National Adherence to Guidelines for Antimicrobial Prophylaxis for Patients Undergoing Radical Cystectomy.

PURPOSE: The sentinel reference for antibiotic prophylaxis for radical cystectomy with ileal conduit in the AUA Guidelines reports data from 2003-2013 and has not been updated in the interim. Here, we assess adherence to antibiotic prophylaxis guidelines among patients undergoing radical cystectomy with ileal conduit for bladder cancer using a large national database. As a secondary objective, we assess the association between antimicrobial use and postoperative infection during the index admission following cystectomy. MATERIALS AND METHODS: The Premier Healthcare Database was queried for all patients undergoing cystectomy with ileal conduit with diagnosis of bladder cancer between 2015 and 2020. Antibiotics used and the duration of use was determined by charge codes and grouped as guidelines-based or not according to 2019 AUA Guidelines. Association with infectious complications was assessed by logistic mixed effects regression models. RESULTS: Among 6,708 patients undergoing cystectomy with ileal conduit, only 28% (1,843/6,708) were given prophylaxis according to AUA guidelines; 1.8% (121/6,708) of patients received an antifungal and 37% (2,482/6,708) received extended duration prophylaxis beyond postoperative day 1. Patients who received guidelines-based prophylaxis were less likely to be diagnosed with a urinary tract infection (21% vs 24%, P = .04), pyelonephritis (5.1% vs 7.7%, P < .001), bacterial infection (24% vs 27%, P = .03), or pneumonia (12% vs 17%, P < .001). There was no statistically significant difference in clostridium difficile infection between guidelines-based and nonguidelines-based prophylaxis (3.2% vs 3.7%, P = .32). In a multivariable logistic regression adjusting for age, race, insurance, and hospital and provider characteristics, nonguideline antibiotic prophylaxis (OR 1.27 [1.12, 1.43], P < .001) was associated with an increased odds of infectious events, whereas a robotic approach (OR 0.82 [0.73, 0.92], P < .001) was associated with lower odds. CONCLUSIONS: Seventy-three percent of patients fail to receive guideline-based antibiotic prophylaxis when undergoing radical cystectomy with conduit, which was largely driven by extended duration antibiotic use. Despite the shorter duration of antibiotics, we found that guideline-based prophylaxis was associated with a 25% decrease in the odds of infectious complications. While residual confounding is possible, these data support current AUA guidelines and suggest a need for outreach to improve guideline adherence.

Trends over 20 years of antimicrobial prophylaxis for artificial urinary sphincter surgery.

INTRODUCTION AND OBJECTIVE: Perioperative antimicrobial prophylaxis is crucial for prevention of prosthesis and patient morbidity after artificial urinary sphincter (AUS) placement. While antibiotic guidelines exist for many urologic procedures, adoption patterns for AUS surgery are unclear. We aimed to assess trends in antibiotic prophylaxis for AUS and outcomes relative to American Urological Association (AUA) Best Practice guidelines. METHODS: The Premier Healthcare Database was queried from 2000 to 2020. Encounters involving AUS insertion, revision/removal, and associated complications were identified via ICD and CPT codes. Premier charge codes were used to identify antibiotics used during the insertion encounter. AUS-related complication events were found using patient hospital identifiers. Univariable analysis between hospital/patient characteristics and use of guideline-adherent antibiotics was done via chi-squared and Kruskal-Wallis tests. A multivariable logistic mixed effects model was used to assess factors related to the odds of complication, specifically the use of guideline-adherent versus nonadherent regimens. RESULTS: Of 9775 patients with primary AUS surgery, 4310 (44.1%) received guideline-adherent antibiotics. The odds of guideline-adherent regimen use increased 7.7% per year with 53.0% (830/1565) receiving guideline-adherent antibiotics by the end of the study period. Patients with guideline-adherent regimens had a decreased risk of any complication (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.74-0.93) and surgical revision (OR: 0.85, 95% CI: 0.74-0.96) within 3 months; however, no significant difference in infection within was noted (OR: 0.89, 95% CI: 0.68-1.17) within 3 months. CONCLUSIONS: Adherence to AUA antimicrobial guidelines for AUS surgery appears to have increased over the last two decades. While guideline-adherent regimens were associated with decreased risk of any complication and surgical intervention, no significant association was found with risk of infection. Surgeons appear to be increasingly following AUA recommendations for antimicrobial prophylaxis for AUS surgery, however, further level 1 evidence should be obtained to demonstrate conclusive benefit of these regimens.

