The use of nephrostomy tubes in optimizing surgical conditions for a patient with xanthogranulomatous pyelonephritis.

Xanthogranulomatous pyelonephritis is a rare variant of pyelonephritis that often requires radical surgery. We report a case of a 51-year-old female patient who was managed with prolonged placement of nephrostomy tubes prior to surgery. This case illustrates the importance of surgical optimization of a poor operative candidate and the use of nephrostomy tubes as a temporizing management strategy.

National Trends in Surgical Management for Benign Prostatic Hyperplasia From 2013 to 2019 in the United States.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is a common urologic pathology for older men. The prevalence and effect on quality of life have prompted the development of new surgical procedures to manage BPH while attempting to minimize treatment side effects. The objective of this study is to utilize TriNetX, a third-party database, to investigate temporal trends in BPH procedures from 2013 to 2019 in the United States. METHODS: Male patients aged 18 to 100 who were diagnosed with BPH from 2013 to 2019 were filtered from the TriNetX Diamond Network. Yearly cohorts undergoing a BPH-related procedure were searched using Current Procedural Terminology and International Classification of Diseases 10th Revision codes. Temporal and descriptive analytics were utilized to describe trends in treatment utilization. RESULTS: There were 302,646 BPH procedures recorded on the TriNetX Diamond Network. Transurethral resection of the prostate was the most commonly performed procedure, accounting for 47.2% of procedures in 2013 and 44.9% in 2019. Photoselective vaporization of the prostate remained a popular treatment but showed the greatest decrease in utilization over time (31.8% in 2013, 21.5% in 2019). Prostatic urethral lift (UroLift) was rapidly embraced as a treatment modality, as usage increased by 18.3% over a 6-year period (0.0% in 2014, up to 18.3% in 2019). Other procedures such as Rezum (5.8%) and holmium laser enucleation of the prostate (5.1%) made up greater proportions of BPH procedures by 2019. CONCLUSIONS: Transurethral resection of the prostate was the most common procedure from 2013 to 2019. However, minimally invasive surgeries represent an increased percentage of BPH surgeries every year.

Incidence of Surgical Reintervention for Benign Prostatic Hyperplasia Following Prostatic Urethral Lift, Transurethral Resection of the Prostate, and Photoselective Vaporization of the Prostate: A TriNetX Analysis.

Background: Prostatic urethral lift, or UroLift, has gained popularity as a treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). Surgical reintervention rates are a reliable indicator for treatment durability. Objective: The objective of this study was to utilize TriNetX, a third-party database, to investigate the incidence of surgical reintervention following UroLift, transurethral resection of the prostate (TURP), and photoselective vaporization of the prostate (PVP) procedures for BPH from 2015 to 2018. Design setting and participants: Male patients aged 18-100 yr diagnosed with BPH were identified in the TriNetX Diamond Network database between January 2015 and December 2018. Cohorts of individuals undergoing their first UroLift procedure were built using Current Procedural Terminology and International Classification of Diseases 10th Revision codes. TURP and PVP cohorts were built as comparison groups. The cohorts were then queried for subsequent BPH-related procedures. Outcome measurements and statistical analysis: Reprocedure rates were assessed and descriptive statistics were used. Results and limitations: The mean age at first-time UroLift was 70.1 ± 9.4 yr (n = 14 343). Cumulative reprocedure rates collected after first-time UroLift included 1 yr after UroLift (5.1%, n = 14 343) and 4 yr after UroLift (16.1%, n = 710), with an average annual increase of +3.6% per year following 1 yr after the procedure. Comparatively, TURP (n = 22 071) and PVP (n = 14 110) had 4-yr reprocedure rates of 7.5% and 7.8%, respectively, during the same timeframe. Limitations include a lack of clinical data and loss of follow-up data outside the Diamond Network. Conclusions: The reprocedure rate of UroLift at 4 yr is double the rate of TURP and PVP. In appropriately selected patients, UroLift might be a suitable option for those who desire symptomatic relief from BPH with minimal erectile and ejaculatory side effects. However, the risk of secondary surgical intervention should be considered when considering BPH treatments. Patient summary: We compared the reintervention rates of prostatic urethral lift (PUL), transurethral resection of the prostate (TURP), and photoselective vaporization of the prostate (PVP) using the TriNetX database, and have found that the highest reintervention rates were for PUL of 16% at 4 yr of follow-up, compared with about 8% for those who had TURP and PVP. Interestingly, the most common reintervention was the same operation at 1 yr. This has important implications when counseling patients about the durability of these various outlet procedures for BPH.

Loose scrotal wound edge approximation in the setting of pyoderma gangrenosum after COVID-19 infection.

