Review of Ischemic and Non-ischemic Priapism.

PURPOSE OF REVIEW: Priapism is a rare condition that has different presentations, etiologies, pathophysiology, and treatment algorithms. It can be associated with significant patient distress and sexual dysfunction. We aim to examine the most up-to-date literature and guidelines in the management of this condition. RECENT FINDINGS: Priapism is a challenging condition to manage for urologists, since the etiology is often multi-factorial and the suggested treatment algorithms are based on small studies and expert anecdotal experience, perhaps due to the rarity of the disorder. Ischemic priapism of less than 24 h can be managed non-surgically in most cases with excellent results. Ischemic priapism of more than 36 h is frequently associated with permanent erectile dysfunction. Management of prolonged priapism with penile shunting still may result in poor erectile function, so penile prosthesis can be discussed in these scenarios.

Transurethral resection of prostatic abscess.

Prostate abscess (PA) is an uncommon prostatic infection, with risk factors including indwelling catheters, acute or chronic prostatitis, bladder outlet obstruction, voiding dysfunction, recent urologic instrumentation (especially transrectal prostate biopsy), chronic kidney disease (CKD), diabetes mellitus (DM), human immunodeficiency virus (HIV), intravenous drug use (IVDU), and hepatitis C. Treatment of PA consists of antibiotics and abscess drainage via transurethral resection (TUR) or image-guided transrectal or transperineal drainage. Numerous studies have demonstrated that TUR of PA has a higher success rate and shorter hospital length of stay when compared to image-guided drainage. Despite this, TUR of PA is a relatively uncommon surgery with few useful recommendations on how to best perform this procedure. We demonstrate the TUR surgical technique for drainage of a 6 cm loculated PA in a 44-year-old man with active IVDU and hepatitis C. The patient presented with progressive voiding symptoms, urinary retention, and leukocytosis. Given the size, loculated nature of the abscess, and its proximity to the prostatic urethra, we decided to proceed to the operating room for surgical drainage as opposed to image-guided transrectal drainage. Herein we describe the trans urethral technique. He clinically improved postoperatively and repeat imaging 4 days later showed decreased abscess size. Transurethral drainage of a PA is a safe, efficient, and effective treatment option. Treatment approach should depend on abscess size, location, and presence of loculations. Combining different endourologic techniques and instruments may be necessary.

Ureteral stenting after routine ureteroscopy: Is earlier stent removal feasible?

INTRODUCTION: Ureteroscopy and laser lithotripsy is a common treatment option for upper urinary tract calculi. Currently, ureteral stents are placed after uncomplicated ureteroscopy for up to 1 week, but the optimal length of placement is not well defined. Ureteral stents are associated with significant morbidity, particularly stent discomfort. This study aims to determine differences in postoperative unplanned clinic or ED visits based on duration of stent placement. MATERIALS AND METHODS: This is a single-institution, IRB-approved, retrospective cohort study of 559 ureteroscopy cases with laser lithotripsy for urinary tract calculi performed from 2016 to 2018. The primary outcome was unplanned ED or clinic visits within 30 days following surgery and there. The patients were separated into three groups based on stent duration: 1 (0-3 days), 2 (4-6 days), and 3 (> 6 days). RESULTS: Fifty-eight (10.31%) patients experienced an unplanned visit within 30 days of the procedure. There was no significant difference in unplanned visits among groups for stent duration (p = 0.45). A Clavien grade analysis showed no difference in grades between groups (p = 0.59). A Cox regression model showed no difference in risk of unplanned visit comparing those in groups 2 and 3 to group 1 (p = 0.157 and 0.374, respectively). This also remains to be the case after adjusting for age, sex, and surgeon (p = 0.166 and 0.376, respectively). CONCLUSIONS: We found no difference in unplanned visits in patients based on the duration of stent placement following routine ureteroscopy. Stent removal within 3 days of surgery appears to be sufficient to minimize morbidity after uncomplicated ureteroscopy.

A Multi-Institutional Matched-Pair Analysis of Robotic Partial Nephrectomy for Single vs Multiple Ipsilateral Renal Masses.

