Prolapse repair with and without apical resuspension-Practice patterns among certifying American urologists.

AIMS: To examine surgeon characteristics in certifying urologists performing prolapse surgeries. Anterior compartment prolapse is often associated with apical prolapse, with high rates of recurrence when anterior repair is performed without apical resuspension. METHODS: Six-month case log data of certifying urologists between 2003 and 2013 was obtained from the American Board of Urology (ABU). Cases with a CPT code for common prolapse repairs in females ≥18 years were analyzed. RESULTS: Among 2,588 urologists logging at least one prolapse surgery and a total of 30,983 surgeries, 320 (1.0% of all cases) uterosacral ligament suspension, 3,673 (11.9%) sacrospinous ligament suspension, and 2,618 (8.4%) abdominal sacrocolpopexy were identified. The remaining 14,585 cases were logged as anterior repair. 54.7% of anterior repairs did not include apical suspension. The proportion of anterior repairs without apical suspension has decreased from 77.7% in 2004 to 41.4% in 2012 (P < 0.001). Female subspecialists before 2011 performed anterior repair without apical suspension in 58.5%, versus 70.3% by all others. Since 2011 there has been a decrease in number of anterior repairs without apical suspension, notably in those applying for Female Pelvic Medicine and Reconstructive Surgery (FPMRS) certification (17.1% vs. 30.7% by all other urologists, P < 0.001); nonacademically affiliated urologists are 2.1 times more likely to report anterior repair without apical suspension than academically affiliated colleagues (P < 0.001). CONCLUSIONS: The proportion of prolapse repairs reported as anterior repairs without apical suspension is decreasing, although it remains a substantial portion. Recent log year, FPMRS, and academic affiliation were associated with prolapse repairs addressing apical support. Neurourol. Urodynam. 36:344-348, 2017. © 2015 Wiley Periodicals, Inc.

Disparities in female urologic case distribution with new subspecialty certification and surgeon gender.

AIMS: To examine surgical case volume characteristics in certifying urologists associated with common female urologic procedures to evaluate the practice patterns, given the recent establishment of subspecialty certification in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) and changes in urologist gender composition. METHODS: Six-month case log data of certifying urologists (2003-2013) was obtained from the American Board of Urology (ABU). We examined case logs for 26 CPT codes for common female urologic procedures focused on four procedure groups: incontinence, prolapse, vesicovaginal fistula (VVF), and revision/removal of vaginal mesh/graft. RESULTS: Among 4802 urologists logging at least one female urology case, 43,949 (55.6% of all cases) incontinence, 30,983 (39.2%) prolapse, 451 (0.6%) VVF, and 3643 (4.6%) revision of mesh/graft surgeries were identified. While 90.8% logging at least one female CPT code were men, women surgeons (9.2%) accounted for a disproportionate volume (22.6%) of cases. With initiation of the FPMRS subspecialty certification in 2011, 225 FPMRS candidates (out of 1716 certifying urologists) were identified, compared to 367 (out of 3828 certifying urologists) female subspecialists prior to 2011. FPMRS accounted for 56.7% of prolapse, 62.9% VVF, 59.0% mesh/graft revisions, and 41.9% of incontinence surgeries, compared to female specialists before 2011 (39.1%, 42.4%, 41.5%, and 21.6% respectively (all P < 0.001)). CONCLUSIONS: A growing proportion of female urologic cases are performed by female subspecialists, with a significant increase since initiation of FPMRS subspecialty certification. Women surgeons account for a disproportionate volume of these cases despite remaining a minority of certifying urologists and female subspecialists. Neurourol. Urodynam. 36:399-403, 2017. © 2015 Wiley Periodicals, Inc.

Two Arabidopsis loci encode novel eukaryotic initiation factor 4E isoforms that are functionally distinct from the conserved plant eukaryotic initiation factor 4E.