Novel Antireflux "RELIEF" Stent to Prevent Vesicoureteral Reflux.

OBJECTIVE: To assess efficacy, comfort, and symptoms of a novel ureteral stent (RELIEF) substituting the distal semirigid coil of a traditional double-J for a floating, monofilament tether allowing coaptation of the ureteral orifice. Ureteral instrumentation notoriously cause discomfort, urgency, frequency, dysuria, and hematuria; prolonged morbidity is likely related to stent-associated vesicoureteral reflux (VUR). We hypothesized this design would eliminate VUR, be safe and provide comfort following intervention. METHODS: Twenty-eight patients within a single institution were enrolled. Passive cystography was performed pre- and post-stent placement assessing VUR. Patients completed Ureteric Stent Symptoms Questionnaires (USSQ) before placement (baseline), postop day 1, and day of removal. RESULTS: Twenty RELIEF stents were placed (11 female and 9 male). 95% demonstrated no VUR following placement. No unexpected adverse complications occurred; 1 patient opted for early stent removal for significant discomfort. Average total USSQ scores demonstrated statistically significant improvement between first and third surveys (P < .001). Statistically significant improvement in body pain, general health, and work performance scores were noted as well (P < .05). CONCLUSION: The RELIEF stent eliminates VUR with similar stent-related morbidity and overall well-tolerance. RELIEF-associated USSQ scores were below published mean symptom scores for standard double-J stents and appear safe in this preliminary clinical trial.

Surgical Outcomes at a Single Institution of Infrapubic Insertion of Malleable Penile Prosthesis in Transmen.

OBJECTIVE: To describe our technique for the infrapubic approach for malleable penile prosthesis (MPP) insertion after phalloplasty in transgender men and review surgical outcomes. METHODS: The infrapubic prosthesis insertion technique involves a horizontal incision anterior to the pubic symphysis, allowing dissection of the neophallus tract and anchor site on the pubic symphysis. Surgical outcomes by a single surgeon using a Spectra or Genesis MPP between October 2017 and May 2022 were retrospectively reviewed. Complications were categorized into erosions, infections, device detachment, device malposition, pain or activity limitation, urethral injury, and flap loss. Implant survival kinetics were assessed by evaluating time to surgical revision. RESULTS: Forty patients underwent infrapubic MPP insertion; 35 patients had a prior radial forearm free flap (RFFF) and 5 had a prior anterolateral thigh flap (ALT) phalloplasty. Of 30 patients who maintained follow-up, mean follow-up was 34.9 months. Complications were not mutually exclusive, with 7 implant detachments from the anchor site, 3 malpositions, 2 with pain/activity limitation, and 1 infection. Surgical revision was required in 12/30 patients (40%). There were no neophallus erosions, flap loss, nor urethral injuries. More complications occurred with the Spectra (9/17 or 53%) than the Genesis MPP (3/13 or 23%), but this was not statistically significant (P = .10). CONCLUSION: Infrapubic insertion in transmen after phalloplasty using commercially available MPPs is safe compared with other post-phalloplasty penile prosthesis insertion techniques, with similarly high surgical revision rates. Further study of techniques is needed to improve outcomes after penile prosthesis insertion in transmen.

Evaluating the readability of online testosterone search results.

With the budding interest in testosterone therapy (TTh), online health information plays a significant role in patients' health care decisions. Therefore, we evaluated the source and readability of web-based information available to patients regarding TTh on Google. From Google search terms "Testosterone Therapy" and "Testosterone Replacement", 77 unique sources were identified. Sources were categorized as Academic, Commercial, Institutional, or Patient Support, then evaluated using validated readability and English language text assessment tools: the Flesch Reading Ease score, Flesch Kincade, Gunning Fog, Simple Measure of Gobbledygook (SMOG), Coleman-Liau Index and Automated Readability index. The average grade level for understanding academic sources was 16 (college senior); commercial, institutional, and patient support sources were 13 (college freshman); 8 and 5 grade levels, respectively, above the average U.S. adult. Patient support sources were most prevalent, while commercial sources were the least at 35 and 14%, respectively. The average reading ease score was 36.8, indicative of difficult-to-read material overall. These results indicate that the most immediate online sources for TTh information exceed the average reading level of most adults within the U.S., hence more effort should be taken to publish accessible and readable material to improve patient health literacy.