Pyoderma gangrenosum (PG) is a rare autoinflammatory skin disease characterized by recurrent ulcers. It is a diagnosis of exclusion and treatment can be challenging due to limited evidence-based therapies. While surgical management is typically avoided due to the risk of pathergy, it can be warranted in specific cases. Here, we have illustrated a unique case of genital PG that began after COVID-19 infection and which resulted in scrotal prolapse with testicular exposure. Loose closure with a horizontal mattress suture while the patient was on immunosuppression allowed for complete wound healing.

Topical antiseptic at time of transrectal ultrasound prostate biopsy is associated with fewer severe clinical infections and improves antibiotic stewardship.

BACKGROUND: The 2017 AUA White Paper on prevention of prostate needle biopsy (PNB) complications highlights an algorithm for reducing procedural related infections. The incorporation of topical rectal antiseptic (TRS) at time of transrectal PNB is listed as one such modality. We present data on over 1000 transrectal PNB procedures to determine the impact of TRS on 1) infectious complications and 2) use of augmented procedural antibiotics. METHODS: The records of 1181 transrectal PNB procedures performed over a 10-year period were reviewed. In 2013, TRS with either 10% povidone iodine or 4% chlorhexidine was more regularly incorporated into PNB procedures. Clinical and procedural factors were analyzed for association with post-procedure infections. Infectious complications outcomes were compared in patients receiving TRS (n = 566) versus those who had not (n = 615). RESULTS: A total of 990 men underwent 1181 transrectal PNB procedures. Median age of the cohort was 63 years with a median PSA of 7 ng/dL. Of them, 86% of the men were Caucasian, 28% had undergone at least one prior biopsy, 14% were diabetic, and 6% had prior hospitalization within 6 months of the procedure. Five hundred sixty-six patients (48%) received TRS at time of biopsy. Perioperative IV adjunctive antibiotics were used less frequently in patients receiving TRS (13.4% vs. 28.6%, p < 0.001). Furthermore, patients receiving TRS experienced lower rates of clinical infections (1.2% vs. 2.4%, p = 0.14), as well as lower likelihood of severe infections evidenced by decreased rates of hospital admission (0.5% vs. 2.3%, p = 0.013). Rectal vault bacteriology obtained before and after TRS was available in 180 men noting a 98.1% decrease in colony counts after local treatment. CONCLUSIONS: TRS at time of transrectal PNB was associated with decreased use of IV procedural antibiotics as well as decreased severity of infections post-biopsy. This simple technique enhances antibiotic stewardship while simultaneously improving quality outcomes of the procedure.

Design, Development, and Multi-Characterization of an Integrated Clinical Transrectal Ultrasound and Photoacoustic Device for Human Prostate Imaging.

The standard diagnostic procedure for prostate cancer (PCa) is transrectal ultrasound (TRUS)-guided needle biopsy. However, due to the low sensitivity of TRUS to cancerous tissue in the prostate, small yet clinically significant tumors can be missed. Magnetic resonance imaging (MRI) with TRUS fusion biopsy has recently been introduced as a way to improve the identification of clinically significant PCa in men. However, the spatial errors in coregistering the preprocedural MRI with the real-time TRUS causes false negatives. A real-time and intraprocedural imaging modality that can sensitively detect PCa tumors and, more importantly, differentiate aggressive from nonaggressive tumors could largely improve the guidance of biopsy sampling to improve diagnostic accuracy and patient risk stratification. In this work, we seek to fill this long-standing gap in clinical diagnosis of PCa via the development of a dual-modality imaging device that integrates the emerging photoacoustic imaging (PAI) technique with the established TRUS for improved guidance of PCa needle biopsy. Unlike previously published studies on the integration of TRUS with PAI capabilities, this work introduces a novel approach for integrating a focused light delivery mechanism with a clinical-grade commercial TRUS probe, while assuring much-needed ease of operation in the transrectal space. We further present the clinical potential of our device by (i) performing rigorous characterization studies, (ii) examining the acoustic and optical safety parameters for human prostate imaging, and (iii) demonstrating the structural and functional imaging capabilities using deep-tissue-mimicking phantoms. Our TRUSPA experimental studies demonstrated a field-of-view in the range of 130 to 150 degrees and spatial resolutions in the range of 300 µm to 400 µm at a soft tissue imaging depth of 5 cm.

Scrotal Hydrocele in Acute Pancreatitis.

