Extratunical grafting for minimally invasive management of complex Peyronie's disease deformities.

BACKGROUND: Penile deformities due to Peyronie's Disease (PD) often significantly impair men's sexual health and quality of life. AIM: In this article we discuss the extratunical graft (ETG) procedure as a management strategy for PD patients with hourglass or indent penile deformities. METHODS: We compiled descriptions of surgical techniques and performed a review of the literature regarding ETG for PD. OUTCOMES: The ETG procedure appears to have promising results in the management of indent/hourglass deformity of PD. RESULTS: The findings of this review of the literature demonstrate that ETG is a safe and effective reconstructive technique for penile deformity with minimal side effects. CLINICAL IMPLICATIONS: We recommend utilizing ETG with or without plication for PD patients with indent or hourglass deformities. STRENGTHS AND LIMITATIONS: Strengths of ETG are the improvement in patients with tunical indents and hourglass deformities secondary to PD. Additionally, patients who underwent ETG maintained sexual function given no significant change in penile length and intact erectile function. Limitations, however, are that the procedure is relatively new, and data are limited to small cohorts. CONCLUSION: The ETG procedure is a safe and effective for management of complex PD in the short- and intermediate-term follow-up cohort.

Mechanical indications for inflatable penile prosthesis revision: analysis and implications for revision surgery.

BACKGROUND: Despite technical advancements, inflatable penile prostheses (IPPs) are inherently at risk of mechanical failure given their nature as hydraulic devices. AIM: To characterize IPP component failure location at the time of device revision and stratify by manufacturer: American Medical Systems (Boston Scientific [BSCI]) and Coloplast (CP). METHODS: A retrospective review of penile prosthesis cases from July 2007 to May 2022 was conducted, identifying men who underwent revision surgery. Cases were excluded if documentation did not denote the cause of failure or the manufacturer. Mechanical indications for surgery were categorized by location (eg, tubing, cylinder, or reservoir leak; pump malfunction). Nonmechanical revisions were excluded (component herniation, erosion, or crossover). Categorical variables were assessed with Fisher exact or chi-square analysis; Student t-test and Mann-Whitney U test were used for continuous variables. OUTCOMES: Primary outcomes included specific location of IPP mechanical failure among BSCI and CP devices and time to mechanical failure. RESULTS: We identified 276 revision procedures, 68 of which met inclusion criteria (46 BSCI and 22 CP). Revised CP devices were longer than BSCI devices (median cylinder length, 20 vs 18 cm; P < .001). Log-rank analysis revealed a similar time to mechanical failure between brands (P = .096). CP devices failed most often due to tubing fracture (19/22, 83%). BSCI devices had no predominant site of failure. Between manufacturers, tubing failure was more common in CP devices (19/22 vs 15/46 for BSCI, P < .001), while cylinder failure was more common among BSCI devices (10/46 vs 0/22 for CP, P = .026). CLINICAL IMPLICATIONS: The distribution of mechanical failure is significantly different between BSCI and CP devices; this has implications regarding the approach to revision surgery. STRENGTHS AND LIMITATIONS: This is the first study to directly compare when and where mechanical failure occurs in IPPs and to compare the 2 main manufacturers head-to-head. This study would be strengthened by being repeated in a multi-institutional fashion to provide more robust and objective evaluation. CONCLUSION: CP devices commonly failed at the tubing and rarely elsewhere, while BSCI devices showed no predominant failure site; these findings may inform decision making regarding revision surgery.

Long-term lower urinary tract sequelae following AUS cuff erosion.

AIMS: To examine the rate of lower urinary tract complications (LUTC) and urinary diversion (UD) after artificial urinary sphincter (AUS) explantation with the acute reconstruction of AUS cuff erosion defects. METHODS: We performed a retrospective study of patients who underwent in-situ urethroplasty (ISU) for AUS cuff erosion from June 2007 to December 2020. Outcomes included LUTC (urethral stricture, diverticulum, fistula), AUS reimplantation, and UD. Defect size was prospectively estimated acutely and a subanalysis was performed to determine the impact of erosion severity (small erosions [<33% circumferential defect] and large erosions [≥33%]) on these outcomes. Kaplan-Meier curves were created to compare survival between the two groups. RESULTS: A total of 40 patients underwent ISU for urethral cuff erosion. The median patient age was 76 years old with a median erosion circumference of 46%. The overall LUTC rate was 30% (12/40) with 35% (14/40) of patients requiring permanent UD. Secondary AUS placement occurred in 24/40 (60%) patients with 11/24 (46%) leading to repeat erosion. On subanalysis, small erosion was associated with improved LUTC-free and UD-free survival but not associated with AUS reimplantation. CONCLUSIONS: Lower urinary tract complications are common after AUS cuff erosion and can lead to the need for permanent UD. Patients with larger erosions are more likely to undergo UD and reach this end-stage condition earlier compared to patients with small erosions.

