF. The Relationship Between Incontinence and Erectile Dysfunction After Robotic Prostatectomy: Are They Mutually Exclusive? J Sex Med 2017;14:1241-1247.

Thirty-day Morbidity of Abdominal Sacrocolpopexy Is Influenced by Additional Surgical Treatment for Stress Urinary Incontinence.

OBJECTIVE: To assess the impact of concurrent anti-incontinence procedure (AIP) at time of abdominal sacrocolpopexy (ASC) on 30-day complications, readmission, and reoperation. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2013 was queried to identify patients who underwent ASC with or without AIP. We assessed baseline characteristics and 30-day perioperative outcomes including complications, readmission, and reoperation. RESULTS: There were 4793 patients who underwent ASC, of whom 1705 underwent concurrent AIP (35.6%). The majority of patients (4414, 92.1%) were treated by a gynecologist, but those treated by a urologist were older, had higher American Society of Anesthesiologists (ASA) class, and had increased frailty. Rates of 30-day postoperative urinary tract infection (UTI) and overall complication were higher among women who underwent concurrent AIP (4.75% vs 2.33%, P <.001; 7.74% vs 6.02%, P = .02). On multivariate analysis controlling for age, body mass index, approach, ASA physical status, modified frailty index, resident involvement, and surgeon specialty, AIP was associated with increased odds of UTI (odds ratio 2.20, 95% confidence interval 1.14-4.13, P = .02) and increased odds of overall complication (odds ratio 1.80, 95%confidence interval 1.10-2.93, P = .02). Thirty-day readmission and reoperation rates did not differ between the groups. CONCLUSION: AIP performed at the time of ASC are associated with higher rates of 30-day postoperative UTI but do not impact 30-day readmission or reoperation. The decision to perform AIP at the time of ASC should be made following a thorough discussion of the risks and benefits, including the potential for increased UTI with concurrent AIP.

Arts, Science, Engineering and Medicine Collaborate to Educate Public on Bioenergetics.

Mitochondrial dysfunction has correlated with a rise in energy deficiency disorders (EDD). The EDDs include mitochondrial disorders, obesity, metabolic disorders, cardiovascular and neurodegenerative disorders. Many individuals in our communities are at high risk of developing these disorders, yet are unaware of it. Our goal was to increase public awareness of mitochondrial health, whilst providing students with an innovative educational experience. We designed a 'Bioenergetics exhibition' by introducing Arts into traditional STEM (Science, Technology, Engineering & Mathematics) disciplines to create a new STEAM-(Health) initiative. Results indicated ~120,000 guests visited the exhibition, including many school-aged children, teachers and families. Comparative analysis of random first-time vs. repeat visitor surveys demonstrated a statistically significant (8.25% at p-value = 0.006) increase in knowledge of mitochondrial disease and bioenergetics. Our findings clearly support the power of the STEAM-H initiative in creatively communicating the complex science to a broader community.

The Impact of Minimally Invasive Surgery on Major Iatrogenic Ureteral Injury and Subsequent Ureteral Repair During Hysterectomy: A National Analysis of Risk Factors and Outcomes.

OBJECTIVE: To identify risk factors for ureteral injury during hysterectomy and to assess outcomes of concurrent minimally invasive vs converted to open repairs. METHODS: We queried the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2013 to identify abdominal hysterectomy (AH), minimally invasive hysterectomy (MIH), or vaginal hysterectomy. Ureteral injury was identified based on intraoperative or delayed management. Multivariate logistic regression was performed to assess the effect of hysterectomy approach on risk of ureteral injury while controlling for covariates. For patients with ureteral injury during MIH, we compared 30-day outcomes following minimally invasive vs converted open repairs. RESULTS: There were 302 iatrogenic ureteral injuries from 96,538 hysterectomies, with 0.18%, 0.48%, and 0.04% from AH, MIH, and vaginal hysterectomy, respectively. Patients who underwent MIH were younger and had decreased comorbidities compared to patients who underwent AH (all P < .001). MIH resulted in lower overall complications (6.6% vs 14.8%, P < .001) but higher ureteral injury rate (0.48% vs 0.18%, P < .001) compared to AH. On multivariate analysis, the minimally invasive approach was associated with increased risk of ureteral injury (odds ratio 4.2, P < .001). Patients undergoing minimally invasive ureteral repairs (89%) during MIH had shorter operating room time and length of stay but similar overall perioperative complications compared to those with converted open repairs (11%). CONCLUSION: Using a large national series, we show that the minimally invasive approach for hysterectomy is an independent risk factor for iatrogenic ureteral injuries. During MIH, concurrent minimally invasive ureteral repairs resulted in comparable 30-day outcomes compared to converted to open repairs.

