A scoping review of penile implant biofilms-what do we know and what remains unknown?

Background: Penile prosthesis (PP) is a gold standard for treatment of erectile dysfunction given its reliability and efficacy. Infection remains the most feared complication of prosthetic surgery, which usually results in device removal, and places a significant economic burden on the healthcare system. While biofilms have shown to support the persistence of microorganisms, the degree by which this matrix is truly pathogenic remains unknown given its high prevalence even in asymptomatic patients. We aim to review and summarize the current literature pertaining to biofilm formation in the setting of PP surgeries in clinically infected and non-infected cases. Methods: Searches were performed in the MEDLINE online database through PubMed using a combination of keywords "penile prosthetic" OR "penile prosthesis" OR "penile implant" AND "biofilm" OR "revision" OR "removal" OR "infection" OR "explant". Eleven articles met inclusion criteria. There were only three studies that explicitly listed the number of biofilms identified in their cohort, but we also included eight articles that mentioned swabbing and culturing of any bacterial biofilm during revision procedures for both clinically infected and non-infected implants. Results: Infected PP yielded a 11-100% rate of biofilm presence, while non-infected PP yielded a 3-70% rate of biofilm presence. Time to reoperation from initial PP placement were also largely variable, ranging from 2 weeks to over 2 years. Coagulase-negative staphylococcus (i.e., Staphylococcus epidermidis) were the most commonly reported organisms among non-infected implants, however, newer studies have identified a change towards more virulent organisms. Conclusions: Since the advent of PP surgery, diabetes control, revision washout protocols and antibiotic-impregnated devices have led to an overall decrease in biofilm formation and infectious complications. There is an overall paradigm shift in microbial profiles with more virulent organisms, such as Escherichia coli, Pseudomonas aeruginosa, Enterococcus species, and even fungal species beginning to replace the more common coagulase-negative staphylococcal species, especially in clinically infected implants. Additional studies are necessary to define the significance of bacterial presence in biofilms using impactful technologies such as next-generation sequencing. Currently, preliminary and experimental biofilm-control strategies are also underway to further address this clinical issue.

HoLEP techniques - lessons learned.

INTRODUCTION Holmium laser enucleation of the prostate (HoLEP) with mechanical tissue morcellation is one of the most effective surgical modalities for the treatment of symptomatic BPH. HoLEP has many advantages over the historical gold standards open prostatectomy (OP) and transurethral resection of the prostate (TURP). HoLEP is an AUA guideline endorsed surgical treatment for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), independent of prostate size. MATERIALS AND METHODS: We provide a detailed presentation of our experience in performing HoLEP in a teaching university hospital, with an emphasis on the surgical technique and its evolution. RESULTS: HoLEP is an efficient and durable procedure, although it is very equipment sensitive and has a relatively long learning curve. HoLEP can be performed by several surgical approaches that can be used according to the specific anatomy of the patient. Advances in laser technology, endoscopic morcellators, and surgical technique has improved the HoLEP procedure in efficiency, hemostasis, and safety. CONCLUSIONS: The HoLEP procedure, first introduced in 1998, has undergone significant changes including advancements in laser technology, endoscopic morcellation devices, and modifications to the surgical technique. These advancements have made HoLEP a more effective, more efficient, easier to perform, and easier to learn technique for the surgical management of BPH. The modified 2-lobe and the en-bloc techniques are a natural progression from the classic 3-lobe technique.

Nonobstetrical Robotic-Assisted Laparoscopic Surgery in Pregnancy: A Systematic Literature Review.

Urologic and gynecologic surgeons are the top utilizers of robotic surgery; however, nonobstetrical robotic-assisted laparoscopic surgery (RALS) in pregnant patients is infrequent. A systematic literature review was performed to ascertain the frequency, indication and complications of RALS in pregnancy. Results showed 38 pregnancies from eleven publications between 2008 and 2020. Five cases were for urologic indication and 33 for gynecologic indication. Minimal surgical alterations were required. Although no adverse maternal-fetal outcomes were reported, there are not enough cases published to determine safety. This review demonstrates the feasibility of RALS for the pregnant population in the hands of competent robotic surgeons.

