Routine Prescription of Opioids for Post-Vasectomy Pain Control Associated with Persistent Use.

PURPOSE: The AUA (American Urological Association) Position Statement on opioid use recommends using opioids only when necessary. We sought to determine if routine prescribing of opioids is necessary for pain control after vasectomy, and if an association exists with persistent use. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent vasectomy in clinic between April 2017 and March 2018. Patients were stratified into 2 groups, including those initially prescribed opioids and those not receiving opioid prescriptions at the time of vasectomy. The initial pain medication regimen depended on the standard prescription practice of each provider. Encounters with a medical provider for scrotal pain within 30 days, subsequent opioid prescriptions and new persistent opioid prescriptions between 90 and 180 days were compared between the 2 groups using the Fisher exact test. RESULTS: Between April 2017 and March 2018 a total of 228 patients underwent clinic vasectomy as performed by 8 urologists. At the time of vasectomy 102 patients received opioid prescriptions and 126 received no opioid prescriptions. There was no statistically significant difference between the opioid and nonopioid groups in encounters for scrotal pain (12.7% vs 18.4%, p = 0.279). The incidence of new persistent opioid use was 7.8% in the opioid cohort compared to 1.5% in the nonopioid cohort (p = 0.046). CONCLUSIONS: Opioids, which do not appear to be necessary in men who undergo vasectomy, were associated with persistent use in 7.8% of patients at 3 to 6 months. In the face of an opioid epidemic urologists should take action to limit over prescription of opioids after vasectomy.

Sonographic evaluation of hydronephrosis in the pediatric population: is well-tempered sonography necessary?

OBJECTIVES: Standardized protocols exist for diuretic renography. There are no specific guidelines regarding hydration before renal sonography. This study assessed the importance of the hydration status by sonographic measurements of the anteroposterior diameter and its effect on Society for Fetal Urology (SFU) hydronephrosis grading. METHODS: Children aged 6 weeks to 16 years (mean age, 22 months) with unilateral SFU grade 3 or 4 hydronephrosis requiring diuretic renal scintigraphy were recruited to undergo prehydration and posthydration renal sonography. Hydrated diuretic renal scintigraphy, or "well-tempered" renography, was then performed. Renal sonograms were reviewed by a blinded pediatric radiologist and pediatric urologist. Two-sided statistical tests assessed whether SFU grades and the anteroposterior diameter changed significantly after hydration. RESULTS: Among 67 kidneys, the pediatric urologist (L.P.M.) and pediatric radiologist (V.J.R.) reported no SFU grade change in 45 (67%) and 52 (78%) kidneys after hydration. In kidneys that changed, the posthydration grade was more likely to be higher. This difference was statistically significant (14 of 22 and 13 of 15 differences were higher grades after hydration for L.P.M. and V.J.R., respectively; P= .06; P= .007). Most kidneys that changed with hydration differed by only 1 SFU grade. Differences greater than 1 grade were seen in 5 control kidneys, which increased from SFU grade 0 to 2. The mean anteroposterior diameter increased significantly between prehydration and posthydration sonography for both hydronephrotic kidneys (1.46 versus 1.72 cm; P< .001) and control kidneys (0.22 versus 0.39 cm; P= .019), but did not correlate with increased SFU grades. CONCLUSIONS: Hydration does have a substantial effect on the anteroposterior diameter, but it does not correlate with a substantial effect on the SFU grade; therefore, well-tempered sonography seems unnecessary.

Hydrocele: an atypical presentation of metastatic sarcomatoid renal cell carcinoma.

Herein is a case of a 55-year-old man who presented with epididymitis. He subsequently failed medical management for the suspected infection and progressed to develop an acute scrotum and sonographic findings consistent with a pyocele. Concurrent computed tomography (CT), obtained for persistent abdominal pain, revealed a large enhancing upper pole renal mass suspicious for malignancy. He was taken for emergent scrotal exploration to drain the presumptive pyocele. However, during scrotal exploration, no purulence or evidence of infection was seen. Although, seemingly unrelated to the renal mass, the thickened hydrocele sac was excised and sent as a specimen. Pathology of the sac revealed a diagnosis of metastatic sarcomatoid renal cell carcinoma. Appropriate chemotherapy was initiated based on the scrotal pathology, circumventing the need for a CT directed retroperitoneal lymph node biopsy or nephrectomy.

