Seizures initiate in zones of relative hyperexcitation in a zebrafish epilepsy model.

Seizures are thought to arise from an imbalance of excitatory and inhibitory neuronal activity. While most classical studies suggest excessive excitatory neural activity plays a generative role, some recent findings challenge this view and instead argue that excessive activity in inhibitory neurons initiates seizures. We investigated this question of imbalance in a zebrafish seizure model with two-photon imaging of excitatory and inhibitory neuronal activity throughout the brain using a nuclear-localized calcium sensor. We found that seizures consistently initiated in circumscribed zones of the midbrain before propagating to other brain regions. Excitatory neurons were both more prevalent and more likely to be recruited than inhibitory neurons in initiation as compared with propagation zones. These findings support a mechanistic picture whereby seizures initiate in a region of hyperexcitation, then propagate more broadly once inhibitory restraint in the surround is overcome.

Does labyrinthectomy have an impact on hearing in the contralateral ear during long-term follow-up?

OBJECTIVE: To quantify contralateral hearing outcomes after labyrinthectomy for unilateral Ménière's disease (MD). STUDY DESIGN: Retrospective case series. SETTING: Tertiary neurotology referral center. PATIENTS: Labyrinth removal for the management of MD or translabyrinthine (TLAB) acoustic neuroma resection between 2008 and 2012. MAIN OUTCOME MEASURE: Long-term hearing changes via pure tone averages (PTA). RESULTS: Upon comparison of low-frequency PTA (250, 500, 1000 Hz), MD patients experienced a greater degree of hearing loss during the follow-up period when compared to the TLAB lab group (7.54 ± 2.11 dB vs 2.39 ± 1.10 dB, p = 0.035). This difference as attributable to 12 (28.6 %) MD patients experiencing a ≥30 dB increase in low-frequency PTA, whereas none (0.0 %) of the TLAB surpassed this threshold. CONCLUSIONS: At 10 years post-labyrinthectomy there is a heightened risk for MD patients to develop low-frequency sensorineural hearing loss. Clinicians should monitor for audiometric changes through regular testing in the decade following labyrinth removal.

Micronutrients in tinnitus: A National Health and Nutrition Examination Survey analysis.

PURPOSE: Micronutrients and their supplementation have been investigated in the development, severity, and treatment of tinnitus. This study aimed to evaluate associations between tinnitus parameters and levels of zinc, manganese, and vitamin B12. MATERIALS AND METHODS: This retrospective study analyzed National Health and Nutrition Examination Survey 2011-2012 and 2015-2016 participants aged 20-69 who answered whether they had symptoms of tinnitus in the past year. Persons with tinnitus symptoms further reported how regularly they had symptoms and how disruptive symptoms were. Multivariable regressions accounting for age, gender, and race/ethnicity were used to evaluate the influence of low serum/blood levels of zinc, manganese, and vitamin B12 on tinnitus presence, regularity, and disruptiveness. RESULTS: This study included 9439 participants, with 16.2% of the sample reporting tinnitus symptoms. In multivariable regression models, low blood manganese was associated with tinnitus regularity (proportional OR: 1.47 [95% CI: 1.06, 2.05], p = 0.0213) and tinnitus disruptiveness (proportional OR: 1.78 [95% CI: 1.08, 2.96], p = 0.0250), but not tinnitus presence (p = 0.4813). Low serum zinc and low serum vitamin B12 did not have statistically significant associations with analyzed tinnitus parameters. CONCLUSIONS: A nationally representative analysis found that low blood manganese was significantly associated with tinnitus regularity and disruptiveness, but found that serum zinc and vitamin B12 had no association with tinnitus parameters. These findings suggest that low micronutrient levels are unlikely to be contributors to tinnitus; however, the results suggest further research on manganese supplementation in patients with tinnitus may be merited.

Time to Complication Detection after Primary Pediatric Hypospadias Repair: A Large, Single Center, Retrospective Cohort Analysis.