Canonical translation initiation in eukaryotes begins with the Eukaryotic Initiation Factor 4F (eIF4F) complex, made up of eIF4E, which recognizes the 7-methylguanosine cap of messenger RNA, and eIF4G, which serves as a scaffold to recruit other translation initiation factors that ultimately assemble the 80S ribosome. Many eukaryotes have secondary EIF4E genes with divergent properties. The model plant Arabidopsis (Arabidopsis thaliana) encodes two such genes in tandem loci on chromosome 1, EIF4E1B (At1g29550) and EIF4E1C (At1g29590). This work identifies EIF4E1B/EIF4E1C-type genes as a Brassicaceae-specific diverged form of EIF4E. There is little evidence for EIF4E1C gene expression; however, the EIF4E1B gene appears to be expressed at low levels in most tissues, though microarray and RNA Sequencing data support enrichment in reproductive tissue. Purified recombinant eIF4E1b and eIF4E1c proteins retain cap-binding ability and form functional complexes in vitro with eIF4G. The eIF4E1b/eIF4E1c-type proteins support translation in yeast (Saccharomyces cerevisiae) but promote translation initiation in vitro at a lower rate compared with eIF4E. Findings from surface plasmon resonance studies indicate that eIF4E1b and eIF4E1c are unlikely to bind eIF4G in vivo when in competition with eIF4E. This study concludes that eIF4E1b/eIF4E1c-type proteins, although bona fide cap-binding proteins, have divergent properties and, based on apparent limited tissue distribution in Arabidopsis, should be considered functionally distinct from the canonical plant eIF4E involved in translation initiation.

Risk of urethral stricture recurrence increases over time after urethroplasty.

OBJECTIVE: To report a single institutional experience with urethroplasty outcomes and success rates at long-term follow up. METHODS: A retrospective review was carried out of all urethroplasties performed by a single surgeon from 2000 to 2010. A total of 347 patients underwent urethroplasty during this time period, of which 227 had minimum 1-year follow-up data available. Demographic, clinical, pathological and outcome data were reviewed. Recurrence was defined by patient reported urinary symptoms or need for subsequent intervention. Statistical analyses were carried out using SPSS statistical software. RESULTS: A total of 26% of all patients had a recurrence at a mean follow up of 62 months (range 13-147 months). The recurrence rate after anastomotic urethroplasty was 18%, as compared with 31% after substitution urethroplasty. Mean time to recurrence was 34 months (range 5-87). On univariate analysis, use of abdominal skin graft, history of prior urethroplasty, lichen sclerosus and length of follow up were statistically significant predictors of recurrence. On multivariate analysis, only history of prior urethroplasty and length of follow-up time exceeding 48 months were statistically significant predictors of recurrence. CONCLUSIONS: Urethroplasty for urethral stricture is the most durable treatment modality, regardless of surgical approach. However, there is an ongoing risk of recurrence with the passage of time. Patients should be counseled appropriately on the potential for late recurrence of stricture disease after urethroplasty.

Lichen sclerosus and isolated bulbar urethral stricture disease.

PURPOSE: Lichen sclerosus is a chronic inflammatory genital skin condition that can cause destructive urethral scarring. To our knowledge no prior study has described lichen sclerosus in isolated bulbar urethral stricture segments without progressive disease originating from the penile urethra. We report the incidence of lichen sclerosus in isolated bulbar urethral stricture segments. MATERIALS AND METHODS: We retrospectively reviewed the records of 70 patients after urethroplasty for isolated bulbar stricture disease was performed from 2007 to 2013. Stricture specimens were re-reviewed by a single uropathologist. Cases were evaluated using common histological features of lichen sclerosus, including hyperkeratosis or epithelial atrophy, basal cell vacuolar degeneration, lichenoid lymphocytic infiltrate and superepithelial sclerosis. RESULTS: Average patient age was 46.5 years (range 19 to 77) and average stricture length was 3.5 cm (range 1 to 7). Of the patients 51 (73.0%) underwent excision and primary anastomosis, and 19 (27.1%) underwent buccal mucosal onlay. In 6 patients (8.6%) stricture recurred during a median followup of 22 months (IQR 14, 44). Three of those patients had lichen sclerosus. Initial pathology assessment revealed lichen sclerosus in 5 patients (7.1%, 95% CI 1.0-13.3). On re-review of specimens using pathology criteria specific to lichen sclerosus 31 patients (44.3%, 95% CI 32.4-56.2) showed pathology findings highly suggestive of (13) or diagnostic for (18) lichen sclerosus (p = 0.0001). On pathological re-review lichen sclerosus was associated with recurrent stricture. CONCLUSIONS: On re-review of surgical specimens we noted a significant incidence of lichen sclerosus in isolated bulbar strictures in men undergoing urethroplasty. The incidence of lichen sclerosus may be higher than reported in isolated bulbar urethral segments without evidence of distal to proximal progressive urethral disease.