Presenting signs and symptoms of artificial urinary sphincter cuff erosion.

PURPOSE: To characterize the most common presentation and clinical risk factors for artificial urinary sphincter (AUS) cuff erosion to distinguish the relative frequency of symptoms that should trigger further evaluation in these patients. MATERIALS AND METHODS: We retrospectively reviewed our tertiary center database to identify men who presented with AUS cuff erosion between 2007 - 2020. A similar cohort of men who underwent AUS placement without erosion were randomly selected from the same database for symptom comparison. Risk factors for cuff erosion - pelvic radiation, androgen deprivation therapy (ADT), high-grade prostate cancer (Gleason score ≥ 8) - were recorded for each patient. Presenting signs and symptoms of cuff erosion were grouped into three categories: obstructive symptoms, worsening incontinence, and localized scrotal inflammation (SI). RESULTS: Of 893 men who underwent AUS placement during the study interval, 61 (6.8%) sustained cuff erosion. Most erosion patients (40/61, 66%) presented with scrotal inflammatory changes including tenderness, erythema, and swelling. Fewer men reported obstructive symptoms (26/61, 43%) and worsening incontinence (21/61, 34%). Men with SI or obstructive symptoms presented significantly earlier than those with worsening incontinence (SI 14 ± 18 vs. obstructive symptoms 15 ± 16 vs. incontinence 37 ± 48 months after AUS insertion, p<0.01). Relative to the non-erosion control group (n=61), men who suffered erosion had a higher prevalence of pelvic radiation (71 vs. 49%, p=0.02). CONCLUSION: AUS cuff erosion most commonly presents as SI symptoms. Obstructive voiding symptoms and worsening incontinence are also common. Any of these symptoms should prompt further investigation of cuff erosion.

Urotrauma Guideline 2020: AUA Guideline.

PURPOSE: The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries. MATERIALS AND METHODS: The Panel amended the Guideline in 2020 to reflect additional literature published through February 2020. When sufficient evidence existed, the Panel assigned the body of evidence a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, the Panel provided additional information as Clinical Principles and Expert Opinions (See table 1[Table: see text]). RESULTS: The Panel updated a total of six existing statements on renal, ureteral, bladder, urethra, and genital trauma. Additionally, four new statements were added based on literature released since the 2017 amendment. Statement 5b was added based on new evidence for treatment of hemodynamically unstable patients with renal trauma. Statement 20b was added based on new literature for percutaneous or open suprapubic tube placement following pelvic fracture urethral injury. Statements 30a and 30b were also added to provide guidance on ultrasonography for blunt scrotal injuries suggestive of testicular rupture and for performing surgical exploration with repair or orchiectomy for penetrating scrotal injuries respectively. CONCLUSIONS: These evidence-based updates to the AUA Guidelines further inform the treatment of urotrauma.

Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice.

