Predictive Risk Factors for Continued Smoking after the Diagnosis of a Genitourinary Malignancy.

OBJECTIVE: To determine risk factors for continued smoking following a diagnosis of a genitourinary (GU) malignancy. Smoking is a well established risk factor in the development of cancers involving the GU tract. Unfortunately, a large percentage of patients continue to smoke or relapse after cancer diagnosis; by doing so, there is an increased risk of recurrence, poor survival rates, treatment complications, secondary primary cancers, and other chronic smoking related illnesses. MATERIALS AND METHODS: Two hundred and five patients who presented to a Urologic Oncology clinic at a single tertiary treatment center were given smoking cessation counseling and pharmacotherapy, as well as a questionnaire which was used to identify smoking status, demographics, and behavioral/psychosocial characteristics. Patients were followed for a minimum of 1 year with a median length of follow up for 13 months. RESULTS: 91% of patients enrolled in the study continued smoking at survey completion. After accounting for age, ethnicity, education and cigarettes consumed/day, 5 variables were independently associated with an increased risk of continued smoking: smoking 20 or more cigarettes per day, less than 2 prior quit attempts, anxiety and/or depression, fear of cancer recurrence, and home secondhand smoke exposure. CONCLUSION: The role of the urologist is imperative for encouraging smoking cessation. While every patient should receive adequate counseling regarding smoking at the time of a GU malignancy diagnosis, identifying patients with the risk factors noted in this study and augmenting smoking cessation efforts may result in stronger efforts to quit and prevention of long-term complications.

Isolated Spongy Urethral Rupture from Abrupt Coital Distractive Force.

The classic presentation of penile fracture is a cracking or snap sound, with sharp pain, immediate detumescence, swelling, deformation and ecchymosis. A penile fracture involves rupture of the tunica albuginea of one or both corpora cavernosa. Concomitant urethral rupture is reported to occur in 10% to 20% of penile fracture cases. Isolated urethral injury without penile fracture is extremely rare. We report the first case of isolated pendulous urethral rupture from an abrupt coital distractive force. We include a literature review and discussion of isolated urethral trauma secondary to sexual intercourse. Retrograde urethrography rendered a stunning clinical image which was integral to the diagnosis and management of this patient's injury.

Forgotten ureteral stents: who's at risk?

The sequelae from forgotten stents carry significant morbidity and costs. In this study, we attempt to identify potential risk factors that may make patients less likely to follow up for stent removal so that more effective prevention efforts may be directed at these persons. A single-institution retrospective analysis of 187 consecutive patients who had stents placed between January 2010 and December 2010 was performed. Chart review was conducted to see if patients had undergone stent removal beyond the intended maximal stent life (MSL). Patients who were lost to follow-up were contacted to determine if stents were overdue. Logistic regression was performed to determine risk factors. Of the 187 patients who had stents placed, 147 had the stent removed before MSL and 28 had stents removed after the MSL. Twelve patients could not be contacted and were excluded from the analysis. Within our cohort of 175 patients, 48% were males, 73% were minorities (33% Latino, 30% Black, 8% Asian, and 2% Native American), 39% did not speak English, 79% were unemployed, 73% were uninsured, and 35% were married. Among the patients with forgotten stents, 68% were male, 64% were minorities (32% Latino, 29% Black, 4% Native American, and 0% Asian), 82% were unemployed, 39% did not speak English, 93% were uninsured, and 43% were married. Multivariate regression analysis demonstrated that uninsured patients (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.4-28.2; P value 0.01) and males (OR, 2.8; CI, 1.2-6.8; P=0.02) had statistically significant associations with forgotten stents. Men were 2.8 times more likely to have forgotten stents than females. Patients without health insurance were six times more likely to have forgotten stents than patients with insurance. As efforts are made to prevent forgotten stents, increased attention should be given to these higher-risk patient populations.

Feasibility and early outcomes of robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy in patients with prune belly syndrome.

OBJECTIVES: To evaluate the feasibility and report our initial experience with Robotic-Assisted Laparoscopic Mitrofanoff Appendicovesicostomy (RALMA) in patients with prune belly syndrome. The Mitrofanoff appendicovesicostomy procedure uses the appendix to create an easily accessible continent, catheterizable channel into the urinary bladder. Historically, the procedure is performed by an open surgical approach in prune belly patients. We describe our initial experience herein. MATERIALS AND METHODS: Between October 2008 and February 2010 three patients with prune belly syndrome underwent RALMA. The appendicovesicostomy anastomosis was performed on the anterior bladder wall and the stoma was brought to the umbilical site or right lower quadrant. At least 4 cm of detrusor backing was ensured. The appendicovesicostomy stent was left in place for 4 weeks postoperatively before initiation of catheterization. RESULTS: Mean age at surgery was 9.7 years (range 5-14 years). Blood loss volume was 20 mL in each case. Overall mean operative time was 352 min (range 319-402 min). There were no intraoperative complications and no open conversions. There was one postoperative complication in the form of wound infection. All patients are catheterizing their stomas and are continent at an average follow-up of 14.7 months (range 5-21 months). CONCLUSION: In our initial experience, RALMA is a feasible option with encouraging early experience for creating a continent catheterizable channel into the urinary bladder in patients with prune belly syndrome.