Trends in testosterone prescription amongst medical specialties: a 5-year CMS data analysis.

Testosterone Therapy (TTh) trends have changed as a result of clinical research and market forces over the past several years. Understanding the trends or preferences regarding testosterone prescriptions remains unknown. Our objective was to assess both regional and national trends in TTh prescriptions amongst medical specialties within the United States between 2013 and 2017. Publicly available data from the Center for Medicare and Medicaid Services (CMS) Part D Prescriber database with regards to TTh prescriptions across a 5-year span (January 1, 2013-December 31, 2017) were analyzed. TTh therapies were consolidated into four categories: Topical, Oral, Injection and Pellet. Statistical analysis utilizing R 4.0.2 was performed on the resulting data. Trends in prescription modality claim count and cost were plotted over the study period while statistical analysis evaluated associations between TTh modality and medical specialist. We found that Endocrinologists and Urologists prescribed topical testosterone more than all other specialties (60.4% and 53.5%, respectively), while Family and Internal medicine physicians were more likely to prescribe injections (59.82% and 50.69%, respectively). Oral and pellet testosterone were rarely prescribed across all specialties. In conclusion, the wide variation in modalities of testosterone prescriptions illustrates an opportunity for treatment guidelines to be streamlined across all specialists to improve patient outcomes.

Median lobe vs. complete gland holmium laser enucleation of the prostate: A propensity score matching.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is a common condition affecting aging men. While holmium laser enucleation of the prostate (HoLEP) is one of the most effective treatments for BPH, variations of the procedure, such as median lobe HoLEP (MLHoLEP), are rarely reported. Here, we report our institution's experience with partial HoLEP. METHODS: Our institutional prospective database was queried for patients having undergone median or individual lateral lobe enucleation between 2007 and 2018. A control cohort of patients who underwent standard HoLEP (sHoLEP) was identified using 1:2 propensity score matching based on age, prostate size, maximal flow rate (Qmax), postvoid residual volume (PVR), and American Urological Association symptom score (AUAss). Three and 12-month AUAss, PVR, and Qmax were compared. RESULTS: Forty-seven patients were identified as having undergone MLHoLEP. At three-month followup, AUAss (p<0.01) and incontinence rates (p=0.045) were lower for MLHoLEP patients, in addition to them having shorter operative (36.5 mins vs. 64.5 mins, p<0.01) and enucleation (13.8 mins vs. 37 mins, p<0.01) times as compared to sHoLEP patients. No difference was noted between MLHoLEP and sHoLEP cohorts with respect to age, prostate volume, PVR, or Qmax. Significant improvement in AUAss, PVR, and Q max from baseline to three and 12 months was noted overall in both groups. CONCLUSIONS: MLHoLEP could provide a surgical option with reduced operative time, quicker improvement in AUAss, and restored continence in appropriately selected patients. Ultimately, MLHoLEP represents a safe and effective treatment option to select patients who may not be eligible for or face potential morbidity concerns associated with sHoLEP.

Is medical dissolution treatment for uric acid stones more cost-effective than surgical treatment? A novel, solo practice, retrospective cost-analysis of medical vs. surgical therapy.

INTRODUCTION: Effective medical dissolution therapy (MDT) for uric acid stones is more cost-effective than surgical treatment; however, treatment failure may be associated with increased cost. We aimed to study the cost-effectiveness of MDT for uric acid stones vs. surgical management. METHODS: We performed a retrospective study within our institution of all patients receiving MDT for uric acid stones from 2008-2019. All patients had a known history of uric acid stones, urine pH ≤5.5, and <500 Hounsfield units on preoperative computed tomography (CT). The cost of treatment in the dissolution group was compared to the cost of primary surgical treatment in a theoretical matched cohort. Cost was estimated using local Medicare reimbursement scales. Statistical analysis was performed with SPSS Statistics. RESULTS: A total of 28 patients were identified, of which 18 were included in the study. Complete and partial dissolution occurred in six (33%) and four (22%) patients, respectively. Five (28%) patients developed symptoms and underwent ureteral stent placement. Ureteroscopy and percutaneous nephrolithotomy (PCNL) were each performed in three (17%) patients in whom dissolution treatment was not effective on followup CT. Following dissolution trial, six (33%) patients had residual stone burden requiring surgical intervention. The average cost of treatment, including surgeries, was $14 604 in the dissolution group vs. $17 680 in the surgical cohort. The average cost to achieve stone-free status in patients with complete, partial, or no response to dissolution were $1675, $10 124, and $21 584, respectively, while primary surgical treatment for the same patients would cost $15 037, $10 901, and $20 511, respectively. CONCLUSIONS: Successful MDT is highly cost-effective. Incomplete response to dissolution can stem from several reasons and contributes to higher costs and likely decreased quality of life.