BACKGROUND: Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR) or alternative locations including the High Submuscular (HSM) space via transinguinal (TI) or counter incision (CI) techniques. A cadaver study showed variability in reservoir location after TI-HSM placement. AIM: To evaluate reservoir location using cross-sectional imaging following IPP insertion. METHODS: We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion between 2007 and 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists evaluated cross-sectional imaging in a blinded manner and categorized reservoir locations as follows: 1) submuscular; 2) posterior to the external oblique fascia and lateral to the rectus abdominis musculature; 3) preperitoneal; 4) retroperitoneal; 5) intraperitoneal; 6) inguinal canal; 7) subcutaneous. Patients were stratified by reservoir placement technique, transinguinal space of Retzius (TI-SOR), transinguinal high submuscular (TI-HSM), or counterincision high submuscular (CI-HSM). Clinical characteristics and outcomes were reviewed and compared. Statistical analysis was performed using Chi-squared and Fisher's exact tests. OUTCOMES: Variability exists in the TI placement of SOR and HSM reservoirs, CI-HSM reservoirs were associated with a low level of variability. RESULTS: Among 561 men who underwent virgin IPP insertion during the 12-year study period, 114 had postoperative cross-sectional imaging (29 TI-SOR, 80 TI-HSM, and 5 CI-HSM). Among the 114 patients imaged, TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (48 vs 14%, P < .01) and were less likely to be located in the preperitoneal space (18 vs 62%, P < .01). Rates of intraperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups (5 vs 7%, P = .66). Among imaged CI-HSM reservoirs, 4 (80%) were anterior to the transversalis fascia and 1 (20%) was within the inguinal canal. Among all 536 transinguinal cases (131 TI-SOR and 405 TI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs 2%, P = .24). No complications were noted among the 25 patients in the CI-HSM cohort. CLINICAL IMPLICATIONS: The level of variability seen in this study did not seem to impact patient safety, complications were rare in all cohorts. STRENGTHS AND LIMITATIONS: This study is the first and largest of its kind in evaluating reservoir positioning in live patients with long-term follow-up. This study is limited in its retrospective and nonrandomized nature. CONCLUSIONS: Despite variability with both TI-HSM and TI-SOR techniques, reservoir related complications remain rare. Kavoussi M, Cook G, Nordeck S, et al. Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice. J Sex Med 2021;18:2039-2044.

Most men with artificial urinary sphincter cuff erosion have low serum testosterone levels.

AIMS: To evaluate the relationship between serum testosterone (T) levels and artificial urinary sphincter (AUS) cuff erosion in a population of incontinent men who underwent AUS placement. METHODS: A retrospective analysis of our single-surgeon AUS database was performed to identify men with T levels within 24 months of AUS placement. Men were stratified into two groups based on serum testosterone: low serum testosterone (LT) (<280 ng/dl) and normal serum testosterone (NT) (>280 ng/dl). Multivariable analysis was performed to control for risk factors. The outcome of interest was the incidence of and time to spontaneous urethral cuff erosion; other risk factors for cuff erosion were also evaluated. RESULTS: Among 161 AUS patients with serum testosterone levels, 84 (52.2%) had LT (mean: 136.8 ng/dl, SD: 150.4 ng/dl) and 77 (47.8%) had NT (mean: 455.8 ng/dl, SD: 197.3 ng/dl). Cuff erosion was identified in 42 men (26.1%) at a median of 7.1 months postoperatively (interquartile range: 3.6-13.4 months), most of whom (30/42, 71.4%) were testosterone deficient. LT levels were less common (54/119, 45.4%) in the non-erosion cohort (p = 0.004). Men with low T were nearly three times as likely to suffer AUS erosion than men with normal T (odds ratio = 2.519, p = 0.021). LT level was the only factor associated with AUS erosion on multivariable analysis. CONCLUSIONS: LT is an independent risk factor for AUS cuff erosion. Men with LT are more likely to present with cuff erosion, but there is no difference in time to erosion.

State of the Reservoir: Current Concepts of Penile Implant Reservoir Placement and Potential Complications.

PURPOSE OF REVIEW: To discuss mechanical and surgical innovations in inflatable penile prosthesis (IPP) surgery and their implications on reservoir placement and patient outcomes. RECENT FINDINGS: The past decade has seen a new emphasis on optimizing outcomes and minimizing complications associated with IPP reservoirs. Innovations in device design have accordingly yielded safer, more durable IPP outcomes over the past four decades. Modifications in surgical approach for reservoir placement abound for both traditional space of Retzius and ectopic reservoir placement techniques. Surgical and medical history, patient anatomy, and patient preference should all be considered when choosing approach for IPP reservoir placement. Prosthetic urologists should be proficient in multiple approaches to provide the best care to their patients.

Artificial Urinary Sphincter Complications: Risk Factors, Workup, and Clinical Approach.