PURPOSE: Controversy remains within the pediatric urology community regarding adequate duration of followup after hypospadias repair. Some have suggested that minimal long-term followup is necessary due to a low incidence of late complications. The objective of this study was to delineate time to complication detection for primary hypospadias repairs. MATERIALS AND METHODS: We queried our prospectively maintained hypospadias database and identified all patients undergoing primary hypospadias repair from June 2007 to June 2018. Patients were excluded if they had undergone primary repair elsewhere or did not have a followup visit. Complications were defined by the need for an additional unplanned surgical procedure. Kaplan-Meier analysis was performed to assess time to complication by degree of hypospadias. RESULTS: A total of 1,280 patients met inclusion criteria, of whom 976 (68.9%) underwent distal, 64 (4.9%) mid shaft and 240 (18.8%) proximal hypospadias repair. Complication rates were 10.7% (104 patients), 18.8% (12) and 53.8% (129, p<0.0001) for distal, mid shaft and proximal hypospadias repair, respectively. Only 47% of complications were detected within the first year postoperatively. Median time to complication for all repair types was 69.2 months (IQR 23 to 131.9), ie 83.1 months (IQR 42.0 to 131) for patients undergoing distal repair and 29.4 months (IQR 11.9 to 82.1) for patients undergoing proximal repair (p <0.001). CONCLUSIONS: In our large single institution series of pediatric patients undergoing hypospadias repair fewer than half of the complications presented within the first year postoperatively. Long-term followup is recommended for patients undergoing hypospadias repair to adequately detect and address complications.

Current Management of Extraperitoneal Bladder Injuries: Results from the Multi-Institutional Genito-Urinary Trauma Study (MiGUTS).

PURPOSE: We studied the current management trends for extraperitoneal bladder injuries and evaluated the use of operative repair versus catheter drainage, and the associated complications with each approach. MATERIALS AND METHODS: We prospectively collected data on bladder trauma from 20 level 1 trauma centers across the United States from 2013 to 2018. We excluded patients with intraperitoneal bladder injury and those who died within 24 hours of hospital arrival. We separated patients with extraperitoneal bladder injuries into 2 groups (catheter drainage vs operative repair) based on their initial management within the first 4 days and compared the rates of bladder injury related complications among them. Regression analyses were used to identify potential predictors of complications. RESULTS: From 323 bladder injuries we included 157 patients with extraperitoneal bladder injuries. Concomitant injuries occurred in 139 (88%) patients with pelvic fracture seen in 79%. Sixty-seven patients (43%) initially underwent operative repair for their extraperitoneal bladder injuries. The 3 most common reasons for operative repair were severity of injury or bladder neck injury (40%), injury found during laparotomy (39%) and concern for pelvic hardware contamination (28%). Significant complications were identified in 23% and 19% of the catheter drainage and operative repair groups, respectively (p=0.55). The only statistically significant predictor for complications was bladder neck or urethral injury (RR 2.69, 95% 1.21-5.97, p=0.01). CONCLUSIONS: In this large multi-institutional cohort, 43% of patients underwent surgical repair for initial management of extraperitoneal bladder injuries. We found no significant difference in complications between the initial management strategies of catheter drainage and operative repair. The most significant predictor for complications was concomitant urethral or bladder neck injury.

A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage.

INTRODUCTION: Despite the pain associated with inflatable penile prosthesis (IPP) implantation, there has been a lack of standardized, nonopioid pain control regimens described to date. AIM: To assess the effectiveness of a multimodal analgesic regimen in patients undergoing implantation of an IPP compared with patients treated with an opioid-only regimen. METHODS: A large, multicenter patient cohort undergoing IPP implantation whose pain was managed using a multimodal analgesia (MMA) protocol (preoperative and postoperative acetaminophen, meloxicam orcelecoxib, and gabapentin and intraoperative dorsal and pudendal nerve blocks) was compared with a matched cohort of patients managed via an opioid-only protocol. Both groups were compared with respect to visual analog score (VAS) and opioid usage (total morphine equivalents [TME]) in the post-anesthesia care unit (PACU), postoperative day 0 (POD0) and postoperative day 1 (POD1), and in the immediate postdischarge period. Narcotic usage on discharge and follow-up were assessed and compared. MAIN OUTCOME MEASURE: Postoperative pain scores and narcotic usage are the main outcome measures. RESULTS: 203 patients were eligible for final analysis: 103 (50.7%) patients receiving MMA medication and 100 (49.3%) patients receiving opioids only. The VAS was significantly lower in the multimodal group in PACU (median 0.0 vs 2.0, P = .001), POD0 (median 3.0 vs 4.0, P = .001), and POD1 (median 3.0 vs 4.3, P = .04). Patients in the multimodal group also used fewer narcotics in PACU (median 0.0 vs 4.0 TME, P = .001), POD0 (median 7.5 vs 12.5 TME, P < .001), and POD1 (median 7.5 vs 13.5 TME, P = .01). Despite being discharged with fewer narcotics (median 20.0 vs 30.0 tablets, P < .001), a smaller proportion of patients in the MMA cohort required narcotic refills (10.7% vs 28.0%, P = .001). There were no narcotic- or MMA medication-related side effects in the entire cohort. CLINICAL IMPLICATIONS: MMA confers significant improvement in pain management while also providing a significant reduction in narcotic usage in patients undergoing implantation of IPP. STRENGTH & LIMITATIONS: This is the 1st large multi-institutional assessment of a multimodal analgesic regimen in urologic prosthetic surgery. The analgesic regimen targets several pain pathways that provide excellent pain control throughout the recovery process. Limitations include retrospective design and lack of standardization of the nonsteroidal anti-inflammatory drug type within the multimodal analgesic regimen. CONCLUSION: The use of a MMA protocol significantly reduces postoperative pain measures in penile implant recipients and further reduces both inpatient and outpatient narcotic usage without any discernable side effects. Lucas J, Gross M, Yafi F, et al. A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage. J Sex Med 2020;17:518-525.