Is Reddit a reliable source for information on erectile dysfunction treatment?

Patients may turn to social media websites, such as Reddit, for information on erectile dysfunction prior to seeking care from a physician. We sought to identify, characterize, and assess the quality of the erectile dysfunction treatments discussed on the highly influential Reddit website. We assessed 2634 comments from two subreddits, r/AskMen and r/ErectileDysfunction, for positive and negative statements regarding treatments for erectile dysfunction. A total of 45 unique treatments were discussed and consisted of changes in sexual behavior (30%), lifestyle changes (29%), medical interventions (23%), talking with a partner about ED (10%), and use of supplements (8%). Only 24.4% of all treatments discussed are in line with current American Urological Association guidelines. Only 43.8% of all positive statements made endorsed a guidelines-based treatment, indicating a high rate of self-proclaimed success with alternative therapies. Our results indicate that there is active discussion of erectile dysfunction treatment on Reddit with a wide range of therapies recommended, however, the majority of the recommendations are not supported by strong clinical evidence.

Trends in Antimicrobial Prophylaxis for Inflatable Penile Prosthesis Surgery From a Large National Cohort.

OBJECTIVE: To assess changes in antibiotic prophylaxis for inflatable penile prosthesis surgery following publication of the American Urological Association (AUA) Best Practice Statement in April 2008. MATERIALS AND METHODS: The Premier Healthcare Database was queried for inflatable penile prosthesis surgeries from January 2000 to March 2020. The primary outcome was administration of an AUA-adherent antimicrobial regimen and secondary outcome was 90-day explant. Piecewise linear regression was used to compare antimicrobial trends before vs after guideline publication. Multivariable logistic regression models were constructed for primary and secondary outcomes. RESULTS: A total of 26,574 patients who underwent inflatable penile prosthesis surgery were identified, of whom 17,754 (67%) received AUA-adherent antibiotics. After guideline publication, there was a 42% relative increase in AUA-adherent regimen usage, with an increase in the usage trend on piecewise linear regression (from 0.1% to 0.8% of encounters per quarter, R2 = 0.75, P < .001). Increased usage trends were also observed for gentamicin (from 0.0% to 1.0% of encounters per quarter, R2 = 0.84, P < .001) and vancomycin (0.1%-0.7%, R2 = 0.77, P < .001). On multivariable regression, odds of AUA-adherence increased after guideline publication (OR: 1.67, 95% CI: 1.54-1.80, P < .001) and with surgery by a high-volume surgeon (OR: 2.21, 95% CI: 2.07-2.35, P < .01). Nonadherence to an AUA-recommended regimen with use of nonstandard antibiotics (OR: 1.16, 95% CI: 0.78-1.71, P = .5) or excess antibiotics (OR: 0.91, 95% CI: 0.62-1.30, P = .6) was not independently associated with increased risk of 90-day explant. CONCLUSIONS: Publication of the AUA Best Practice Statement was associated with subsequent increases in the usage of guideline-adherent antibiotic regimens, particularly vancomycin and gentamicin, despite absence of level-1 evidence supporting this combination.

How Female Is the Future of Urology? Projecting Various Trajectories of the United States Urology Workforce.