PURPOSE OF REVIEW: To review risk factors for AUS complications and present a systematic approach to their diagnosis and management. RECENT FINDINGS: Established risk factors for AUS complications include catheterization, channel TURP, pelvic radiation, urethroplasty, anticoagulation, cardiovascular disease, diabetes mellitus, frailty index, hypertension, low albumin, and low testosterone. We present our algorithm for diagnosis and management of AUS complications. Despite being the gold standard of treatment for men with SUI, major and minor complications can occur at any point after AUS insertion. Careful consideration of the urologic, medical, and operative risk factors for each patient can help prevent complications. A systematic approach to early and late complications facilitates their identification and effective management. The evaluating urologist must have a thorough understanding of potential AUS complications in order to restore quality of life in men with bothersome SUI.

Male stress urinary incontinence is often underreported.

INTRODUCTION Patient-reported pads per day use is a widely used metric in grading the severity of stress urinary incontinence and guiding surgical decision-making, particularly in mild-to-moderate cases. We sought to compare patient-reported stress urinary incontinence severity by pads per day with objective findings on standing cough test. We hypothesize that patient-reported pads per day often underestimates stress urinary incontinence severity. MATERIALS AND METHODS: We retrospectively reviewed our male stress urinary incontinence surgical database and identified 299 patients with self-reported mild-to-moderate stress urinary incontinence who were evaluated with standing cough test prior to surgical intervention between 2007 and 2019. Patients were evaluated with the Male Stress Incontinence Grading Scale for urinary leakage during a standing cough test. This test has been shown to reliably and accurately predict surgical success. Binary logistic regression analysis was used to identify parameters associated with stress urinary incontinence upgrading in a multivariable model. RESULTS: Among 299 patients with reported mild-to-moderate stress urinary incontinence, 101 (34%) were upgraded to severe stress urinary incontinence by standing cough test. Prior stress urinary incontinence surgery (OR 4.1, 95% CI 2.0-8.0, p < 0.0001) and radiation (OR 3.2, 95% CI 1.7-5.7, p < 0.0001) were significantly associated with Male Stress Incontinence Grading Scale upgrading in multivariable analysis. CONCLUSIONS: Roughly one-third of men who report mild-to-moderate stress urinary incontinence actually have severe incontinence observed on physical examination. All men being evaluated for stress urinary incontinence should undergo standing cough test to accurately grade incontinence severity and guide surgical management.

Clinical and radiographic outcomes following salvage intervention for ureteropelvic junction obstruction.

PURPOSE: We aimed to assess failure rates of salvage interventions and changes in split kidney function (SKF) following failed primary repair of ureteropelvic junction obstruction (UPJO). MATERIALS AND METHODS: A retrospective review of adult patients at an academic medical center who underwent salvage intervention following primary treatment for UPJO was performed. Symptomatic failure was defined as significant flank pain. Radiographic failure was defined as no improvement in drainage or a decrease in SKF by ≥7%. Overall failure, the primary outcome, was defined as symptomatic failure, radiographic failure, or both. RESULTS: Between 2008-2017, 34 patients (median age 38 years, 50% men) met study criteria. UPJO management was primary pyeloplasty/secondary endopyelotomy for 21/34 (62%), primary pyeloplasty/secondary pyeloplasty for 6/34 (18%), and primary endopyelotomy/secondary pyeloplasty for 7/34 (21%). Median follow-up was 3.3 years following secondary intervention. Patients undergoing primary pyeloplasty/secondary endopyelotomy had significantly higher overall failure than those undergoing primary pyeloplasty/secondary pyeloplasty (16/21 [76%] vs. 1/6 [17%], p=0.015). Among patients undergoing secondary endopyelotomy, presence of a stricture on retrograde pyelogram, stricture length, and SKF were not associated with symptomatic, radiographic, or overall failure. Serial renography was performed for 28/34 (82%) patients and 2/28 (7%) had a significant decline in SKF. CONCLUSIONS: Following failed primary pyeloplasty, secondary endopyelotomy had a greater overall failure rate than secondary pyeloplasty. No radiographic features assessed were associated with secondary endopyelotomy failure. Secondary intervention overall failure rates were higher than reported in the literature. Unique to this study, serial renography demonstrated that significant functional loss was overall infrequent.

Standing cough test stratification of moderate male stress urinary incontinence.