Improving the Efficiency of a Military Treatment Facility Transfer Center Process.

INTRODUCTION: A performance improvement project was initiated at Tripler Army Medical Center (TAMC) to decrease the amount of inpatient stays by military beneficiaries at civilian hospitals. Before the start of the project, the transfer process from external emergency rooms was completed by patient administration personnel and residents. This process had a median time to disposition decision of 40 minutes and led to missed opportunities for TAMC to care for military beneficiaries. The goals for the project were to have the median transfer process at less than 30 minutes from first call to time of disposition, to minimize unnecessary transfer denials, and to improve the perception of TAMC transfer process. MATERIALS AND METHODS: The team implemented multiple countermeasures as a performance improvement project to improve the transfer process. These included enhancing technological capabilities, providing clinically trained personnel to answer initial telephone calls, establishing rapid attending physician contact for acceptance, and standardizing data collection. Descriptive data were used to describe the progress toward project goals to include median time to disposition, number of monthly calls, and reasons for denials of patient transfers. RESULTS: The project met all proposed goals. The median time to disposition decision was reduced to 22 minutes. The primary reasons for denials included that the transfer was considered medically unnecessary (40.6%), no beds were available (18.9%), and the patient was unstable for transport (14.9%). As a reflection of improved customer service, there was an overall increase in transfer requests and positive feedback from the referring physicians at the local civilian hospitals. CONCLUSION: The improved transfer process at TAMC resulted in a decreased median time of transfer request process, increased total transfer requests, and improved relationships with local civilian hospitals. While we acknowledge that each MTF has facility and regional characteristics (such as capability, capacity, military staffing, and degree of availability of civilian healthcare resources) that may contribute to variation from TAMC, the concepts and changes made in the transfer process may be considered a best practice to be adopted by other military facilities to promote the recapture of beneficiaries into the Defense Health Agency system.

Oral ketoconazole for prevention of postoperative penile erection: a placebo controlled, randomized, double-blind trial.

PURPOSE: Patients undergoing penile surgery often have postoperative erections that can be painful and may interfere with wound healing. In retrospective studies ketoconazole has been shown to decrease the number and pain of postoperative erections. We conducted a prospective, randomized, double-blind, placebo controlled study to evaluate the efficacy of ketoconazole in the prevention of postoperative erections. MATERIALS AND METHODS: Patients undergoing penile reconstructive surgery were randomized to receive ketoconazole (400 mg 3 times a day) or placebo starting 2 days before surgery and continuing for 7 days after surgery. We recorded the number and characteristics of each erection on a standardized log. Liver function tests were drawn before and after surgery. RESULTS: Of the 40 patients enrolled 20 were randomized to the ketoconazole group and 20 to placebo. In the ketoconazole group 81.25% reported postoperative erections compared to 83% in the placebo group. Of those patients who had postoperative erections 85% in the ketoconazole group reported painful erections compared to 80% in the placebo group. These differences were not statistically significant (p >0.99). In the ketoconazole group 3 patients (15.8%) withdrew early because of nausea and 1 in the ketoconazole group had a transient increase in liver function tests. CONCLUSIONS: To our knowledge this is the only prospective, double-blind, placebo controlled study to evaluate the use of ketoconazole in the prevention of postoperative erections. While prior retrospective reports showed promise for this medication, our study suggests that ketoconazole is not effective in preventing postoperative erections.

Preoperative Albumin Is Predictive of Early Postoperative Morbidity and Mortality in Common Urologic Oncologic Surgeries.

