Incontinence after radical prostatectomy: a patient centered analysis and implications for preoperative counseling.

PURPOSE: Incontinence after radical prostatectomy is common yet poorly defined in the current literature. We aimed to accurately characterize incontinence after robot-assisted radical prostatectomy to achieve improved preoperative patient counseling. MATERIALS AND METHODS: After receiving institutional review board approval we performed a cross-sectional survey of the first 600 patients with prostate cancer who underwent robot-assisted radical prostatectomy at our institution. The International Consultation on Incontinence Modular Questionnaire-Lower Urinary Tract Symptoms Quality of Life and Urinary Incontinence Short Form were used to evaluate incontinence and quality of life after robot-assisted radical prostatectomy. Surveys were mailed by a third party. Data were analyzed on the prevalence of incontinence after robot-assisted radical prostatectomy. More specifically we characterized in detail the nature of incontinence and its effect on quality of life. RESULTS: The response rate was 68% (408 of 600 participants). Response time since surgery was 2.5 months to 4 years. Overall incontinence bother scores and ratings of life interference were quite low. Patients reported that most incontinence occurred during physical activity but 35% reported interference with sleep. Of the patients 31% experienced some anxiety due to urinary difficulties and 51% had to occasionally change clothes due to leakage. Patients did not report much interference with traveling, visiting friends or family and family life. The most bothersome aspects of incontinence were its effects on partner relationship, sexual life and energy levels. CONCLUSIONS: Despite patient concerns of incontinence after prostatectomy they report little interference with quality of life.

Urinary bladder injuries during vascular surgery.

Urologic complications related to vascular surgery involving the ureter have been well recognized. These include ureteral compression from aneurysms, congenital anomalies such as retrocaval ureter, obstruction from retroperitoneal fibrosis, iatrogenic injury, and ureteric fistulas. Complications involving the bladder are more infrequent. Most of these bladder-related complications involve the use of tunneling devices for synthetic bypass grafts. We report an unusual case of a transvesically placed femoral-femoral bypass graft with delayed presentation. We also reviewed the English literature for experience with diagnosis and treatment of bladder injuries during vascular surgical procedures.

Post-infant circumcision amongst children in Hawai'i.

BACKGROUND: The purpose of this study is to determine the frequency of circumcision in children older than 12 months of age in US born versus non-US born children in Hawai'i from 1996-2005. METHODS: Aggregate circumcision data from a children's hospital was obtained from medical records. Birth place was also identified for circumcisions (ICD9 code 64.0) in children 12 months to 18 years of age. Birth place is a surrogate marker of immigration status. RESULTS: During the 1996-2005 study period, there were 29,408 male births with an average newborn circumcision rate of 89%. The rate of circumcisions has declined from 93% in 1997 to 88% in 2005. There were 552 circumcisions performed on children 12 months to 18 years of age during this study period. Of these, 45 were performed in 1996 and 81 cases were performed in 2005. Birthplace data was missing from 25% of these cases. For those with birthplace data available, 60% of the circumcisions were amongst those born in Hawai'i, 15% were born in the other 49 states and US territories, and 24% were born in a foreign country. CONCLUSION: In a community in which newborn circumcision rates are high, the frequency of circumcision is declining, while the number of circumcisions performed in children aged 1-18 is increasing. The number of circumcisions performed in non-US born children is disproportionately higher than what would be expected suggesting that the post-infant circumcision rates for this age group is higher in immigrants.

The Role of Chronic Mesh Infection in Delayed-Onset Vaginal Mesh Complications or Recurrent Urinary Tract Infections: Results From Explanted Mesh Cultures.

OBJECTIVES: Vaginal mesh complications necessitating excision are increasingly prevalent. We aim to study whether subclinical chronically infected mesh contributes to the development of delayed-onset mesh complications or recurrent urinary tract infections (UTIs). METHODS: Women undergoing mesh removal from August 2013 through May 2014 were identified by surgical code for vaginal mesh removal. Only women undergoing removal of anti-incontinence mesh were included. Exclusion criteria included any women undergoing simultaneous prolapse mesh removal. We abstracted preoperative and postoperative information from the medical record and compared mesh culture results from patients with and without mesh extrusion, de novo recurrent UTIs, and delayed-onset pain. RESULTS: One hundred seven women with only anti-incontinence mesh removed were included in the analysis. Onset of complications after mesh placement was within the first 6 months in 70 (65%) of 107 and delayed (≥6 months) in 37 (35%) of 107. A positive culture from the explanted mesh was obtained from 82 (77%) of 107 patients, and 40 (37%) of 107 were positive with potential pathogens. There were no significant differences in culture results when comparing patients with delayed-onset versus immediate pain, extrusion with no extrusion, and de novo recurrent UTIs with no infections. CONCLUSIONS: In this large cohort of patients with mesh removed for a diverse array of complications, cultures of the explanted vaginal mesh demonstrate frequent low-density bacterial colonization. We found no differences in culture results from women with delayed-onset pain versus acute pain, vaginal mesh extrusions versus no extrusions, or recurrent UTIs using standard culture methods. Chronic prosthetic infections in other areas of medicine are associated with bacterial biofilms, which are resistant to typical culture techniques. Further studies using culture-independent methods are needed to investigate the potential role of chronic bacterial infections in delayed vaginal mesh complications.

Comparing the portable laparoscopic trainer with a standardized trainer in surgically naïve subjects.