PURPOSE: Patient-reported history of pads per day (PPD) is widely recognized as a fundamental element of decision-making for anti-incontinence procedures. We hypothesize that SUI severity is often underestimated among men with moderate SUI. We sought to compare patient history of incontinence severity versus objective in-office physical examination findings. MATERIALS AND METHODS: We retrospectively reviewed our single-surgeon male SUI surgical database from 2007-2019. We excluded patients with incomplete preoperative or postoperative data and those who reported either mild or severe SUI, thus having more straightforward surgical counseling. For men reported to have moderate SUI, we determined the frequency of upgrading SUI severity by recording the results of an in-office standing cough test (SCT) using the Male Stress Incontinence Grading Scale (MSIGS). The correlation of MSIGS with sling success rate was calculated. Failure was defined as >1 PPD usage or need for additional incontinence procedure. RESULTS: Among 233 patients with reported moderate SUI (2-3 PPD), 89 (38%) had MSIGS 3-4 on SCT, indicating severe SUI. Among patients with 2-3 PPD preoperatively, sling success rates were significantly higher for patients with MSIGS 0-2 (76/116, 64%) compared to MSIGS 3-4 (6/18, 33%) (p <0.01). CONCLUSIONS: Many men with self-reported history of moderate SUI actually present severe SUI observed on SCT. The SCT is a useful tool to stratify moderate SUI patients to more accurately predict sling success.

Artificial Urinary Sphincter Cuff Erosion Heat Map Shows Similar Anatomical Characteristics for Transcorporal and Standard Approach.

PURPOSE: We describe and compare artificial urinary sphincter cuff erosion sites and associated clinical implications. MATERIALS AND METHODS: We retrospectively reviewed men who presented with artificial urinary sphincter erosion treated by a single surgeon between 2007 and 2019 at a tertiary medical center. Transcorporal indications included complications of prior anti-incontinence procedures and prior urethral reconstruction. Location of artificial urinary sphincter cuff erosion defects was assessed by cystoscopy prior to device explantation, and findings were stratified into patients who had transcorporal vs standard artificial urinary sphincter placement. RESULTS: Out of 723 artificial urinary sphincter cases in 611 patients we identified 54 (7.5%) cuff erosions. Erosion developed in 15 of 82 (18.3%) cases of transcorporal artificial urinary sphincter and 39 of 641 (6.1%) cases of standard artificial urinary sphincter (p <0.05). Artificial urinary sphincter cuff erosions occurred predominantly ventrally in both groups (66.7% for transcorporal and 79.5% for standard artificial urinary sphincter, p=0.4) followed by lateral urethral location (33.3% transcorporal and 20.5% standard, p=0.3). Dorsal erosions were rare in both groups (20% transcorporal and 5.1% standard, p=0.1). History of artificial urinary sphincter and previous erosion were associated with transcorporal artificial urinary sphincter erosion. History of radiotherapy, prior urethroplasty, hypogonadism and urethral cuff size were similar between groups. CONCLUSIONS: Artificial urinary sphincter cuff erosions appear to occur ventrally and laterally in most patients regardless of cuff placement. Dorsal erosions were the least common in both groups. The protective effect of transcorporal artificial urinary sphincter could not be conclusively demonstrated.

Avoiding deep pelvic complications using a 'Five-Step' technique for high submuscular placement of inflatable penile prosthesis reservoirs.

OBJECTIVES: To compare our extended experience with high submuscular (HSM) reservoir placement to traditional space of Retzius (SOR) placement and to present our current, refined 'Five-Step' technique (FST) for HSM placement. PATIENTS AND METHODS: Data were retrospectively collected on patients undergoing inflatable penile prosthesis (IPP) placement between January 2009 and June 2019. Re-operative cases were excluded. Reservoir-related complications and subsequent revisions were compared between SOR (2009-2012) and HSM reservoir groups (2012-2019). HSM patients were subdivided into two cohorts: 'Initial Technique' (2012-2014) and FST (2014-2019). The refined FST protocol was developed in 2014 to optimise outcomes and includes the following steps: (i) Position and Access; (ii) Develop Lower HSM Pocket; (iii) Develop Upper HSM Pocket; (iv) Reservoir Delivery (fill and fine-tune); (v) Confirm and Connect. RESULTS: Between January 2009 and June 2019, 733 total IPP procedures (586 HSM, 147 SOR) were performed by a single surgeon at our institution, 561 of which were virgin cases (430 HSM, 131 SOR) and included in this analysis. Overall, surgical revision was required in 10/430 (2.3%) HSM cases (one delayed bowel obstruction, nine herniations) and six of 131 (4.6%) SOR cases (one bladder erosion, two vascular injuries, and three herniations, P = 0.22). When comparing the FST to the Initial Technique, we noted a significant decrease in complications requiring surgical revision (P = 0.01). Among 133 cases performed with the Initial Technique, seven (5.3%) required surgical revision (one bowel obstruction after placement into the peritoneal cavity, six herniations). Among 297 FST cases, three (1.0%) required revision, all due to herniation. CONCLUSION: HSM placement of IPP reservoirs is a safe alternative to traditional SOR placement. Major deep pelvic reservoir complications were minimised using our current refined FST.