Iatrogenic Bladder Injury: National Analysis of 30-Day Outcomes.

OBJECTIVE: To examine the risk factors and outcomes of BI, a rare complication of abdominopelvic surgery. METHODS: We queried the National Surgical Quality Improvement Program database to identify intraoperative bladder injury (BI) defined by the Current Procedural Terminology code for cystorrhaphy from 2005 to 2013. Propensity-score matching balanced the differences between patients with BI and the controls. The factors matched included age, body mass index, race, modified frailty index, and procedure category. RESULTS: There were 1685 cases of BI in 1,541,736 surgeries (0.11%). Although 49.5% of surgeries were performed in an open fashion, this approach accounted for 69.3% of BI (P < .001). Prior to matching, mortality rates and morbidity were increased for the BI group (P < .001). Moreover, age, recent chemotherapy or radiation or steroid history, and smoking were among the risk factors for BI (all P < .05). Resident involvement increased the odds of BI and complications after BI, but decreased the risk of readmission (all P < .05). After matching, 30-day mortality was no longer increased for patients with BI (P < .001). Patients with BI requiring repair did have increased median length of stay (6 days [interquartile range {IQR}: 3-11] vs 5 [IQR: 2-9]; P < .001) and operative time (203 min [IQR: 140-278] vs 134 [IQR: 86-199]; P < .001). BI patients were more likely to undergo reoperation (7.7% vs 5.3%; P = .005). Urine infection, sepsis, and bleeding were more likely in the BI group compared with the matched controls (all P < .001). Delayed repair was rare. CONCLUSION: We present the largest national series assessing iatrogenic BI and subsequent repair. BI increases 30-day complications, reoperation, and length of stay but does not increase 30-day mortality compared with matched controls. More complex surgical cases and increased baseline comorbidity were risk factors for BI.

Open Vs Minimally Invasive Adult Ureteral Reimplantation: Analysis of 30-day Outcomes in the National Surgical Quality Improvement Program (NSQIP) Database.

OBJECTIVE: To examine 30-day outcomes of robotic-assisted and pure laparoscopic ureteral reimplantation (LUR) vs open ureteral reimplantation (OUR) in adult patients for benign disease. METHODS: We identified adult patients undergoing LUR or OUR by urologists between 2006 and 2013 using the American College of Surgeons National Surgical Quality Improvement Program database, excluding those with concomitant partial cystectomy or ureterectomy. Multivariable regression modeling was used to assess for the independent association of minimally invasive surgery (MIS) with 30-day complications, reoperations, or readmissions. RESULTS: Of 512 patients identified, 300 underwent LUR and 212 underwent OUR. Baseline characteristics including age, race, body mass index, and cardiovascular comorbidities were similar between LUR and OUR (all P > .05). Patients who underwent LUR had higher median preoperative serum creatinine (1.1 mg/dL vs 1.0 mg/dL, P = .03), increased presence of a resident (51% vs 34%, P < .01), and shorter hospitalization (1 [interquartile range 0-3] days vs 4 [interquartile range 3-6] days, P < .01) compared to patients who underwent OUR. LUR had lower overall complications (9% vs 28%, P < .01), especially with regard to transfusions (1% vs 11%, P < .01), superficial wound infections (0% vs 5%, P < .01), and urinary tract infections (5% vs 11%, P = .03). On multiple regression analyses, MIS was an independent predictor of lower overall complication rate (odds ratio [OR] 0.24 [0.14-0.40], P < .01), but was not predictive of readmission (OR 0.93 [0.44-1.98], P = .16) or reoperation (OR 2.09 [0.90-4.82], P = .10). CONCLUSION: In the largest current series assessing the impact of MIS on adult ureteral reimplantation, data from the National Surgical Quality Improvement Program demonstrate that LUR results in decreased 30-day complications.

30-Day Morbidity and Reoperation Following Midurethral Sling: Analysis of 8772 Cases Using a National Prospective Database.