OBJECTIVE: To project the number and proportion of women in the urology workforce using recent demographic trends and develop an app to explore updated projections using future data. METHODS: Demographic data were obtained from AUA Censuses and ACGME Data Resource Books. The proportion of female graduating urology residents was characterized with a logistic growth model. "Stock and Flow" models were used to project future population numbers and proportions of female practicing urologists, accounting for trainee demographics, retirement trends, and growth in the field. RESULTS: Assuming growth in urology graduate numbers and continued logistic growth in the proportion of women, 10,957 practicing urologists (38%) will be female by 2062. If the rate of women entering urology residency stagnates, 7038 urologists (24%) will be female. If the retirement rates for women in urology change to mirror those of men and the proportion of female residents continues to experience logistic growth, 11,178 urologists (38%) will be female. An interactive app was designed to allow for a range of assumptions and future data: https://stephenrho.shinyapps.io/uro-workforce/. CONCLUSION: Workforce projections should incorporate recent growth in numbers of female residents. If current growth continues, 38% of urologists will be female by 2062. The app allows for exploration of different scenarios and can be updated with new data. The projections demonstrate the need for targeted efforts to recruit women into urology, address disparities within the field, and work toward retaining female urologists. We must continue working toward an equitable future workforce that can address the impending shortage of urologists.

Revision Labiaplasty After Penile Inversion Vaginoplasty Using Costal Cartilage Allograft.

BACKGROUND: Gender-affirming surgery leads to high satisfaction for patients; however, patients often require revision surgery. Revision labiaplasty is one of the most common surgeries following vaginoplasty. The labia minora commonly become incorporated into the labia majora and lose definition even after revision leading to patient dissatisfaction. DESCRIPTION OF TECHNIQUE: We propose a technique of incorporating cadaveric costal cartilage allograft into the revised labia minora to increase the definition. PATIENT AND METHODS: The procedure was demonstrated in a 38-year-old MTF patient who had previously undergone inversion vaginoplasty. The cartilage allograft was incorporated within the labia minora flaps dur ing labiaplasty. RESULTS: The patient had lasting definition of her labia minora post-operatively at 6 weeks without adverse effects. CONCLUSION: We believe that this technique may be effective and safe in patients requesting more defined labia minora after vaginoplasty.

Where to draw the line? Understanding preferences in mucosal collar length after circumcision: A crowdsourced survey from the U.S. general population.

INTRODUCTION: Male circumcision is a polarizing and prevalent procedure. Little understanding exists regarding patient preferences for circumcision appearance. Our objective was to elicit how mucosal collar length may be perceived in terms of overall cosmesis and desirability among adults. METHODS: A questionnaire using REDCap was created and distributed through Amazon Mechanical Turk. Respondents provided demographic information and circumcision status before being challenged with artistic representations of circumcised penises with increasing lengths of mucosal collar. Participants were asked to select the most and least esthetically pleasing image, as well as rate the "importance of appearance" from 0-100. Responses were analyzed with ordinal regression models. RESULTS: Preference for shorter mucosal collars were seen in respondents with a postgraduate education (p=0.013) and no religious affiliation (p=0.034). In contrast, participants reporting a religious affiliation preferred longer mucosal collars (p=0.034). Circumcised males rated appearance as being more important (p=0.001) in contrast to uncircumcised males who did not (p=0.001). Circumcised fathers were more likely to circumcise their sons relative to uncircumcised fathers (p<0.05) and women preferred circumcision (p<0.05). CONCLUSIONS: Our study revealed polarized esthetic preferences in the sample as a whole, with large proportions of respondents selecting the longest or shortest collar length. Preferences regarding mucosal collar length appear to be most influenced by education and religion. Overall, our study did not observe a predominant preference for mucosal collar length following circumcision. Surgeons should engage patients and/or caregivers/parents preoperatively in discussions regarding preferences and desired cosmetic outcomes.

Impact and Implications of the COVID-19 Pandemic on Urological Training.