Favourable multi-institutional experience with penoscrotal decompression for prolonged ischaemic priapism.

OBJECTIVES: To report our multi-institutional experience using penoscrotal decompression (PSD) for the surgical treatment of prolonged ischaemic priapism (PIP). MATERIALS AND METHODS: We retrospectively reviewed clinical records for patients with PIP treated with PSD between 2017 and 2020. Priapisms were confirmed as ischaemic based on clinical presentations and cavernosal blood gas abnormalities. Treatment with irrigation and injection of α-agonists in all patients had failed prior to PSD. Patient characteristics, peri-operative variables and outcomes, and changes in International Index of Erectile Function (IIEF) scores were evaluated. RESULTS: We analysed 25 patients who underwent a total of 27 PSD procedures. The mean duration of priapism at initial presentation was 71.0 h. Irrigations and injections in all patients had failed, while corporoglanular shunt treatment in 48.0% of patients (12/25) had also failed prior to PSD. Of the 10 patients who underwent unilateral PSD, two (20.0%) had priapism recurrence. Both were treated with bilateral PSD, with prompt and lasting detumescence. Among the 15 patients undergoing primary bilateral PSD, none had priapism recurrence. Of the 15 patients with documented sexual function status at last follow-up, nine (60%) reported spontaneous erectile function adequate for penetration, while six (40%) reported erectile dysfunction. The median (interquartile range) decrease in IIEF-5 score was 3.5 (0-6.75) points after PSD. Two patients underwent uneventful inflatable penile prosthesis placement following PSD. CONCLUSIONS: Penoscrotal decompression presents a simple, safe, highly effective and easily reproducible procedure for resolution of PIP. PSD should be considered as a viable salvage or alternative strategy to corporoglanular shunt procedures.

Explantation of High Submuscular Reservoirs: Safety and Practical Considerations.

BACKGROUND: Over the past decade, high submuscular (HSM) placement of inflatable penile prosthesis (IPP) reservoirs has emerged as a viable alternative to space of Retzius (SOR) placement; however, data comparing the feasibility and complications of HSM vs SOR reservoir removal do not presently exist. AIM: To present a comparison of the safety, feasibility, and ease of removal of HSM vs SOR reservoirs in a tertiary care, university-based, high-volume prosthetic urology practice. METHODS: Data were retrospectively collected on patients who underwent IPP reservoir removal between January 2011 and June 2020. Cases were separated into 2 cohorts based on reservoir location. Statistical analysis was performed using Fisher's exact and Chi-squared tests for categorical variables and Student's t-test for continuous variables. Timing from IPP insertion to explant was compared between the HSM and SOR groups using the Mann-Whitney U test. OUTCOMES: Time from IPP insertion to explant, operative time, intraoperative and postoperative complications, and need for a counter incision were compared between the HSM and SOR groups. RESULTS: Between January 2011 and June 2020, 106 (73 HSM, 33 SOR) patients underwent IPP removal or replacement by a single surgeon at our institution. Average time from IPP insertion to removal was 43.6 months (24.2 HSM, 52.7 SOR, P = .07)-reservoir removal occurred at the time of device explant in 70 of 106 (66%) cases. More HSM reservoirs were explanted at the time of IPP removal compared with the SOR cohort (54 of 73, 74% HSM vs 16 of 33, 48.5% SOR, P = .01). Similar rates of complications were noted between the HSM and SOR groups (1.9% vs 6.3%, P = .35). There was no significant difference in need for counter incision between the 2 groups (24 [42%] HSM vs 4 [25%] SOR, P = .16) or in average operative times (76.5 ± 38.3 minutes HSM vs 68.1 ± 34.3 minutes SOR, P = .52). CLINICAL IMPLICATIONS: Our experience with explanting HSM reservoirs supports the safety and ease of their removal. STRENGTHS AND LIMITATIONS: Although the absolute cohort size is relatively low, this study reflects one of the largest single-institution experiences examining penile implant reservoir removal. In addition, reservoir location was not randomized but was instead determined by which patients presented with complications necessitating reservoir removal during the study period. CONCLUSIONS: HSM reservoir removal has comparable perioperative complication rates and operative times when compared with SOR reservoir removal. Kavoussi M, Bhanvadia RR, VanDyke ME, et al. Explantation of High Submuscular Reservoirs: Safety and Practical Considerations. J Sex Med 2020;17:2488-2494.