Testosterone replacement therapy in patients with prostate cancer after radical prostatectomy.

PURPOSE: Testosterone replacement therapy in men with prostate cancer is controversial, with concern that testosterone can stimulate cancer growth. We evaluated the safety and efficacy of testosterone in hypogonadal men with prostate cancer treated with radical prostatectomy. MATERIALS AND METHODS: We performed a review of 103 hypogonadal men with prostate cancer treated with testosterone after prostatectomy (treatment group) and 49 nonhypogonadal men with cancer treated with prostatectomy (reference group). There were 77 men with low/intermediate (nonhigh) risk cancer and 26 with high risk cancer included in the analysis. All men were treated with transdermal testosterone, and serum hormone, hemoglobin, hematocrit and prostate specific antigen were evaluated for more than 36 months. RESULTS: Median (IQR) patient age in the treatment group was 61.0 years (55.0-67.0), and initial laboratory results included testosterone 261.0 ng/dl (213.0-302.0), prostate specific antigen 0.004 ng/ml (0.002-0.007), hemoglobin 14.7 gm/dl (13.3-15.5) and hematocrit 45.2% (40.4-46.1). Median followup was 27.5 months, at which time a significant increase in testosterone was observed in the treatment group. A significant increase in prostate specific antigen was observed in the high risk and nonhigh risk treatment groups with no increase in the reference group. Overall 4 and 8 cases of cancer recurrence were observed in treatment and reference groups, respectively. CONCLUSIONS: Thus, testosterone therapy is effective and, while followed by an increase in prostate specific antigen, does not appear to increase cancer recurrence rates, even in men with high risk prostate cancer. However, given the retrospective nature of this and prior studies, testosterone therapy in men with history of prostate cancer should be performed with a vigorous surveillance protocol.

Obesity and anthropometry in spina bifida: What is the best measure.

OBJECTIVE: Diagnosis of obesity using traditional body mass index (BMI) using length may not be a reliable indicator of body composition in spina bifida (SB). We examine traditional and surrogate measures of adiposity in adults with SB, correlated with activity, metabolic disease, attitudes towards exercise and quality of life. DESIGN: Adult subjects with SB underwent obesity classification using BMI by length and arm span, abdominal girth and percent trunk fat (TF) on dual energy X-ray absorptiometry (DXA). Quality of life measures, activity level and metabolic laboratory values were also reviewed. RESULTS: Among eighteen subjects (6 male, 12 female), median age was 26.5 (range 19-37) years, with level of lesion 16.7% ≤L2, 61.1% L3-4, and 22.2% ≥L5, respectively. Median weight was 71.8 (IQR 62.4, 85.8) kg, similar between sexes (P = 0.66). With median length of 152.0 (IQR 141.8, 163.3) cm, median conventional BMI was 29.4 m/kg2, with 7 (43.8%) subjects with BMI >30. Median BMI by arm span was 30.2 m/kg2, abdominal girth of 105.5 cm, and TF 45.7%. More subjects were classified as obese using alternate measures, with 9 (56.3%) by arm span, 14 (82.4%) by abdominal girth and 15 (83.3%) by TF (P = 0.008). Reclassification of obesity from conventional BMI was significant when using TF (P = 0.03). No difference in quality of life measures, activity level and metabolic abnormalities was demonstrated between obese and non-obese subjects. CONCLUSIONS: Conventional determination of obesity using BMI by length is an insensitive marker in adults with SB. Adults with SB are more often classified as obese using TF by DXA.