INTRODUCTION: COVID-19 has forever impacted health care in the U.S. Changes to health and hospital policies led to disruptions to both patient care and medical training. There is limited understanding of the impact on urology resident training across the U.S. Our aim was to examine trends in urological procedures, as captured by the Accreditation Council for Graduate Medical Education resident case logs, throughout the COVID-19 pandemic. METHODS: Retrospective review of publicly available urology resident case logs between July 2015 and June 2021 was performed. Average case numbers were analyzed via linear regression with different models specifying different assumptions regarding the impact of COVID-19 on procedure in 2020 and onward. Statistical calculations utilized R (version 4.0.2). RESULTS: Analysis favored models which assumed the impact of COVID-related disruptions were specific to 2019-2020. Analysis of procedures performed indicate an average upward trend of urology cases nationally. An average annual increase of 26 procedures between 2016 and 2021 was noted, except for 2020 which saw an average drop of approximately 67 cases. However, in 2021 case volume dramatically increased to the same rate as projected had there not been a disruption in 2020. Stratifying by category of urology procedure revealed evidence for variability between categories in the magnitude of the 2020 decrease. CONCLUSIONS: Despite widespread pandemic-related disruptions in surgical care, urological volume has rebounded and increased, likely having minimal detriment to urological training over time. Urological care is essential and in high demand as evidenced by the uptick in volume across the U.S.

Symptom Resolution and Recurrent Urinary Incontinence Following Removal of Painful Midurethral Slings.

OBJECTIVE: To evaluate pain improvement and recurrent stress incontinence (SUI) following painful synthetic midurethral sling (MUS) removal. METHODS: We conducted a retrospective review of patients who underwent synthetic MUS removal at our institution from 2009-2016 for the indication of pain. We recorded sling type (transobturator vs retropubic), complete vs partial removal, and presenting symptoms. Postoperative pain improvement was categorized as resolved (pain resolved, requiring no further therapy), improved (pain less bothersome, may require further therapy), or unresolved (no/minimal improvement, requiring further management). Recurrent incontinence and further reconstructive procedures were assessed. RESULTS: 87 patients (49 complete and 38 partial removal) with pain as the primary indication for removal were included. Median age at intervention was 54 years with median follow-up of 8 months. Overall, pain improved or resolved in 78.1% of cases. Complete removal was associated with significantly greater percentage of pain resolution (63.3%) compared to partial removal (26.3%) (P = 0.002) regardless of sling type. No significant differences in recurrent SUI were noted in complete vs partial removal. Additional reconstructive procedures were performed in 28 patients, most commonly sling placement, with no significant difference in complete (20.4%) vs partial (28.9%) removal groups (P = 0.36). The overall complication rate was low (5.7%), a majority of which were transfusions (4.6%). CONCLUSION: Following MUS removal, most patients experienced resolution or improvement of pain. Complete sling removal was associated with significantly greater percentage of pain resolution compared to partial removal in both retropubic and transobturator slings. Rates of recurrent SUI and reintervention for SUI were not related to the extent of sling removal.

Opioid prescription patterns among urologists as compiled from within Medicare.

INTRODUCTION: We aimed to evaluate opioid prescribing patterns of urologists across the United States (U.S.) and the District of Columbia (D.C.) using publicly available data from Medicare Part D. Our secondary analysis was to identify any loco-regional trends that may exist within the U.S. METHODS: We queried publicly reported information from the Part D prescriber database, which is compiled from beneficiaries enrolled within the Medicare Part D prescription drug program. Only providers with the specialty description of urologist were included in this study. RESULTS: Between 2013 and 2017, a five-year average of 452 901 opioid claims by 9640 urologists - amounting to $5 357 114 USD and comprising 3.78% of all claims made - were identified. The state of Maine featured the highest percentage of opioid claims in relation to all claims (5.81%). West Virginia had the greatest average total opioid claims per provider (90), while Michigan featured the highest average proportion of opioid claims per provider (10.63%). The fewest opioid claims were processed within the Mid-Atlantic and New England regions. CONCLUSIONS: A multitude of factors likely contributes to variability between states. Urologists should be increasingly aware of their individual prescription tendencies and use available drug monitoring programs to reduce unnecessary prescriptions, all while providing more targeted and appropriate pain management.

Pain Resolution and Recurrent Prolapse Rates Following Vaginal Mesh Removal.