Long-term outcomes of anastomotic urethroplasty for radiation-induced strictures.

PURPOSE: To present our experience with excision and primary anastomosis (EPA) of radiation-induced urethral strictures (RUS) in men, including risk factors for stricture recurrence and long-term recurrence rates. METHODS: A retrospective review was performed of patients who underwent EPA of RUS between 2007 and 2018 at a single tertiary referral center. Demographic information, stricture location and length, complications, and stricture recurrence were analyzed. Univariate and multivariate Cox regression analyses were performed to identify variables impacting recurrence. RESULTS: EPA was performed in 116 patients with RUS. The majority of patients (86.2%, 100/116) underwent at least one prior urologic intervention. Mean stricture length was 2.3 cm. Stricture recurrence occurred in 19.0% (22/116) at a mean of 8.6 months. For patients with at least 1 year of postoperative follow-up (mean 30.7 months), stricture recurrence significantly increased to 36.6% (15/41; p = 0.03). On univariate and multivariate analyses, postoperative complications were associated with stricture recurrence (p < 0.001). CONCLUSION: EPA remains a viable option for men with RUS. Nearly two-thirds of RUS patients remain recurrence-free with long-term follow-up following EPA.

Strong correlation between standing cough test and 24-hour pad weights in the evaluation of male stress urinary incontinence.

AIMS: We sought to compare in-office physical exam findings via standing cough test (SCT) versus 24-hour pad weights among men seeking treatment for postprostatectomy stress urinary incontinence (SUI). METHODS: A retrospective review of a single surgeon database of incontinence procedures was performed. Documentation of SUI severity (grades 0-4) was completed by SCT preoperatively utilizing the Male Stress Incontinence Grading Scale (MSIGS). All patients had pads per day (PPD) and 24-hour pad weights obtained. We determined the Spearman's correlation coefficient between these variables. RESULTS: We identified 104 men who underwent anti-incontinence surgery (AdVance Sling or artificial urinary sphincter [AUS]). In the sling group (65 patients), nearly all (97%) had minimal incontinence with SCT (MSIGS = 0-2). In the AUS group (39 patients), most patients (69%) had an MSIGS 3 or 4 with SCT. Spearman's coefficient between quantification of SCT and pad weight for the overall group was ρ = .68 (P < .0001) demonstrating a strong positive correlation. PPD was also strongly correlated with pad weight (ρ = .55, P < .0001). As seen previously, SCT and PPD were correlated (ρ = .47, P < .0001). In a multivariable model predicting pad weight, the effect of SCT was greater than PPD (ß = 83 [54-111], P < .0001 vs 45 [2169], P = .0004). CONCLUSIONS: SCT findings strongly correlate to 24-hour pad weights in the evaluation of male SUI. The SCT shows promise as a rapid, reliable, noninvasive measure of SUI severity before anti-incontinence surgery.

Erosion rates of 3.5-cm artificial urinary sphincter cuffs are similar to larger cuffs.