Introduction: Nephron-sparing surgery is important in patients with multiple renal tumors, especially if associated with a solitary kidney or hereditary syndrome. Prior studies have shown partial nephrectomy (PN) of multiple ipsilateral renal masses to have good oncologic and renal function outcomes. We aim to compare renal function changes, complications, and warm ischemia time (WIT) of partial nephrectomy of a single renal mass (sPN) vs those of partial nephrectomy of multiple ipsilateral renal masses (mPN). Materials and Methods: We retrospectively reviewed our multi-institutional PN database. We matched robotic sPN and mPN patients ∼3:1 using "nearest neighbor" propensity score matching based on age, Charlson comorbidity index (CCI), total tumor size, and nephrometry score. Univariate analysis was performed, and multivariable models were fit controlling for age, gender, CCI, and tumor size. Results: Fifty mPN and 146 sPN patients were matched. The mean total tumor size was 3.3 and 3.2 cm, respectively (p = 0.363). The mean nephrometry score in both groups was 7.3 and 7.2, respectively (p = 0.772). Estimated blood loss (EBL) was 137.6 and 117.8 mL, respectively (p = 0.184). The mPN group had higher operative time (174.6 vs 156.4 minutes, p = 0.008) and WIT (17.0 vs 15.3 minutes, p = 0.032). There was no significant difference in the change in glomerular filtration rate (mPN -6.4% vs sPN -8.7%, p = 0.712). Complications (Clavien 2+) occurred in 10.2% of mPN and 11.3% of sPN patients (p = 0.837). A multivariable linear model predicts a nonstatistically significant difference of 1.4 minutes of additional WIT in the mPN group (p = 0.242). There was no statistical difference in complication rates between groups in a multivariable model (odds ratio 1.00, p = 0.991). Conclusions: Robotic PN in our multi-institutional matched comparison of mPN and sPN showed no difference in complications, renal functional outcomes, or EBL. mPN was associated with increased operative time and WIT, though the WIT difference was not significant on multivariable analysis.

Closed suction drain outputs at 12 and 24 hours after primary three-piece inflatable penile prosthesis surgery.

This is a single-institution retrospective study of closed suction drain outputs in primary three-piece IPP cases performed between 2014 and 2017 by a single surgeon. The aim was to investigate the impact of closed suction drains (CSD) during penile prosthesis placement. One hundred and sixty-nine patients underwent intraoperative placement of a closed suction drain. Drain outputs were measured at 12 and 24 h, and postoperative complications were documented. There were no hematomas or infections observed within the patient cohort. The drain output decreased significantly between the first and subsequent 12 h period. Surgical time was associated with statistically significant increases in CSD output at 12 and 24 h with a near linear relationship between surgical times and CSD at 12 and 24 h. Penile prosthesis placement in patients on aspirin did not affect the CSD output volume. Closed suction drains should be considered in all patients undergoing placement of inflatable penile prosthesis, particularly in those cases with longer operative time.

The Effect of Radical Prostatectomy, External Beam Radiation Therapy and Active Surveillance on Life Insurance Premiums in Patients with Prostate Cancer.

INTRODUCTION: Patients with early stage, low risk prostate cancer are typically treated with radical prostatectomy, external beam radiation therapy or active surveillance. We examine how these different management options affect life insurance underwriting practices. METHODS: A total of 20 life insurance companies were sent questionnaires with 9 sample patient cases. Patients were diagnosed with low risk prostate cancer at age 55, 65 or 75 years, and treated with radical prostatectomy, external beam radiation therapy or active surveillance. The life insurance companies were then asked what their underwriting decision would be (standard, substandard or decline) for each sample patient if he submitted a $500,000 term life insurance application at 1, 3 and 5 years after treatment initiation with no evidence of disease on followup. RESULTS: Of the 20 life insurance companies 12 (60%) responded to the questionnaire. In all age groups standard life insurance premiums were most likely to be granted after radical prostatectomy (52.7%), followed by external beam radiation therapy (36.0%) and lastly by active surveillance (5.6%). Regardless of management option, standard premiums were also more likely to be granted if prostate cancer was diagnosed at an older patient age and if there had been a longer duration of disease-free followup (54.6% after 5 years vs 31.0% after 1 year). CONCLUSIONS: For patients diagnosed with low risk prostate cancer life insurance companies are more likely to grant standard life insurance premiums after radical prostatectomy or external beam radiation therapy rather than active surveillance. Other predictors of favorable underwriting decisions are older age at diagnosis as well as longer duration of disease-free followup.

Male Sexual Function and Smoking.

INTRODUCTION: Erectile dysfunction (ED) is a common disorder that has many potential etiologies, including hormonal imbalances, psychogenic factors, neurologic disorders, vascular insufficiency, and other risk factors. Cigarette smoking has been well established as a risk factor for cardiovascular disease and stroke, but the relation between smoking and ED is less frequently considered. AIM: To review the current literature that analyzes the association between cigarette smoking and ED. METHODS: The PubMed database was searched using the terms erectile dysfunction and smoking and erectile dysfunction and tobacco through December 2015. MAIN OUTCOME MEASURES: Main outcome measures were significant changes in erectile function in relation to smoking status. RESULTS: Eighty-three studies and articles were reviewed. Multiple human studies, animal studies, case series, cross-sectional, and cohort studies analyzed the relation between smoking or nicotine and ED. CONCLUSION: There is substantial evidence showing that cigarette smoking is a risk factor for ED. Multiple human, animal, case series, cross-sectional, and cohort studies support this conclusion. A positive dose-response relation also is suggested such that increased quantity and duration of smoking correlate with a higher risk of ED. Smoking cessation can lead to recovery of erectile function, but only if limited lifetime smoking exposure exists. Smoking contributes to ED in different ways, especially by causing penile vasospasm and increased sympathetic nervous system tone.