Acute pancreatitis is a common diagnosis. Although extremely rare, extravasated pancreatic fluid has the potential to third space into the peritoneal cavity or retroperitoneal space. We report the case of a 33-year-old male with idiopathic subacute pancreatitis who developed acute scrotal pain and swelling. Computer tomography of the abdomen/pelvis revealed tracking of peritoneal fluid into the scrotum consistent with a pancreatic hydrocele, confirmed by ultrasound. He was taken to the operating room for exploration and evacuation of the scrotal hydrocele. This case highlights the importance of active surveillance for the potential development of a scrotal hydrocele in acute pancreatitis.

Longitudinal Rupture of Distal Corpus Cavernosum With Concomitant Urethral Injury: An Uncommon Result of a Common Mechanism.

Fracture of the penis is a well-recognized yet relatively uncommon urologic event. Forceful, blunt trauma with lateral bending of the penis in an erect state typically results in a transverse rupture of the tunica albuginea of the corpus cavernosum. Longitudinal tears of the corpus cavernosum are by themselves considered infrequent. We present a rare case of a patient with longitudinal rupture of the distal corpus cavernosum with concomitant extension to the corpus spongiosum causing partial urethral disruption as a result of trauma during sexual intercourse.

Topical rectal antiseptic at time of prostate biopsy: how a resident patient safety project has evolved into institutional practice.

PURPOSE: To report outcomes 5 years after a resident quality initiative incorporated topical rectal antiseptic into our ultrasound-guided prostate needle biopsy (TRUS PNB) protocol. METHODS: A chart review was conducted on 1007 men who underwent TRUS PNB between 2010 and 2017. Comparison groups include those who received a topical rectal antiseptic (N = 437) compared to those who did not (N = 570). Povidone-iodine (N = 303) or 4% chlorhexidine solution without alcohol (N = 134) were topical agents. Outcomes of interest included post-biopsy infection (urinary tract infection and/or sepsis), hospital admission, and need for ICU monitoring. RESULTS: Median age and PSA of men included in this study were 64 years and 12 ng/mL. Almost 90% of patients were Caucasian, 13% had diabetes, 3% were on immunosuppression, 32% had at least one prior biopsy, 14% received antibiotics, and 7% were hospitalized in the past 6 months. 22 patients (2.2%) developed a post-biopsy infection with a significant reduction in the group receiving topical rectal antiseptic (0.8 vs. 3.3%, p = 0.01). Post-biopsy UTI rates (p = 0.04) and hospital admission (p = 0.03) were also lower in the topical antiseptic group with trends to reduction in sepsis and need for ICU monitoring. CONCLUSIONS: What started as a resident quality safety project 5 years ago has demonstrated a reduction in infections and hospital admissions following TRUS PNB. Our institutional practice now routinely uses povidone-iodine or chlorhexidine as an adjunct to oral quinolones for TRUS PNB perioperative prophylaxis.

Impact of United States Preventive Services Task Force recommendations on prostate biopsy characteristics and disease presentation at a tertiary-care medical center.

BACKGROUND: To evaluate early consequences of 2012 United States Preventive Services Task Force (USPSTF) recommendations for decreased prostate-specific antigen (PSA) screening on prostate biopsy characteristics and prostate cancer presentation. MATERIALS AND METHODS: A single tertiary-care institution, multisurgeon, prospectively maintained database was queried for patients undergoing prostate biopsy from October 2005 to September 2016. Patient demographics, biopsy characteristics, and extent of disease were reported. Patient cohorts before and after USPSTF recommendations were compared using two-sample t test, Chi-square test, and Wilcoxon rank sum test with significance at P < 0.05. RESULTS: A total of 2,000 patients were analyzed, including 1,440 patients before and 560 patients after USPSTF recommendations. Following the recommendations, patients had higher prebiopsy PSA (5.90 vs. 6.70, P < 0.001). Overall, 817 (40.9%) patients had prostate cancer detected at biopsy with an increase from 37.0% before to 50.8% after (P < 0.001). Biopsies detected less low-risk Gleason ≤6 prostate cancer (47.4% vs. 41.1%) and more intermediate-risk Gleason 7 cancer (30.9% vs. 39.7%), with comparable findings of high-risk Gleason ≥8 cancer (21.7% vs. 19.2%), P = 0.042. In addition, greater percentage of core involvement (P < 0.001) was seen. At the time of diagnosis, extraprostatic extension identified by pelvic imaging increased from 12.6% to 18.9%, P = 0.039, with a trend toward lymph node positivity (1.1% vs. 2.2%, P = 0.078). Of those with metastatic disease, bony involvement occurred more often (1.7% vs. 3.2%, P = 0.041). CONCLUSIONS: After 2012 USPSTF guidelines, patients presented with higher PSA with prostate cancer were detected more frequently. More adverse, pathologic prostate cancer features were found on biopsy with the extent of disease implicating locally advanced/metastatic disease. These findings should be considered when counseling patients about prostate cancer screening importance.