Continence outcomes in patients undergoing robotic assisted laparoscopic mitrofanoff appendicovesicostomy.

PURPOSE: Continent catheterizable channels for emptying the bladder are typically performed via an open surgical approach. We present our surgical approach and initial outcomes with specific attention to continence for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy formation. MATERIALS AND METHODS: Between February 2008 and April 2010, 13 patients were considered for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy and 11 underwent the procedure (2 open conversions). Five patients underwent enterocystoplasty with appendicovesicostomy and 6 underwent isolated appendicovesicostomy. The appendicovesicostomy anastomosis was performed on the anterior (without augmentation) or posterior (with augmentation) bladder wall and the stoma was brought to the umbilical site or right lower quadrant. Detrusor backing (4 cm) was ensured except in 1 patient (number 5). RESULTS: Mean patient age at surgery was 10.4 years (range 5 to 14). Mean estimated blood loss was 61.8 cc. Mean operative time for isolated appendicovesicostomy was 347 minutes and there were no intraoperative complications. Incontinence through the stoma developed in 1 patient with inadequate detrusor backing (less than 4 cm), which resolved with dextranomer/hyaluronic acid injection into the appendicovesicostomy anastomosis. This patient had resolution of incontinence with an increase in bladder capacity to 300 cc. Three patients required skin flap revision for cutaneous scarring. To date all patients are catheterizing without difficulty and are continent. Median followup was 20 months (range 3 to 29). CONCLUSIONS: We are encouraged by our preliminary experience with the robotic assisted laparoscopic Mitrofanoff appendicovesicostomy continent urinary diversion with or without ileocystoplasty. Early in the experience we emphasize the importance of 4 cm of detrusor backing to maintain stomal continence.

Continued improvement of perioperative, pathological and continence outcomes during 700 robot-assisted radical prostatectomies.

BACKGROUND: Several robot-assisted radical prostatectomy (RARP) series have reviewed the impact of the initial learning curve on perioperative outcomes. However, little is known about the impact of experience on urinary and sexual outcomes. Herein, we review the perioperative, pathological and functional outcomes of our initial 700 consecutive procedures with at least 1 year follow up. METHODS: From 2003-2006, 700 consecutive men underwent RARP at a single, academic institution. Perioperative data and pathologic outcomes were prospectively collected. Validated, UCLA-PCI-SF36v2 quality-of-life questionnaires were also obtained at 1, 3, 6 and 12 months following surgery. Outcomes between groups (cases 1-300, 301-500, and 501-700) were compared. RESULTS: Mean operative time (OT) and blood loss significantly decreased during the experience (286, 198, 190 min; p or=7 in 24%, 40%, 44%; p

Novel technique for proximal anchoring of penile prostheses in female-to-male transsexual.

OBJECTIVES: To present our initial experience with a novel technique for fixation of an inflatable penile prosthesis in the female-to-male transsexual in 2 patients. METHODS: Proximal fixation of an inflatable penile prosthesis is challenging in the female-to-male transsexual because of the lack of normal corporal bodies. This technique uses a bone drill to create a fixation chamber in the symphysis pubis. A rear tip extender is then secured into bone, providing a stable fixation point for the proximal aspect of the penile cylinder. RESULTS: Two patients successfully underwent placement of a 2-cylinder inflatable penile prosthesis using this technique without any complications. At 8 and 13 months postoperatively, their Sexual Health Inventory for Men score was 23 and 25 of a possible 25 points, respectively. CONCLUSIONS: With modest follow-up, bone anchoring appears to provide improved support and better performance of the inflatable penile implant in the female-to-male transsexual patient.

Salvage of end-stage erectile dysfunction using vascularized fibula as autologous implant.

INTRODUCTION: Patients in whom medical and surgical options for the treatment of erectile dysfunction have failed pose a unique challenge to reconstructive genitourinary surgeons. We report a novel reconstructive option for the treatment of end-stage erectile dysfunction using a microsurgically transferred vascularized fibula as an autologous implant in a patient in whom multiple inflatable prostheses had failed. TECHNICAL CONSIDERATIONS: A reconstructive team, consisting of urologic and plastic reconstructive surgeons, transferred a vascularized fibula into the corporeal body in 1 patient to restore sexual function. Using this technique, successful intercourse was achieved by 6 months of follow-up. We describe the surgical technique of autologous implant of a vascularized fibula in the salvage treatment of end-stage erectile dysfunction. CONCLUSIONS: Patients with multiple failed inflatable penile implants can present a formidable challenge to reconstructive surgeons with regard to restoring adequate sexual function. The standard approach to the patient after repeated episodes of unsuccessful salvage of penile prosthesis due to infection and/or extrusion is to remove the prosthesis, leaving the patient impotent. Vascularized autologous tissue transfer provides an option to salvage end-stage erectile dysfunction.

Primary malignant melanoma of the urethra.

Primary malignant melanoma of the urethra is an aggressive neoplasm associated with a poor prognosis. The outcome is dependent on early diagnosis and surgical intervention. However, the diagnosis is often delayed as a result of difficulties related to differentiating this lesion from other disorders. Such difficulties result from the variety of clinical and pathologic presentations that are common to melanoma. We report a case of primary malignant melanoma of the urethra with subsequent retrograde seeding of the bladder initially diagnosed and managed as invasive urothelial carcinoma.