OBJECTIVE: To compare long-term outcomes and erosion rates of 3.5-cm artificial urinary sphincter (AUS) cuffs vs larger cuffs amongst men with stress urinary incontinence (SUI), with and without a history of pelvic radiotherapy (RT). PATIENTS AND METHODS: We reviewed the records of all men who underwent AUS placement by a single surgeon between September 2009 and June 2017 at our tertiary urban medical centre. A uniform perineal approach was used to ensure cuff placement around the most proximal corpus spongiosum after precise spongiosal measurement. Patients were stratified by cuff size and RT status, and patient demographics and surgical outcomes were analysed. Cases of AUS revision in which a new cuff was not placed were excluded. Success was defined as patient-reported pad use of ≤1 pad/day. RESULTS: Amongst 410 cases included in the analysis, the 3.5-cm cuff was used in 166 (40.5%), whilst 244 (59.5%) received larger cuffs (≥4.0 cm). Over a median follow-up of 50 months, there was AUS cuff erosion in 44 patients at a rate nearly identical in the 3.5-cm cuff (10.8%, 18/166) and the ≥4-cm cuff groups (10.7%, 26/244, P = 0.7). On multivariate logistic regression, clinical factors associated with AUS cuff erosion included a history of pelvic RT, prior AUS cuff erosion, prior urethroplasty, and a history of inflatable penile prosthesis (IPP) placement. Patient demographics were similar between the cuff-size groups; including age, body mass index, comorbidities, smoking history, RT history, prior AUS, and prior IPP placement. Continence rates were high amongst all AUS patients, with similar success in both groups (82% for 3.5-cm cuff, 90% for ≥4-cm cuff, P = 0.1). CONCLUSIONS: After 8 years of experience and extended follow-up, the outcomes of the 3.5-cm AUS cuff appear to be similar to ≥4-cm cuffs for effectiveness and rates of urethral erosion. RT patients have a higher risk of cuff erosion regardless of cuff size.

Synchronous Urethral Repair During Prosthetic Surgery: Safety of Planned and Damage Control Approaches Using Suprapubic Tube Urinary Diversion.

BACKGROUND: Urethral injury during inflatable penile prosthesis (IPP) or artificial urinary sphincter (AUS) placement is rare, and traditionally most prosthetic surgeons abort prosthetic implantation when urethral repair is necessary. AIM: To report our experience with synchronous urethroplasty (SU) as a planned or damage control surgery during urologic prosthetic surgery, to evaluate the safety and outcomes of the procedure. METHODS: A retrospective review of our IPP and AUS database was completed to identify patients who underwent an SU between 2007 and 2018. We included patients who underwent an SU during prosthetic surgery in either a planned procedure for known stricture or diverticulum or a "damage control" procedure after intraoperative injury. OUTCOME: Patient characteristics and surgical outcomes were assessed, with success defined as the absence of urethral stricture and revision surgery. RESULTS: From our database of 1,508 prosthetic cases, we identified 7 patients (0.46%) who had an SU in the same setting as complete prosthesis placement (4 AUS and 3 IPP [1 combined IPP/AUS], and 1 sling). Three patients underwent planned repair of a known urethral abnormality (urethral diverticulum, urethrocutaneous fistula, and urethral stricture), and 4 underwent repair of an intraoperative urethral injury. Among the patients who experienced an intraoperative urethral injury, contributing etiologies included previous anti-incontinence surgery with periurethral fibrosis (n = 2), severe corporal fibrosis from priapism, and previous urethral disruption from pelvic fracture. Nearly all of the urethroplasties (6 of 7; 86%) were completed with a primary closure. The average indwelling duration of suprapubic tube (SPT) catheters was 4.1 weeks (range, 7 to 47 days). The average duration of follow-up was 21.5 months, and all patients were continent at follow-up. No device infections or urethral complications were identified. CLINICAL IMPLICATIONS: Our study illustrates the safety of concomitant urethral repair at time of prosthetic placement as an option to avoid the use of 2 anesthetics and prevent further scarring in high-risk patients. STRENGTHS & LIMITATIONS: This is the first study to address definitive urethral reconstruction during anti-incontinence procedures along with planned concomitant urethroplasty during IPP placement. This promising initial experience is relevant for surgeons who may encounter concomitant urethral pathology in the setting of complex reoperative prosthetic cases. The need for SU is rare, and thus our cohort size was limited in this retrospective, single-institution experience. CONCLUSION: SU with prolonged SPT urinary diversion offers a safe damage control approach for men with concomitant urethral pathology during prosthetic surgery without conferring an increased risk of infection or stricture. Yi YA, Fuchs JS, Davenport MT, et al. Synchronous Urethral Repair During Prosthetic Surgery: Safety of Planned and Damage Control Approaches Using Suprapubic Tube Urinary Diversion. J Sex Med 2019;16:1106-1110.