INTRODUCTION: Multiple studies have linked preoperative nutrition status to postoperative outcomes. This relationship has been little studied in urology. We used a standardized, national, risk-adjusted surgical database to evaluate 30-day outcomes of patients undergoing common urologic oncologic procedures as they related to preoperative albumin. METHODS: The American College of Surgeons National Surgical Quality Improvement Program is a risk-adjusted dataset analyzing preoperative risk factors, demographics, and 30-day outcomes. From 2005 through 2012, we identified a total of 17,805 patients who underwent prostatectomy, nephrectomy, partial nephrectomy, cystectomy, or transurethral resection of bladder tumor (TURBT). Hypoalbuminemic patients were compared with those with normal preoperative albumin, and 30-day outcomes were evaluated. Logistic regression analyses were used to estimate odds ratios for mortality and complication rates. RESULTS: Evaluation of the cohort noted significantly increased overall morbidity, serious morbidity, and mortality in the hypoalbuminemic group (P < .01 for all procedures). Hypoalbuminemia was associated with a significantly higher 30-day mortality in major procedures such as cystectomy, and in smaller procedures such as TURBT (P < .01). Hypoalbuminemia was associated with a 6.4% 30-day mortality in the TURBT group compared with 0.6% in those with normal albumin (P < .0001). These findings remained significant after adjustment for other risk factors. CONCLUSIONS: The large sample size, standardized data definitions, and quality control measures of the American College of Surgeons National Surgical Quality Improvement Program database allow for in-depth analysis of subtle but significant differences in outcomes between groups. Serum albumin is a strong predictor of short-term postoperative complications in the urologic oncology patient.

Ovotesticular Disorders of Sexual Development: A Case of Hernia Uteri Inguinalis.

Ovotesticular disorders of sexual development result in the presence of both testis and ovarian tissue. Most commonly, gonadal structures in the scrotum or inguinal canal are comprised of testis tissue. The presence of a uterus within an inguinal hernia sac in a phenotypically male patient is referred to as hernia uteri inguinalis. This condition has rarely been reported in patients with ovotesticular disorders of sexual development. We present a patient with rare mosaicism in combination with an unusual location of Müllerian duct structures within an inguinal hernia sac.

Impact of the 2012 American Urological Association vasectomy guidelines on postvasectomy outcomes in a military population.

OBJECTIVE: To evaluate the impact of the 2012 American Urological Association vasectomy guidelines on postvasectomy clinical outcomes in a highly mobile military cohort and compare these outcomes with those of civilian counterparts. METHODS: The records of service members who underwent vasectomy between January 2008 and December 2013 and provided at least 1 postvasectomy semen analysis (PVSA) were analyzed in the context of the 2012 guidelines. Time to occlusive success, repeat PVSAs and vasectomies, and health care cost savings were compared between our prior definition of vasectomy success, which required azoospermia, and the 2012 criteria, which included rare nonmotile sperm. RESULTS: Of the 1623 men who underwent vasectomy, 738 men (45%) failed to submit a PVSA, leaving 895 men (55%) who provided at least 1 PVSA. A total of 1084 PVSAs were obtained in these men, who had a mean age of 37 ± 6 years. Defining success as azoospermia on first PVSA resulted in a sterility rate of 69%. After application of the 2012 guidelines, 845 patients (94%) achieved sterility by the first PVSA and more patients achieved sterility 60 days from vasectomy (96% vs 72%; P <.001). Inclusion of rare nonmotile sperm in our definition of success would have allowed 228 men to forego a second PVSA and prevented 2 (0.002%) unnecessary vasectomies, a savings of $6297. CONCLUSION: PVSA compliance in our military cohort was similar to that of civilian counterparts. The American Urological Association vasectomy guidelines have the potential to decrease the number of repeat vasectomies and laboratory tests, improve the documented success rate, and increase follow-up compliance when applied to a military population.

Penile Squamous Cell Carcinoma After a Childhood Hypospadias Repair With Bladder Mucosa Graft.