Transurethral ventral buccal mucosa graft inlay for treatment of distal urethral strictures: international multi-institutional experience.

PURPOSE: To critically evaluate a multi-institutional patient cohort undergoing single-stage distal urethral repair using a novel transurethral buccal mucosa graft inlay urethroplasty technique (TBMGI). METHODS: A retrospective multi-institutional review of consecutive patients with fossa navicularis (FN) strictures treated with a single-stage TBMGI technique at 12 institutions from March 2014-March 2018 was performed. Patient demographics, stricture characteristics, clinical and patient-reported outcomes were analyzed. The primary outcomes were stricture recurrence and complications. Secondary outcomes were change in maximum urinary flow rate (Qmax), PVR, and changes in IPSS, SHIM and global response assessment (GRA) questionnaire responses. Descriptive statistical analysis was used for evaluation of outcomes. RESULTS: Sixty-eight men met inclusion criteria. Median age and stricture length were 60 years (IQR 48-69) and 2 cm (IQR 2-3), respectively. Most common stricture etiology was lichen sclerosus (34%). Median operative time and EBL were 72 min (IQR 50-120) and 20 mL (IQR 10-43), respectively. Fifty-seven men completed ≥ 12-month follow-up. At a median follow-up of 17 months (IQR 13-22), 54 patients (95%) remained stricture-free. Median Qmax improved from 5 to 18 mL/s (p < 0.0001), PVR 76-21 mL (p < 0.0001), and IPSS 15-5 (p < 0.0001); IPSS-QOL score: 5-1 (p < 0.0001). SHIM score did not significantly change following repair (median 22-21 p = 0.85). On GRA assessment, a majority of men reported "marked" (64%) or "moderate" (28%) overall improvement. No patient developed fistula, glanular dehiscence, graft necrosis or chordee. CONCLUSIONS: This novel minimally invasive transurethral urethroplasty technique is feasible and has demonstrated generalizable outcomes in a multi-institutional cohort with varying etiologies.

Clinical predictors of immediate intervention for isolated renal trauma.

INTRODUCTION Evidence suggests overutilization of procedural intervention for renal traumas. The objective of this study was to assess clinical factors associated with procedural intervention for patients presenting to the emergency department (ED) with isolated renal trauma. MATERIALS AND METHODS: A United States statewide trauma registry was queried for trauma patients presenting to level I or II trauma centers with isolated renal injuries (Grades I-V) from 2000-2013. Patient demographics, mechanism, American Association for the Surgery of Trauma (AAST) grade, trauma center level designation, presenting ED vital signs, Glasgow Coma Scale (GCS), intubation status, and blood product transfusion were assessed. RESULTS: Of 449,422 patients, 1383 patients (78% male, median age 29 years [range 2-92]) with isolated renal injuries had data available for analysis. Controlling for demographics, presenting vitals, GCS, trauma center level, mechanism and intubation status, level I status (OR 2.1 [1.3-3.4], p = 0.0021), white race (OR 2.5 [1.3-4.7], p < 0.005), AAST IV/V injury (OR 4.79 [3.1-6.5], p < 0.0001) and blood product administration (OR 2.7 [1.5-4.9], p = 0.0009) were independently associated with an immediate interventional radiology procedure. Independent predictors of immediate surgical intervention include level I status (OR 2.2 [1.2-4.0], p = 0.0075), penetrating mechanism of injury (OR 15.6 [8.4-28.9], p < 0.0001, AAST IV/V injury (OR 13.6 [8.7-21.1], p < 0.0001), and clinical hypotension (SBP < 95 mmHg, OR 2.1 [1.1 4.2], p = 0.03). CONCVLUSION: Level 1 trauma center designation, white race, penetrating mechanism of injury, high-grade injury, transfusion of blood products, and hypotension were all independent predictors of immediate procedural intervention following ED presentation with isolated renal trauma.

Novel Multi-Modal Analgesia Protocol Significantly Decreases Opioid Requirements in Inflatable Penile Prosthesis Patients.