OBJECTIVE: To determine 30-day complications, risk of readmission, and reoperation for midurethral slings (MUS). METHODS: The National Surgical Quality Improvement Program database from 2006 to 2013 was queried for MUS alone by excluding concurrent reconstructive, urologic, or gynecologic procedures. We assessed baseline characteristics, 30-day perioperative outcomes and 30-day readmission. Logistic regression analysis identified risk factors for the frequent complications. RESULTS: There were 8772 women who underwent MUS, of which 3830 (43.7%) and 4942 (56.3%) were performed by urologists and gynecologists, respectively. Patients of urologists were older, had higher frailty, and were more likely diabetic (all P < .05). Patients of gynecologists were more likely to have resident involvement compared to urologists (16.4% vs 11.2%, P < .001). Mean operative time was shorter for urologists compared to gynecologists (35.6 ± 29.2 minutes vs 38.1 ± 34.3 minutes, P < .001). The overall 30-day rate of any complication was 3.52%. Urinary tract infection (UTI) occurred in 2.2% vs 3.5% of the urologic and gynecologic patients, respectively (P=.001). After adjusting for frailty, body mass index, steroid use, age, operative time, and residency involvement, gynecologic performed surgery incurred an increased risk of UTI (OR 1.67, 95% CI 1.27-2.19; P=.001). Sixty-five (0.90%) patients were readmitted within 30 days, most commonly due to urinary symptoms. Sling revision for urinary obstruction occurred in 15 patients; 10 underwent repair of the bladder, urethra, or vagina. CONCLUSION: To our knowledge, we present the largest American cohort of MUS 30-day outcomes to date, stratified by specialty of performing surgeon. Overall, morbidity is low. UTI is the most common complication, and occurs at increased frequency for patients of gynecologists.

Assessment of the Male Urethral Reconstruction Learning Curve.

OBJECTIVE: To evaluate the urethroplasty learning curve. Published success rates of urethral reconstruction for urethral stricture disease are high even though these procedures can be technically demanding. It is likely that success rates improve with time although a learning curve for urethral reconstruction has never been established. MATERIALS AND METHODS: We retrospectively reviewed anterior urethroplasties from a prospectively maintained multi-institutional database. Success was analyzed at the 18-month mark in all patients and defined as freedom from secondary operation for stricture recurrence. A multivariate logistic regression was performed for outcomes vs time from fellowship and case number. RESULTS: A total of 613 consecutive cases from 6 surgeons were analyzed, with a functional success rate of 87.3%. The success rate for bulbar urethroplasties was higher than that for penile urethroplasties (88.2% vs 78.3%, P = .0116). The success rate of anastomotic repairs was higher than that for substitution repairs (95.0% vs 82.4%, P = .0001). There was a statistically significant trend toward improved outcomes with increasing number of cases (P = .0422), which was most pronounced with bulbar repairs. There was no statistical improvement in penile repairs over time. The case number to reach proficiency (>90% success) was approximately 100 cases for all types of reconstruction and 70 cases for bulbar urethroplasty. There were statistical differences in success rates among the participating surgeons (P = .0014). Complications decreased with time (P = .0053). CONCLUSION: This study shows that success rates of anterior urethral reconstruction improve significantly with surgeon experience. Proficiency occurs after approximately 100 cases.

Urinary diversions after radiation for prostate cancer: indications and treatment.

OBJECTIVE: To characterize the presentation and symptom progression culminating in urinary diversion after radiotherapy for prostate cancer at a tertiary care reconstructive urology practice. MATERIALS AND METHODS: Retrospective review of electronic medical records was performed for all patients between 2005 and 2011 who underwent urinary diversion for urologic complications of radiation therapy for treatment of prostate cancer. We analyzed demographics, type of radiation, presenting symptoms, diagnostic evaluation, and surgical interventions. RESULTS: Of the 30 patients identified, 20% underwent external beam radiotherapy, 37% underwent brachytherapy, and 43% underwent combination therapy. Average time from radiation treatment until presentation to our institution was 4.6 years. Overall indications for urinary diversion included fistula (37%), end-stage bladder (20%), devastated outlet (27%), and a combination of end-stage bladder and devastated outlet (17%). Types of urinary diversion included cystectomy with conduit diversion, conduit diversion alone, and chronic indwelling suprapubic catheter. Eight patients additionally required bowel diversion for intractable gastrointestinal symptoms. Patients underwent an average of 4.4 procedures attempting to salvage native voiding function before urinary diversion. CONCLUSION: The reported need for urinary diversion after radiation therapy for prostate cancer is rare and thus indications have not been well characterized. We found that all of our patients with rectourethral fistula had prior placement of brachytherapy seeds. External beam radiotherapy resulted in a higher incidence of end-stage bladder dysfunction, whereas brachytherapy seed placement was more commonly associated with a devastated outlet. Surgical management for end-stage disease included cystectomy with conduit diversion, conduit diversion alone, and indwelling suprapubic catheter.