Metagenomic Discovery of 83 New Human Papillomavirus Types in Patients with Immunodeficiency.

Several immunodeficiencies are associated with high susceptibility to persistent and progressive human papillomavirus (HPV) infection leading to a wide range of cutaneous and mucosal lesions. However, the HPV types most commonly associated with such clinical manifestations in these patients have not been systematically defined. Here, we used virion enrichment, rolling circle amplification, and deep sequencing to identify circular DNA viruses present in skin swabs and/or wart biopsy samples from 48 patients with rare genetic immunodeficiencies, including patients with warts, hypogammaglobulinemia, infections, myelokathexis (WHIM) syndrome, or epidermodysplasia verruciformis (EV). Their profiles were compared with the profiles of swabs from 14 healthy adults and warts from 6 immunologically normal children. Individual patients were typically infected with multiple HPV types; up to 26 different types were isolated from a single patient (multiple anatomical sites, one time point). Among these, we identified the complete genomes of 83 previously unknown HPV types and 35 incomplete genomes representing possible additional new types. HPV types in the genus Gammapapillomavirus were common in WHIM patients, whereas EV patients mainly shed HPVs from the genus Betapapillomavirus. Preliminary evidence based on three WHIM patients treated with plerixafor, a leukocyte mobilizing agent, suggest that longer-term therapy may correlate with decreased HPV diversity and increased predominance of HPV types associated with childhood skin warts.IMPORTANCE Although some members of the viral family Papillomaviridae cause benign skin warts (papillomas), many human papillomavirus (HPV) infections are not associated with visible symptoms. For example, most healthy adults chronically shed Gammapapillomavirus (Gamma) virions from apparently healthy skin surfaces. To further explore the diversity of papillomaviruses, we performed viromic surveys on immunodeficient individuals suffering from florid skin warts. Our results nearly double the number of known Gamma HPV types and suggest that WHIM syndrome patients are uniquely susceptible to Gamma HPV-associated skin warts. Preliminary results suggest that treatment with the drug plerixafor may promote resolution of the unusual Gamma HPV skin warts observed in WHIM patients.

Treatment of Radiation-Induced Urethral Strictures.

Radiation therapy may result in urethral strictures from vascular damage. Most radiation-induced urethral strictures occur in the bulbomembranous junction, and urinary incontinence may result as a consequence of treatment. Radiation therapy may compromise reconstruction due to poor tissue healing and radionecrosis. Excision and primary anastomosis is the preferred urethroplasty technique for radiation-induced urethral stricture. Principles of posterior urethroplasty for trauma may be applied to the treatment of radiation-induced urethral strictures. Chronic management with suprapubic tube is an option based on patient comorbidities and preference.

Risk Factors and Timing of Early Stricture Recurrence After Urethroplasty.

OBJECTIVE: To compare recurrence after urethroplasty, identifying associated risk factors for early recurrence. MATERIALS AND METHODS: Among 262 urethroplasties (2001-2010) with ≥6 months of follow-up, we identified 65 patients (24.8%) with recurrence (defined by obstruction in the area of repair on cystoscopy). RESULTS: Median stricture length was 4.5 cm (range 1-24 cm). Median follow-up was 85.2 (6.7-160.1) months, with median time to recurrence of 8.0 (0.5-88.0) months. Substitution urethroplasty was the most frequent repair (70.8%), followed by excision and primary anastomosis (23.1%). When graft was used, buccal was most common (66.0%), followed by abdominal wall skin (AWS) (24.5%). Twenty-one percent of recurrences presented within 3 months, 40.0% by 6 months, 55.4% by 1 year, whereas 9.2% recurred more than 5 years later. Recurrences ≤6 months were significantly longer strictures (median 5.5 cm vs 4.0 cm, P = .009). Strictures ≤4 cm, ≤3 cm, and ≤2 cm recurred at a median of 10.6, 18.2, and 30.3 months, respectively (P = .08). Most lichen sclerosis (LS)-related recurrences occurred within 6 months (62%). Patients recurring within 6 months were older, had history of LS, or more likely had AWS. Forty percent suffered from multiple recurrences at a median of 12 months and were associated with longer stricture, prior instrumentation, substitution urethroplasty, AWS, and LS. CONCLUSION: Half of recurrences following urethroplasty present within one year, with most declaring within 6 months. Early recurrence is associated with older age, LS, AWS and longer strictures. The duration and intensity of surveillance protocols following urethroplasty should be individualized in order to account for these characteristics.