Bladder mucosa grafts were historically used for hypospadias surgical repairs, when preputial or penile skin was unavailable and in cases of prior failed hypospadias repairs. We present a case of advanced penile squamous cell carcinoma diagnosed 22 years after a childhood hypospadias repair with a free bladder mucosa graft.

Testicular Cystic Walthard Cell Nest in a 7-Month-Old.

Walthard cell nests have previously been reported arising from paratesticular structures; however, this is the first reported case of an intratesticular Walthard cell nest. We report our experience with this lesion which is interesting not only because of its extreme rarity but also because of the proposed histogenesis of such lesions.

Outcomes of Extravesical Versus Intravesical Ureteral Reimplantation.

PURPOSE: The purpose of our study was to examine outcomes and compare length of stay after extravesical and intravesical ureteral reimplantation at our institution. MATERIALS AND METHODS: Retrospective review was performed of 30 patients (55 ureters) with vesicoureteral reflux who underwent either the Cohen (intravesical) cross-trigonal procedure or the extravesical (detrusorrhaphy) approach. Each patient had documented follow-up consisting of a postoperative renal ultrasound and/or a voiding cystourethrogram (VCUG). Inclusion criteria was the presence of primary vesicoureteral reflux. Exclusion criteria were patients who had undergone a previous repair and patients in whom results of neither the renal ultrasound nor the VCUG were available. RESULTS: There were no significant cases of obstruction or wound infection with either approach. Two patients who underwent the extravesical approach had persistent reflux on VCUG three months postoperatively, but both resolved by fifteen months. Average length of stay was only 3.00 ± 1.33 days for the extravesical approach, compared to 5.36 ± 1.75 days for the intravesical approach ( P = .0003 ). CONCLUSIONS: Given that by fifteen months success rates were the same with either approach, the extravesical approach is comparable to the intravesical technique and is a viable option in terms of outcome and economics given the shorter length of hospital stay.

Spontaneous perinephric hemorrhage associated with urolithiasis in pregnancy.

Spontaneous perinephric hematoma in the absence of anticoagulation, arteritis, or trauma is uncommon. We report the case of a postpartum patient with nephrolithiasis who initially presented to the obstetric service with a spontaneous perinephric hemorrhage.

Laparoscopic radical prostatectomy demonstrates less morbidity than open radical prostatectomy: an analysis of the American College of Surgeons-National Surgical Quality Improvement Program database with a focus on surgical trainee involvement.

INTRODUCTION: Complication rates of open radical prostatectomies (ORPs) and laparoscopic radical prostatectomies (LRPs) performed by highly experienced surgeons in centers of excellence are well known. Using a standardized, national, risk-adjusted surgical database, we compared 30-day outcomes following ORP and LRP and analyzed how trainee involvement influenced outcomes. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) is a risk-adjusted data collection analyzing preoperative risk factors, demographics, and 30-day postoperative outcomes. From 2005 to 2011, we identified 10,669 total prostatectomies. Of these, 2278 were ORP and 8391 were LRP. Data on trainee involvement were available on 63% of cases. RESULTS: Comparison of all 10,669 prostatectomies showed a decreased incidence of overall morbidity, serious morbidity, surgical site infections, mortality, wound disruption, urinary tract infection, bleeding, and sepsis or septic shock (p<0.05) for LRP compared with ORP. Trainee involvement was associated with a higher incidence of bleeding, overall and serious morbidity (p<0.001). This difference is isolated to postgraduate year (PGY) 6-10 trainees performing ORP (p<0.001). Overall and serious morbidity was equivalent between PGY groups 1-10 versus attending without trainee performing LRP and PGY groups 1-5 versus attending without trainee performing ORP. Operative times were shorter for ORP versus LRP by an average of 38 minutes (p<0.05), and in cases involving trainees, operative times decreased with trainee experience for both procedures. The length of stay was shorter for LRP compared with ORP (3.2 vs. 1.8 days, p<0.001). CONCLUSIONS: The large sample size, standardized data definitions, and quality control measures of the ACS-NSQIP database allow for in-depth analysis of subtle, but significant differences in outcomes between groups. Trainee involvement in LRP appears safe to patients. However, the increased morbidity in ORP involving trainees may be mitigated by awareness, simulation laboratories, and standardized competency assessment.

