Transition from standard robotic prostatectomy to Retzius-sparing prostatectomy: feasibility and early outcomes.

BACKGROUND AND OBJECTIVE: Retzius-sparing robotic-assisted radical prostatectomy (rsRARP) has gained popularity due to superior early continence outcomes compared to standard robotic prostatectomy (sRARP). We evaluate the results of a single surgeon who transitioned from sRARP to rsRARP and compare oncologic and functional outcomes. METHODS: We retrospectively reviewed all prostatectomies performed by a single surgeon between June 2018 and October 2020. Perioperative, oncologic, and functional data were collected and analyzed. Patients who underwent sRARP were compared with those who underwent rsRARP. RESULTS: Both groups contained 37 consecutive patients each. Preoperative patient characteristics and biopsy results were similar between the two groups. Perioperative outcomes were significant for longer operative room time and higher proportion of T3 tumors in the rsRARP group. Thirty-day complication and readmission rates were similar between groups. There was no difference in early oncologic outcomes, including positive surgical margin rate, biochemical recurrence, and need for adjuvant or salvage treatments. The time to urinary continence and immediate continence rate was superior in the rsRARP group. CONCLUSIONS: The Retzius-sparing approach can be safely adopted by surgeons experienced in sRARP without compromising early oncologic outcomes and with the benefit of improved early continence recovery.

Using Intraoperative Portable CT Scan to Minimize Reintervention Rates in Percutaneous Nephrolithotomy: A Prospective Trial.

Background and Purpose: More than 40% of patients undergoing percutaneous nephrolithotomy (PCNL) are left with residual stone fragments and often require secondary procedures. Portable CT (PCT) technology allows surgeons to obtain intraoperative cross-sectional imaging, identify and extract residual stones immediately, and thereby reduce the need for subsequent procedures. This prospective trial evaluates how incorporation of PCT during PCNL affects perioperative outcomes. Patients and Methods: We prospectively enrolled eligible patients undergoing initial PCNL for this trial (n = 60), which entailed a single intraoperative CT abdomen and ipsilateral antegrade ureteroscopy when the surgeon felt stone treatment was visually complete. If residual fragments were identified, the surgeon continued nephroscopy to find and remove them; if not, the procedure was concluded. These patients were compared with a retrospective cohort (n = 174) who underwent initial PCNL with postoperative imaging performed the following day. Results: The two cohorts had similar demographic properties and stone characteristics, and location of percutaneous access. In the prospective arm, 50% of intraoperative PCT scans identified residual fragments, prompting continuation of surgery to remove them. This cohort had significantly higher stone-free rate (82% vs 36%, p < 0.01), lower rate of planned reintervention (7% vs 32%, p < 0.01), lower rate of urgent presentation with ureteral obstruction (0% vs 7%, p = 0.04), lower total CT-based effective radiation dose (8.4 mSv vs 14.6 mSv, p < 0.01), and shorter length of stay (2.3 days vs 3.5 days, p < 0.01) when compared with the retrospective cohort that did not use intraoperative PCT. Conclusions: Obtaining an intraoperative PCT scan during PCNL can substantially improve perioperative outcomes. Further evaluation of this modality through a randomized controlled trial is warranted. Clinical Trial Registration Number: NCT04556396.

Long-term patient-reported outcomes in men with Peyronie's disease undergoing nonsurgical and nonintralesional injection management.