Characterizing Pelvic Organ Prolapse in Adult Spina Bifida Patients.

OBJECTIVE: To report the distribution of pelvic organ prolapse (POP) stages in adult spina bifida (SB) patients. The severity of POP in the SB population has not been previously reported. MATERIALS AND METHODS: Retrospective review of SB patients ≥18 years with a documented POP quantification examination between 2006 and 2014 were included. Patient demographics, gestation, parity, POP quantification examinations and prolapse symptoms were obtained. RESULTS: Thirty-three SB patients were identified with a mean age of 33.2 years. Five patients (15.2%) had stage 0 prolapse, 12 (36.4%) had stage 1, 12 (36.4%) had stage 2, 3 (9.1%) had stage 3, and 1 (3.0%) had stage 4. Of the 16 patients with advanced POP (stage 2 prolapse or greater), only 6 patients (37.5%) reported symptoms related to POP. All 6 symptomatic patients endorsed sensation of a vaginal bulge. Two of the 6 patients also reported dyspareunia. Additionally, 1 patient with advanced POP presented with vaginal bulge, noted by a caregiver, and cervical bleeding, but was otherwise asymptomatic. Twenty-four patients (72.7%) were nulliparous, and 12 of the 24 nulliparous patients (50%) demonstrated prolapse. CONCLUSION: Despite young age and frequent nulliparity, patients with SB are more likely to have POP than the general population. Additionally, the majority of SB patients with prolapse are asymptomatic. Assessment of pelvic organ prolapse should be included in the evaluation of adult SB females due to the low rate of symptoms even in the setting of advanced stage prolapse and potential impact on both urinary and bowel function.

A snapshot of the adult spina bifida patient - high incidence of urologic procedures.

INTRODUCTION: To describe the urologic outcomes of contemporary adult spina bifida patients managed in a multidisciplinary clinic. MATERIAL AND METHODS: A retrospective chart review of patients seen in our adult spina bifida clinic from January 2004 to November 2011 was performed to identify urologic management, urologic surgeries, and co-morbidities. RESULTS: 225 patients were identified (57.8% female, 42.2% male). Current median age was 30 years (IQR 27, 36) with a median age at first visit of 25 years (IQR 22, 30). The majority (70.7%) utilized clean intermittent catheterization, and 111 patients (49.3%) were prescribed anticholinergic medications. 65.8% had urodynamics performed at least once, and 56% obtained appropriate upper tract imaging at least every other year while under our care. 101 patients (44.9%) underwent at least one urologic surgical procedure during their lifetime, with a total of 191 procedures being performed, of which stone procedures (n = 51, 26.7%) were the most common. Other common procedures included continence procedures (n = 35, 18.3%) and augmentation cystoplasty (n = 29, 15.2%). Only 3.6% had a documented diagnosis of chronic kidney disease and 0.9% with end-stage renal disease. CONCLUSIONS: Most adult spina bifida patient continue on anticholinergic medications and clean intermittent catheterization. A large percentage of patients required urologic procedures in adulthood. Patients should be encouraged to utilize conservative and effective bladder management strategies to reduce their risk of renal compromise.

Bone Marrow Stem/Progenitor Cells Attenuate the Inflammatory Milieu Following Substitution Urethroplasty.