OBJECTIVE: To evaluate pain resolution and recurrent prolapse following removal of painful pelvic organ prolapse (POP) mesh. METHODS: This was an IRB-approved retrospective review of patients who underwent POP mesh removal from 2009 to 2018 for the primary indication of pain and/or dyspareunia. Factors of interest included mesh type, complete versus partial removal, presenting symptom(s), and recurrent prolapse. Complete removal was defined as complete excision of all possible mesh, including arms, and partial removal was anything less. Postoperative symptom improvement was categorized as resolved, improved, or unresolved. RESULTS: Ninety-two mesh removal patients were identified, 78 of whom underwent mesh removal for pain or dyspareunia, with mean follow-up of 17.25 months (range: 0.46-60.25). Overall, presenting symptoms resolved or improved in 85.9%. In the 45 complete removal patients, 46.7% resolved, 40.0% improved, and 11.1% unresolved compared to 51.5% resolved, 33.3% improved, and 12.1% unresolved in the 33 partial removal patients (P = .82). Recurrent symptomatic POP developed in 31.1% of patients after complete removal compared to 15.2% after partial removal (P = .12). Overall, 23 (30.3%) patients required additional reconstructive procedures. CONCLUSION: Most patients experienced resolution or improvement in painful symptoms after any degree of mesh removal. Complete removal was not significantly associated with greater symptom improvement compared to partial removal. Complete removal was associated with a higher percentage of recurrent POP, but this association was not statistically significant. Less than one-third of patients required additional surgery.

Peri-operative outcomes between primary and replacement artificial urinary sphincter surgery: An ACS-NSQIP analysis.

OBJECTIVE: To evaluate differences in perioperative clinical outcomes in men undergoing artificial urinary sphincter (AUS) implantation in primary versus replacement settings. Secondarily, we aimed to identify patient-related factors contributing to complications associated with AUS placement. MATERIALS AND METHODS: A review of the American College of Surgeons-National Surgical Quality Improvement Program was performed between 2010 and 2018 identifying males undergoing AUS implantation. Subjects were further subdivided into primary implantation or removal/replacement of AUS simultaneously via current procedural terminology codes 53445 and 53447, respectively. 30-Day postoperative outcomes were compared between cohorts using t-test and Fisher's exact test. The relationship between patient factors and complications was evaluated using logistic regression. RESULTS: A total of 1,892 patients were identified: 1,445 primary AUS placement and 447 AUS replacement procedures. Patients undergoing AUS replacement were statistically older than those undergoing primary implantation (71.4 vs 69.7 years, P < .001). AUS replacement procedures were associated with an increased rate of superficial surgical site infection (SSI) compared to primary procedures (1.3% vs 0.4%, P » .042). There were no differences identified between cohorts for deep SSI, cardiopulmonary complications, reoperation, operative time, or length of stay. Logistic regression demonstrated that higher body mass index was found to be independent risk factors for any complications, and diabetes mellitus was associated with increased risk of AUS-related readmission. CONCLUSION: Within the perioperative period, patients undergoing replacement AUS have an increased risk of superficial SSI compared to primary AUS implantation. These findings can assist with appropriate perioperative counseling of patients undergoing primary and replacement AUS implantations.

Direct Cost Savings Analysis of Nurse Practitioner for Inpatient Urology Practice.

INTRODUCTION: A 2015 survey of members of the American Urological Association found the majority of urologists (62.7%) work with an advanced practice provider. The aim of this study was to analyze direct cost savings of inpatient advanced practice provider hiring focusing on direct cost, length of stay, readmission rate and discharge planning. METHODS: Data from a single tertiary care referral center was collected between 2015 Q (quarter) 1 to 2018 Q2. Seven quarters before inpatient advanced practice provider implementation (2015 Q1 to 2016 Q3) were compared to 7 subsequent quarters after initiation of inpatient nurse practitioner program (2016 Q4 to 2018 Q2). A total of 1,190 major urological cases were performed during this time (178 cystectomies, 663 nephrectomies, 349 prostatectomies). Factors influenced by inpatient advanced practice provider such as length of stay, discharge before 11 a.m. and total direct cost were analyzed before advanced practice provider and after advanced practice provider. Mann-Whitney U and chi-square tests were used for continuous and categorical data, respectively. RESULTS: Advanced practice provider inclusion as part of a urology health care team showed an overall decreased length of stay (p=0.042) with an increase in discharges before 11 a.m. (p <0.001). There was no significant change in direct cost (p=0.89) combined for all 3 groups, but direct cost in the cystectomy group was significantly lower (p=0.048). There was a statistically significant improvement in discharge time for nephrectomy (p=0.039) and cystectomy (p=0.02) after advanced practice provider program initiation. CONCLUSIONS: Inclusion of an advanced practice provider within inpatient setting was shown to consistently improve length of stay and direct cost for cystectomy care.