Female Representation at High-profile Urology Conferences, 2014-2019: A Leadership Metric.

OBJECTIVE: To measure female leadership through speakership at urology conferences and compare involvement to the overall representation of women in the urologic workforce. METHODS: A cross-sectional analysis was conducted to identify the gender of conference speakers from 2014 to 2019. Six high-profile urology conferences were selected: AUA; SUFU; SPU; SUO; GURS; WCE. Using programming published by each society, the number of invited female speakers at each conference was recorded. Comparisons were made to the proportion of practicing female urologists based on AUA census data. RESULTS: A total of 34 conferences were reviewed. From 2014 to 2019, the percentage of female representation increased from 13.7% to 19.3% (P < .05). The proportion of female speakers at all conferences ranged from 0% to 35.6%. The average absolute increase was 1.3% each year. Female representation at urology conferences in 2019 was significantly greater than female representation in the field (19.3% vs 9.9%, P < .05). CONCLUSION: There is a slight trend of increasing proportion of invited female speakers at academic urology conferences from 2014 to 2019. Although the proportion of women in urology remains low, the trend indicates that the mean proportion of female speakers is higher than the proportion of women in the field. Inclusion of female conference speakers presents an opportunity for increased gender parity within urology leadership.

Impact of Tumor Regional Involvement on Active Surveillance Outcomes: Validation of the Cumulative Cancer Location Metric in a US Population.

BACKGROUND: Treatment progression for men on active surveillance (AS) for prostate cancer (PCa) is driven primarily by grade and volume progression on isolated prostate biopsies (PBx). As PCa is a multifocal disease, regional disease progression over time should be accounted for. OBJECTIVE: To validate the utility of the cumulative cancer location (CCLO) metric, which assesses regional core involvement, as described by Erickson et al (Cumulative cancer locations is a novel metric for predicting active surveillance outcomes: a multicenter study. Eur Urol Oncol 2018;1:268-75), in predicting AS outcomes in a North American cohort. DESIGN, SETTING, AND PARTICIPANTS: A single-institutional retrospective chart review of all AS patients evaluated between 2015 and 2017. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: CCLO defined as the total number of cancer-positive sextant locations among all PBx to that point in time (range 1-6). Baseline demographics and clinical characteristics of the entire cohort were stratified by CCLOΔ, defined as the difference between the first and the last CCLO. CCLOΔ then correlated with progression to treatment and treatment outcomes. RESULTS AND LIMITATIONS: A total of 261 men met the inclusion criteria. Though the mean number of biopsies was slightly higher in the CCLOΔ 3-5 cohort than in the CCLOΔ 0-2 cohort (p = 0.006), mean AS follow-up time (3.3 yr) was not significantly different (p = 0.327). As CCLOΔ increased, the proportion of men remaining on AS decreased, while the proportion of men receiving treatment increased (p < 0.001). In men undergoing radical prostatectomy, a higher CCLOΔ was not associated with higher rates of Gleason 7-10 (p = 0.38) or pT3 (p = 0.52) disease. However, as CCLOΔ increased, upgrading from final PBx to RP pathology increased, while downgrading decreased (p = 0.12). In Kaplan-Meier analyses, lower CCLOΔ and lower initial cancer location scores were associated with the highest 5-yr treatment-free survival rates (p < 0.001). CONCLUSIONS: Higher regional cancer core involvement is associated with higher rates of progression to treatment in AS patients. The CCLO metric is a potentially useful modality in stratifying AS patients among the North American cohort for treatment, while not compromising disease outcomes. PATIENT SUMMARY: In the North American population, cumulative cancer-positive locations among biopsies can be used to predict active surveillance outcomes in men with prostate cancer.