Substitution urethroplasty for the treatment of male stricture disease is often accompanied by subsequent tissue fibrosis and secondary stricture formation. Patients with pre-existing morbidities are often at increased risk of urethral stricture recurrence brought upon in-part by delayed vascularization accompanied by overactive inflammatory responses following surgery. Within the context of this study, we demonstrate the functional utility of a cell/scaffold composite graft comprised of human bone marrow-derived mesenchymal stem cells (MSC) combined with CD34+ hematopoietic stem/progenitor cells (HSPC) to modulate inflammation and wound healing in a rodent model of substitution urethroplasty. Composite grafts demonstrated potent anti-inflammatory effects with regards to tissue macrophage and neutrophil density following urethral tissue analyses. This was accompanied by a significant reduction in pro-inflammatory cytokines TNFα and IL-1ß and further resulted in an earlier transition to tissue remodeling and maturation with a shift in collagen type III to I. Grafted animals demonstrated a progressive maturation and increase in vessel size compared to control animals. Overall, MSC/CD34+ HSPC composite grafts reduce inflammation, enhance an earlier transition to wound remodeling and maturation concurrently increasing neovascularization in the periurethral tissue. We demonstrate the feasibility and efficacy of a stem cell-seeded synthetic graft in a rodent substitution urethroplasty model.

An Analysis of Case Logs From American Urologists in the Treatment of Peyronie's Disease.

OBJECTIVE: To review recent trends in the treatment of Peyronie's disease (PD), we assess surgical practice patterns of urologists in the United States with emphasis on specialty training, demographics, and temporal changes. METHODS: Six-month case log data of American urologists between 2004 and 2013 were obtained from the American Board of Urology. Current Procedural Terminology (CPT) codes were used to identify surgical procedures, including plaque injection. RESULTS: A total of 6564 urologists were included in the surgical cohort, logging 8195 surgical procedures for PD. Only 15.4% of urologists (1012/6564) reported a surgical case for PD. Andrologists (urologist subspecialty designation) accounted for 5.3% of these urologists (54/1012) and performed 18.5% of PD procedures (P = .0001). The frequency of plaque injections increased from 499 in 2004 to 797 in 2013, a 59% increase, whereas surgical correction remained stable. Urologists performed four times as many injections as surgical procedures for PD (P = .001) with andrologists more likely to attempt injection than surgical correction (P = .045). Among surgeries performed, 73.2% were corrections of angulation without plaque excision, 20.5% were excisions of plaque (with possible grafting) up to 5 cm, and 6.2% were excisions of plaque (with possible grafting) >5 cm. There was a 313% increase in the ratio of plication to plaque manipulation (0.92 in 2004 to 2.91 in 2013). CONCLUSION: PD is treated by a minority of urologists and disproportionately by subspecialist in andrology. When compared with surgical interventions, excluding prosthesis implantation, most surgeons favor conservative treatment. The majority of surgical corrections were corrections of angulation without plaque manipulation.

Male Sling and Artificial Urethral Sphincter for Male Stress Urinary Incontinence Among Certifying American Urologists.

OBJECTIVE: To examine case volume characteristics among certifying urologists performing male sling and artificial urinary sphincter (AUS) procedures to evaluate practice patterns in male stress urinary incontinence (SUI). MATERIALS AND METHODS: Six-month case log data of certifying urologists (2003-2013) were obtained from the American Board of Urology. Cases specifying Current Procedural Terminology code for male sling, AUS, and removal or revision of either procedure in males ≥18 years were analyzed. RESULTS: Among 1615 urologists (568 certifying and 1047 recertifying) logging at least 1 male incontinence procedure, 2109 (48% of all procedures) male sling and 2284 (52%) AUS cases were identified. The mean age of patients undergoing AUS was 74.9 years and the mean age of patients undergoing sling procedures was 67.3 years (P <.001). An increase in male incontinence procedures from 2003 to 2013 was demonstrated. The rate of male sling procedure increased from 32.7% of incontinence surgeries in 2004 to 45.5% in 2013 (P <.001). Academically affiliated urologists are 1.5 times more likely to perform AUS than male sling for SUI (P <.001). Median number of slings performed was 2 (range 1-40), with 32.7% placing slings exclusively. A small group of certifying urologists (3.4%) accounted for 22% of all male slings placed. This same cohort logged 10.2% of all AUS performed. Surgical management of male SUI varies widely across states (P <.001), with slings performed between 21% and 70% of the time. CONCLUSION: Overall the number of male incontinence procedures has increased over time, with a growing proportion of male slings. Most slings and AUS cases are performed by a small number of high-volume surgeons.