Peyronie's disease (PD) has a negative impact on overall quality of life for many patients and their partners. There is a significant portion of patients who elect noninvasive therapy and in this scenario we have little data with which to counsel patients. We aim to evaluate long-term patient-reported outcomes in a cohort of men with PD who elected conservative treatment. We identified all males with a diagnosis of PD evaluated at our institution by a single provider between May 2012 and January 2018. We excluded men who were <18 years old or had undergone surgical or intralesional injection (ILI) treatments. A PD-specific questionnaire was sent to those who met our inclusion criteria. 88/514 patients completed the survey and met the inclusion criteria. Penile curvature subjectively improved in 49%, remained stable in 34%, and worsened in 17%. Penile shortening was reported in 89% of patients. Penile shortening subjectively improved in 27%, remained stable in 59%, and worsened in 14%. Roughly 60% reported worsened intercourse satisfaction and erectile function. 60% reported that PD had negatively impacted their self-esteem and 69% felt that PD negatively impacted their sexual partner. Patients who utilized penile traction therapy (PTT) were significantly more likely to report improvements in penile curvature, shortening, and ability to engage in penetrative intercourse. Our survey provides important data on patient-reported outcomes in men with PD electing nonsurgical and non-ILI interventions. Although 49% of men noted at least a mild subjective improvement in their curvature over time, a majority had declining erectile function, decreased intercourse satisfaction, and psychosocial distress. These data can be used when counseling patients with a new diagnosis of PD who are considering treatment options.

The Use of Serum Procalcitonin in the Setting of Infected Ureteral Stones: A Prospective Observational Study.

Introduction: Infected ureteral stones are a urologic emergency and require urgent decompression. We set out to determine whether serum procalcitonin (PCT) could aid in the diagnosis of infected ureteral stones. Methods: All consecutive patients presenting to the emergency room from November 9, 2016, to November 10, 2018, with an obstructing ureteral stone were included. All patients had complete blood count, urinalysis (UA), PCT, and urine culture (UCx). Subgroup analysis was performed in a "clinically equivocal" cohort of afebrile patients defined as a leukocytosis >104/µL and UA with <50 white blood cells (WBCs) per high powered field (hpf). Patients with positive and negative UCx were compared. Results: A total of 231 patients were included, of whom 56 had a positive UCx. Of all covariates, UA WBCs with a cutoff of 9 per hpf performed best at predicting positive UCx with an area under the curve (AUC) of 0.87. PCT did not perform as well with an ideal cutoff of 0.08 ng/mL, having an AUC of 0.77, sensitivity 70.6%, specificity 73.9%, positive predictive value (PPV) 34.3%, and negative predictive value (NPV) 92.9%. When looking at the clinically equivocal cohort, UA WBCs with a cutoff of 6 per hpf appeared to perform best at predicting a positive UCx with an AUC of 0.72. PCT was less predictive in this cohort with an ideal cutoff of 0.3 ng/mL, having an AUC of 0.32, sensitivity 47.1%, specificity 85.2%, PPV 38.1%, and NPV 89.3%. Conclusion: PCT does not appear to be a superior marker for diagnosing urinary tract infection in the setting of obstructing ureterolithiasis when compared with components of the standard work-up.

Risk Factors and Management Options for the Adult Failed Ureteropelvic Junction Obstruction Repair in the Era of Minimally Invasive and Robotic Approaches: A Comprehensive Literature Review.

Guidelines for the management of pyeloplasty failure remain elusive given the rarity of this condition and the difficulty of integrating and analyzing reported outcomes given the varying definition of failures. In this article, we aim to review the existing literature on risk factors that may influence the surgical outcomes of reconstructive pyeloplasty for ureteropelvic junction obstruction. Furthermore, we discuss management options and review success outcomes of treatment options for patients with pyeloplasty failure.

The Urology Residency Interview: Prevalence of Potentially Discriminatory Questions and the Financial Burden on Applicants.

INTRODUCTION: We assessed the prevalence of potentially illegal questions asked as well as the financial burden faced by applicants during the 2017 and 2018 urology match. METHODS: A survey was e-mailed to all candidates applying to a single urology residency program during the 2017 and 2018 matches. Data collected included demographic information, estimate of the total money spent during interviews and whether applicants were asked any of the potentially discriminatory questions outlined by the NRMP (National Residency Match Program) at any interview. RESULTS: An e-mail was sent to 609 applicants, with 201 responses (33% response rate). The median amount of money spent per applicant during the interview process was $5,000 (IQR $3,000-$8,000). Of the potentially discriminatory questions outlined by the NRMP, "other programs for which you applied" was asked for 96.8% of respondents, "where you planned on ranking their program" for 34.6%, pregnancy status of you or your significant other for 14.7%, religious affiliation for 4.5% and sexual orientation for 0.6%. CONCLUSIONS: Potentially discriminatory questions are still prevalent in urology residency interviews and the financial expense of interviewing remains immense. Urology has a separate match and can be a leader in making changes to limit the prevalence of these questions with the goal of making the match process as fair and nondiscriminatory as possible. Efforts should also be made to minimize costs so that highly qualified candidates do not miss interviews due to financial constraints.