Comparison of outcomes after minimally invasive versus open partial nephrectomy with respect to trainee involvement utilizing the American College of Surgeons National Surgical Quality Improvement Program.

PURPOSE: Complication rates of open partial nephrectomies (OPN) and minimally invasive partial nephrectomies (MIPN) have largely been reported by single and multi-institutional tertiary care centers. We sought to identify complication rates of these approaches and how they are influenced by trainee involvement utilizing an independent national surgical database. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a risk-adjusted data collection analyzing risk factors, demographics, and 30-day perioperative outcomes. From 2005 to 2010, we identified 1251 partial nephrectomies, of which 525 were MIPN and 726 were OPN. RESULTS: Analysis showed a decreased risk of overall morbidity, serious morbidity, and surgical site infections (SSIs); specifically superficial SSI, urinary tract infection, and bleeding (p<0.005) in MIPN than OPN. Resident and fellow versus attending only involvement was associated with increased rates of overall, serious, and nonserious morbidity, superficial and overall SSI, bleeding, and sepsis or septic shock (p<0.05). Postgraduate year (PGY) 6 residents and fellows had a significantly higher likelihood of nonserious morbidity, organ space and overall SSI, and sepsis or septic shock compared to PGY 1-5 residents. Length of stay, which was significantly shorter with MIPN than OPN (3.2 vs. 5.1 days; p<0.0001), however, was associated with longer operative times (185.7 vs. 209.7 minutes, p<0.001). CONCLUSIONS: This is the first report utilizing ACS NSQIP to review surgical approaches as well as the impact of trainee involvement on clinical outcomes. The increased complication rates and cost of healthcare might be mitigated by awareness, investment in surgical simulation laboratories, and competency assessment.

Upper urinary tract abnormalities: a case of bilateral kidneys within a left-sided omphalocele.

Children with omphalocele, exstrophy, imperforate anus, and spinal defects complex present with the most severe form of birth defects in the exstrophy-epispadias spectrum. Prenatal diagnosis is difficult, but improved survival over the past several decades makes understanding the potential anatomic manifestations imperative for expeditious and appropriate surgical care. The upper urinary tract is often normal in children with omphalocele, exstrophy, imperforate anus, and spinal defects complex, but malposition of one of the kidneys has previously been reported. We present the first case of bilateral kidney herniation into the omphalocele sac.

Impact of race in using PSA velocity to predict for prostate cancer.

OBJECTIVE: To assess whether race is a significant factor in the ability of prostate-specific antigen velocity (PSAV) for predicting high-grade prostate cancer (HGPC). METHODS: Records of men who underwent prostate biopsy between January 2003 and December 2007 were retrospectively reviewed to collect demographic data, self-reported race, prostate-specific antigen (PSA) data, and pathology results. PSAV was calculated using linear regression. Subjects were stratified by the presence or absence of HGPC. Median PSA and PSAV values were compared within each racial group using receiver operating characteristic analysis and Student t test. RESULTS: Static PSA was significantly higher in Caucasian men with HGPC (4.81 vs. 8.3 ng/mL, p = 0.0000001) while PSAV was also higher in men with HGPC (0.639 vs. 1.15 ng/mL/yr, p = 0.081). Static PSA in Asians did not perform well in predicting HGPC (5.3 vs. 9.42 ng/mL, p = 0.11), but fared much better than PSAV (0.51 vs. 0.93 ng/mL/yr, p = 0.27). PSA in African Americans did not significantly predict HGPC (6.27 vs. 7.7 ng/mL, p = 0.474), but PSAV showed a stronger trend toward significance (0.615 vs. 1.54 ng/mL/yr, p = 0.068). CONCLUSIONS: PSAV may complement static PSA in African Americans and help identify early stage aggressive cancers.