Quality of life related to urinary continence in adult spina bifida patients.

INTRODUCTION: To analyze the correlations of bladder management technique, ambulatory status and urologic reconstruction on quality of life (QOL) as affected by urinary symptoms in adult spina bifida (SB) patients. MATERIAL AND METHODS: Sixty-six adult SB patients completed the RAND 36-Item Health Survey (mSF-36) and Incontinence Quality of Life (I-QOL). Demographic information, history of urinary reconstruction, and bladder management techniques were reviewed and analyzed with respect to survey scores. RESULTS: Mean age of patients was 32.3 (SD ±7.2) years and 44 patients (66.7%) were female. Forty-five patients (68.2%) were mainly ambulatory, 21 (31.8%) use a wheelchair and 10 (15.2%) had urologic reconstruction, while 56 (83.3%) did not. Twelve patients (18.2%) void, 42 (63.6%) perform clean intermittent catheterization (CIC), 4 (6.1%) use an indwelling catheter, 3 (4.5%) have an ileal conduit (IC) and 5 (7.6%) mainly use diapers. Mean mSF-36 General Health score was 56.5 (SD ±22.9) and mean I-QOL Sum score was 50.9 (SD ±21.7), where lower scores reflect lower QOL. mSF-36 and I-QOL scores did not significantly correlate with bladder management technique, ambulatory status or urologic reconstruction. A correlation was noted between I-QOL scales and most mSF-36 scales (all p <0.02). CONCLUSIONS: In our cohort study of adult SB patients, bladder management technique and urologic reconstruction did not correlate with urinary (I-QOL) or general health (mSF-36) domains, although I-QOL and mSF-36 scores correlated closely, suggesting urinary continence is significantly related to general QOL. However, we are unable to identify a single factor that improves either urinary or general QOL.

Practice Patterns in the Treatment of Urethral Stricture Among American Urologists: A Paradigm Change?

OBJECTIVE: To examine surgical case volume characteristics among certifying urologists associated with treatment of urethral stricture to compare practice patterns of recent graduates to recertifying attending urologists and trends over time. MATERIALS AND METHODS: Six-month case log data of certifying and recertifying urologists (2003-2013) were obtained from the American Board of Urology. Cases specifying a CPT code for urethral dilation, direct vision internal urethrotomy (DVIU), urethroplasty, and graft harvest in males ≥18 years were analyzed for surgeon-specific variables. RESULTS: Among 6320 urologists logging at least one reconstructive urology procedure, 95,747 (86.2%) urethral dilations, 10,986 (10.0%) DVIU, and 4349 (3.9%) urethroplasties were identified, with 99 (0.9%) using graft and 405 (9.3%) staged procedures. Overall ratio of urethral dilation/DVIU to urethroplasty was 24.5:1. More recent log year and new certification correlated with a decrease in ratio of dilation/DVIU to urethroplasty, but stable use of graft. The ratio of dilation/DVIU to urethroplasty for new certification was much lower (7.9:1), compared to first (24.4:1), second (63.3:1), and third recertification cycles (99.5:1), wherein urethroplasty was increasingly rare. Newly certifying urologists performed urethroplasty 4.5 times more often than those recertifying. Academically affiliated urologists were 8 times more likely to perform urethroplasty. CONCLUSION: Most urethral strictures are treated with dilation/DVIU, but a changing paradigm favoring urethroplasty is evident. Most urethroplasties are performed by a small number of urologists with high volume, academic affiliation, recent residency graduation, and residence in a state with a reconstructive urology fellowship.

Long-term outcomes of urethroplasty with abdominal wall skin grafts.