Contemporary Review of Peyronie's Disease Treatment.

PURPOSE: To analyze the literature on the current treatment options for Peyronie's disease (PD). RECENT FINDINGS: Intracavernosal injection therapy using collagenase clostridium histolyticum (CCH) has been widely adopted since its FDA approval in 2013. Based on the current evidence, it appears to be moderately efficacious for men with mild curvatures. Although a recent study has shown similar outcomes using a modified protocol requiring fewer injections, CCH remains an expensive medication. Surgery provides the most definitive treatment. The most common adverse effect following surgery is perceived loss of length. Length restoration procedures have recently been developed to address this with promising results reported in small series. There are a variety of medical treatment options for PD, with CCH getting the most attention for being the first drug to be FDA approved for PD treatment. It is the authors' opinion that the non-surgical therapy most likely to provide meaningful results is combination therapy utilizing oral, intralesional, and external traction therapy. Surgery remains the gold standard for definitive treatment.

Modified Inflatable Penile Prosthesis Reservoir Placement Into Space of Retzius: Comparing Outcomes in Men With or Without Prior Pelvic Surgery.

BACKGROUND: Traditional inflatable penile prosthesis (IPP) reservoir placement has rare but potentially serious complications including damage to local structures, and Levine and Hoeh (J Sex Med 2012;9:2759-2769) described a modified technique designed to avoid these complications. AIM: To determine whether the modified Jorgenson scissors technique is safe and effective in patients who have had prior pelvic surgery. METHODS: A retrospective chart review was performed on all patients who had a three-piece IPP placed by a single urologist from 2011 to 2015. Complication rates between the prior pelvic surgery group and the virgin pelvis group were compared using χ2 test. Differences between the two groups were considered statistically significant at a P value less than .05. OUTCOMES: Reservoir-related complication rate and rate of converting to ectopic placement. RESULTS: A total of 246 procedures were included, with 174 having no prior pelvic surgery and 72 with prior pelvic surgery. The reservoir-related complication rates were 2.8% (2 of 72) in the prior pelvic surgery group and 3.4% (6 of 174) in the virgin pelvis group. This difference was not statistically significant (P = .79). The two complications from the prior pelvic surgery cohort were inguinal hernias requiring surgical repair, which occurred in the same patient. In the virgin pelvis cohort, there were five inguinal hernias and one autoinflation. There were 16 patients who required ectopic placement of the reservoir owing to difficulty in entering the space of Retzius (SOR), 14 of whom had prior pelvic surgery. CLINICAL IMPLICATIONS: We believe this modified technique for IPP reservoir placement into the SOR is a safe alternative because the Jorgenson scissors allow perforation into the SOR away from vital structures. STRENGTHS AND LIMITATIONS: The study is limited by the fact that it is a retrospective, single-center, chart review of a non-randomized surgical procedure with variable follow-up in a limited number of patients. Its strength is its applicability to provide surgeons a modified technique that can be used routinely for IPP reservoir placement that appears to be safe and effective, even in men who have had prior pelvic surgery. CONCLUSION: In our experience, the modified Jorgenson scissors technique allows for safe entry into the SOR through a transverse scrotal incision and is a viable alternative to the standard SOR placement and the ectopic approach. Capoccia EM, Phelps JN, Levine LA. Modified Inflatable Penile Prosthesis Reservoir Placement Into Space of Retzius: Comparing Outcomes in Men With or Without Prior Pelvic Surgery. J Sex Med 2017;14:968-973.