PURPOSE: To evaluate the effectiveness of the portable laparoscopic trainer in improving skills in subjects who have had no previous laparoscopic experience. MATERIALS AND METHODS: Twenty-nine medical students were given a pretest of three tasks on a standardized laparoscopic trainer. Subjects were evaluated objectively and subjectively. Fifteen subjects were randomized to receive a portable laparoscopic trainer and 14 subjects were assigned to the standardized laparoscopic trainers at our facility. The portable trainer group subjects were advised but not required to complete at least 3 hours of training. The group at the facility had a proctored 1-hour session each week for 3 weeks. Each subject was then retested and evaluated with the same pretest tasks. Objective and subjective improvements between the groups were compared. RESULTS: Baseline demographics and pretest scores were similar between both groups. All students in the facility group completed the three 1-hour proctored sessions. The portable trainer group reported an average 204 minutes of practice. The facility group did objectively better on the post-test in overall time, and in two exercises. Subjectively, the facility group had a significant improvement compared with the portable trainer group (4.6 vs 2.4 point average increase, P=0.03). CONCLUSIONS: Both groups showed objective and subjective improvement after a 3-week period of training. The portable trainer group did report longer average practice time, but this made no significant difference in subjective or objective improvement. The portable laparoscopic trainer is comparable to the standard trainer for improvement of basic laparoscopic skills.

Different approaches to an inguinal hernia repair during a simultaneous robot-assisted radical prostatectomy.

OBJECTIVES: To determine if different approaches to an inguinal hernia repair (robotic, laparoscopic, or open) results in different outcomes during a simultaneous robot-assisted radical prostatectomy (RARP). METHODS: We performed a retrospective review of a prospectively generated database of all RARPs performed at our institution. Patients who had a simultaneous inguinal hernia repair were identified. We compared them to an age-matched and body mass index-matched cohort who underwent RARP alone. We also compared outcomes between robotic versus laparoscopic versus open inguinal hernia repair. RESULTS: A total of 1224 RARPs were performed between March 2004 and September 2009. Eighteen patients had simultaneous inguinal hernia repairs during their RARP performed by a general surgeon (5 laparoscopic, 8 open, and 5 robotic). When compared with the cohort who underwent RARP only, there were no statistically significant differences in blood loss, length of stay, or complications. The control group had a significantly shorter OR time (179.5 vs. 215.5 minutes, p = 0.007). When comparing the different approaches of an inguinal hernia repair, the only statistically significant differences noted were body mass index and operative time. Operative time was longer in open versus robotic inguinal hernia repair (74 vs. 31.6 minutes, p = 0.006). There were only two recurrences, both after the simultaneous open inguinal hernia repair. CONCLUSIONS: Simultaneous inguinal hernia repair is a safe and feasible operation to perform during RARP. Although it does extend overall operative time, approaching the repair robotically is quicker than an open approach. A randomized study is needed to truly determine if one approach has better outcomes than the rest.

Older age does not impact perioperative complications after robot-assisted radical prostatectomy.

To determine whether men aged 70 years and older had more perioperative complications after robot-assisted radical prostatectomy (RARP) compared with younger patients, a retrospective review was performed on patients who underwent RARP between March 2004 and September 2009. Subjects were stratified according to age into four groups (age 30-49, 50-59, 60-69, and ≥70 years). American Society of Anesthesiologists (ASA) scores were obtained. Complication rates in the perioperative period, transfusion rates, and length of stay were compared. Complications were classified using the previously validated Clavien system. There were a total of 293 patients aged 70 years and older amongst the 1,223 total subjects. ASA comorbidity scores did vary significantly amongst the different age groups, and there was modest correlation noted between ASA and age. There was no statistically significant difference amongst complication rates in men aged 70 years and older (15%) compared with the other cohorts (P = 0.832). There was also no significant difference in transfusion rates (P = 0.170) or length of stay (P = 0.131). Patients with higher ASA scores (ASA 3-4) had more Clavien I-II complications compared with patients with ASA scores of 1-2 (15.5% versus 10.3%, P = 0.03). There was no difference in transfusion rates or length of stay between the ASA scores. There are no more complications in men aged 70 years and older compared with men <70 years of age undergoing robot-assisted radical prostatectomy. RARP is a safe treatment option to offer to the selected elderly patient.

Primary signet ring cell carcinoma of the prostate.

Nine patients treated with primary signet ring cell carcinoma of the prostate were identified among 29,783 cases of prostate cancer evaluated at Mayo Clinic from January 15, 1970, until January 2, 2009. A PubMed search of the English-language literature published from January 1, 1980, to January 1, 2010, was then performed using the key words signet ring cell and prostate, identifying 42 cases. This study reviews those cases, along with the additional 9 reported herein, and evaluates clinical characteristics, histologic diagnoses, treatment modalities, and outcomes. Mean age at diagnosis was 68 years (range, 50-85 years), and mean prostate-specific antigen level was 95.3 ng/mL (range, 1.9-536.0 ng/mL; to convert to µg/L, multiply by 1). Most patients (66%) had non-stage IV carcinoma, the most common Gleason sum was 8 (33%), and mean survival was 29 months. The presence of a primary signet ring cell carcinoma of the prostate was best confirmed by negative findings on gastrointestinal work-up, a positive stain for prostate-specific acid phosphatase, and negative carcinoembryonic antigen test results.