OBJECTIVE: To report the long-term outcomes of urethroplasty using abdominal wall skin (AWS) grafts. Men with long-segment strictures, prior urethroplasty, and lichen sclerosus (LS) pose challenges in surgical management, including the choice of graft tissue for urethral reconstruction. AWS grafts are an alternative when buccal mucosa or penile grafts are not feasible or chosen by the patient. METHODS: We retrospectively reviewed 238 patients who underwent urethroplasty (2000-2010) with at least 1 year of follow-up. Demographics, etiology, comorbidities, prior procedures, and surgical technique were analyzed for correlation with recurrence. RESULTS: Mean age was 42.9 years (range, 15-79 years), mean stricture length 5.6 cm (1-24 cm), and median follow-up of 59.3 months (12.5-147 months). A total of 58.4% patients had prior intervention, of which 15 patients (6.3%) had urethroplasty and 41 patients (17.2%) had hypospadias repair. Twenty-six patients (10.9%) underwent urethroplasty with AWS graft, whereas 107 (45.0%) and 12 (5.0%) patients were augmented with buccal mucosa or genital skin. Sixty-six patients (27.7%) had stricture recurrence at a mean of 34.5 months (range, 1.87-87.1 months). On univariate analysis, patients with AWS graft had longer strictures (P = .0001), were more likely to have LS (P = .0002), prior urethroplasty (P = .007), and recurrence (P = .002). On multivariate analysis, prior urethroplasty (odds ratio [OR], 5.3; P = .009), diabetes (OR, 2.6; P = .04), and LS (OR, 2.8; P = .05) were significantly associated with recurrence, whereas AWS graft was not (OR, 2.0; P = .28). CONCLUSION: AWS grafts are an alternative tissue source for urethral stricture, but may be associated with greater risk of recurrence. This may be secondary to patient selection, with this population often having other risk factors for recurrence.

Novel use of carbon dioxide arteriography in renal artery pseudoaneurysm in patients with poor renal function.

Renal artery pseudoaneurysm (RAP) is a rare complication of partial nephrectomy, but is usually effectively managed with renal vessel embolisation. We report a particularly challenging case of a patient with chronic kidney disease (CKD) who developed a RAP following a laparoscopic heminephrectomy and was treated using superselective renal vessel coil embolisation with carbon dioxide (CO2) as the primary contrast agent for arteriographic localisation of the RAP and feeder artery. To the best our knowledge we report the first utilisation of CO2 arteriography in the definitive diagnosis and treatment of RAP following heminephrectomy in a patient with severe CKD.

Diagnosis of varicoceles in men undergoing vasectomy may lead to earlier detection of hypogonadism.

OBJECTIVE: To determine the temporal relationship between vasectomy, varicocele, and hypogonadism diagnosis. Many young men undergo their first thorough genitourinary examination in their adult lives at the time of vasectomy consultation, providing a unique opportunity for diagnosis of asymptomatic varicoceles. Varicoceles have recently been implicated as a possible reversible contributor to hypogonadism. Hypogonadism may be associated with significant adverse effect, including decreased libido, impaired cognitive function, and increased cardiovascular events. Early diagnosis and treatment of hypogonadism may prevent these adverse sequelae. METHODS: Data were collected from the Truven Health Analytics MarketScan database, a large outpatient claims database. We reviewed records between 2003 and 2010 for male patients between the ages of 25 and 50 years with International Classification of Diseases, Ninth Revision codes for hypogonadism, vasectomy, and varicocele, and queried dates of first claim. RESULTS: A total of 15,679 men undergoing vasectomies were matched with 156,790 men with nonvasectomy claims in the same year. Vasectomy patients were diagnosed with varicocele at an earlier age (40.9 vs 42.5 years; P=.009). We identified 224,817 men between the ages of 25 and 50 years with a claim of hypogonadism, of which 5883 (2.6%) also had a claim of varicocele. Men with hypogonadism alone were older at presentation compared with men with an accompanying varicocele (41.3 [standard deviation±6.5] vs 34.9 [standard deviation±6.1]; P<.001). CONCLUSION: Men undergoing vasectomies are diagnosed with varicoceles at a younger age than age-matched controls. Men with varicoceles present with hypogonadism earlier than men without varicoceles. Earlier diagnosis of varicocele at the time of vasectomy allows for earlier detection of hypogonadism.