Bilateral fibrous pseudotumors of the tunica albuginea in a pediatric patient.

Fibrous pseudotumor, previously named nodular fibrous periorchitis, is a very rare disease entity in the pediatric patient. This is the first reported case of bilateral synchronous fibrous pseudotumors in the testes of a pediatric patient.

Primary adenocarcinoma of the rete testis: improved staging accuracy with CT-PET.

A case of adenocarcinoma of the rete testis in a 54-year-old man is presented. Most such patients harbor metastatic disease, even in clinically localized presentations. CT-PET may provide improved diagnostic sensitivity over conventional CT in this setting.

Ambiguous genitalia in a newborn with 45,X/46,X,idic(Y) ovotesticular disorder of sex development.

OBJECTIVE: To discuss a case of ovotesticular disorder of sex development (DSD) with ambiguous genitalia, isodicentric Y sex chromosome mosaicism, and unique histopathologic findings. METHODS: We report the clinical, laboratory, imaging, and operative findings, and we highlight the pertinent features of this case. Results of hormonal and genetic testing are reviewed, and histopathologic findings are illustrated. RESULTS: A term newborn had ambiguous genitalia and was found to have an uncommon 45,X/46,X,idic(Y) karyotype. This infant had a 2-cm phallic structure, a penoscrotal hypospadias, a gonad easily palpable in the right scrotum, and a second gonad palpable high in the left inguinal canal. On ultrasonography, both gonads appeared as normal testicles, and no müllerian structures were identified. Testosterone and dihydrotestosterone levels were normal for a male neonate. After assessment of the patient at 2 months of age because of an incarcerated left inguinal hernia, both gonads were removed and were found to have both testicular and ovarian tissues spread throughout, with a fallopian tube on the left and an incipient juvenile granulosa cell tumor on the right. He was then diagnosed with ovotesticular DSD and continued to be raised as a boy. CONCLUSION: This male infant had undervirilization and an ovotesticular DSD. He had evidence of both ovarian and testicular tissues, in conjunction with apparent alterations in local müllerian inhibiting substance levels that allowed one fallopian tube to be preserved. The proportion of actively transcribed Y material in the chromosomes of patients with this karyotype may partially explain the variable phenotypes that can occur.

Long-term preservation of dextranomer/hyaluronic acid copolymer implants after endoscopic treatment of vesicoureteral reflux in children: a sonographic volumetric analysis.

PURPOSE: We compared injected volume of dextranomer/hyaluronic acid with sonographic volumes obtained 2 weeks to 36 months postoperatively to evaluate the amount of volume retention with time and to correlate volume retention with voiding cystourethrogram results. MATERIALS AND METHODS: We retrospectively reviewed sonographic volume measurements of dextranomer/hyaluronic acid implants in children at 2 weeks to 36 months postoperatively. Hydronephrosis and percentage of dextranomer/hyaluronic acid retained at each interval were recorded. Average change in volume at each interval was used to compare volume retention with time. The fraction of dextranomer/hyaluronic acid retained was compared to voiding cystourethrogram at 3 months. RESULTS: No patient had new or worsened hydronephrosis. Volumetric data were available for 296, 150, 42, 23 and 20 ureters at 2, 3, 6 and 12 weeks, and 24 to 36 months postoperatively, respectively. Percentage of dextranomer/hyaluronic acid retained was 79% at 2, 74% at 3, 70% at 6 and 78% at 12 weeks, and 65% at 24 to 36 months (p >0.05). While there was no significant difference in mean volume retained between cures (74%) and treatment failures (67%), the 94% cure rate with mega-implants (greater than anticipated volume retention) was higher than that with micro-implants (75%) or nonvisualized implants (70%). CONCLUSIONS: After the initial volume reduction at 2 weeks dextranomer/hyaluronic acid implants remained durable with insignificant volume reduction for up to 36 months postoperatively. Although overall mean volume retention did not correlate with cure, mega-implants were associated with high cure rates and may justify elimination of postoperative voiding cystourethrography.