BACKGROUND: Inflatable penile prosthesis (IPP) surgery is associated with significant perioperative pain that may reduce patient satisfaction. Though various pain management strategies have been proposed, most implanters manage postoperative patients with only prescription opioids. No protocol to date has been implemented and reported for pain management in IPP patients throughout the entire recovery process following surgery. AIM: Develop a multimodal analgesic (MMA) regimen consisting of perioperative administration of acetaminophen, meloxicam, and gabapentin with intraoperative local anesthetic injections, and compare post-operative pain control to a matched cohort of patients managed with an opioid-based (OB) regimen. METHODS: We retrospectively analyzed our prospectively maintained IPP database from November 2015-January 2018. The MMA protocol was instituted for all patients beginning June 2017, and these patients were matched in a 1:2 ratio to a cohort of eligible IPP patients managed through an OB protocol. Only patients receiving a 3-piece IPP were included; those with a history of narcotic dependence, neuropathy, or chronic non-steroidal anti-inflammatory drug use were excluded. Postoperative pain scores (visual analog scale) and opioid usage (total morphine equivalents [TME] in milligrams) were compared temporally in the post-anesthesia care unit, postoperative day (POD) 0, POD 1, and following discharge. OUTCOMES: The primary outcomes of the study are postoperative pain scores and narcotic usage. RESULTS: 57 patients were eligible for analysis: 19 (33%) and 38 (66%) in the MMA and OB groups, respectively. Groups were similar in demographics. MMA patients had significantly lower visual analog scale scores in post-anesthesia care unit, POD 0, or POD 1 (mean 0.84 vs 2.97, P = .01; 2.62 vs 4.73, P = .003; and 2.26 vs 4.0, P = .01, respectively) and used fewer narcotics on POD 0 (mean 4.08 vs 13.8 mg TME, P < .001) and POD 1 (mean 5.05 vs 25.1 mg TME, P < .001). MMA patients were discharged home with fewer narcotics (mean 12.7 vs 51.3 tabs, P < .001), and despite this, the MMA group needed less narcotic medication refills (11% vs 49%, P = .007). Neither group experienced a medication-related postoperative adverse event. CLINICAL IMPLICATIONS: Multimodal pain management allows for effective pain control with minimal side effects, enhancing recovery. STRENGTHS & LIMITATIONS: This is the first report to assess use of a multi-modal pain regimen on IPP recipients with demonstration of tangible benefit throughout the recovery process. Limitations include a single-surgeon and retrospective study design. CONCLUSION: In our rigorous assessment of IPP patients, implementation of a novel MMA protocol achieved equivalent and effective pain control, while resulting in substantially fewer narcotics throughout the entire post-operative period following IPP implantation. Tong CMC, Lucas J, Shah A, et al. Novel Multi-Modal Analgesia Protocol Significantly Decreases Opioid Requirements in Inflatable Penile Prosthesis Patients. J Sex Med 2018;15:1187-1194.

Endoscopic Management of Ureteral Strictures: an Update.

PURPOSE OF REVIEW: This review focuses on the role of endoscopic treatment of ureteral stricture disease (USD) in the era of minimally invasive surgery. RECENT FINDINGS: There is a relative paucity of recent literature regarding the endoscopic treatment of USD. Laser endopyelotomy and balloon dilation are associated with good outcomes in treatment-naïve patients with short (< 2 cm), non-ischemic, benign ureteral strictures with a functional renal unit. If stricture recurs, repetitive dilation and laser endopyleotomy is not recommended, as success rates are low in this scenario. Patients with low-complexity ureteroenteric strictures and transplant strictures may benefit from endoscopic treatment options, although formal reconstruction offers higher rates of success. Formal ureteral reconstruction remains the gold-standard treatment for ureteral stricture disease as it is associated with higher rates of complete resolution. However, in carefully selected patients, endoscopic treatment modalities provide a low-cost, low-morbidity alternative.

Crohn's-related enterocutaneous fistula: a unique cause of penile prosthesis infection.

Genitourinary manifestations are rare in patients with Crohn's disease, and a small percentage of patients will experience enterocutaneous fistulas. Infection is one of the most common complications associated with inflatable penile prosthesis placement, which can be associated with fistula formation. In this report, we present a patient with Crohn's disease who developed an inflatable penile prosthesis infection secondary to an undiagnosed enterocutaneous fistula.

Rurality Effect on Michigan Newborn Hearing Screening.

OBJECTIVES: Evaluate the effect of rurality on newborn hearing screen outcomes in Michigan. METHODS: Patients in the Michigan Department of Health and Human Services (MDHHS) Newborn Hearing Screening database that failed or did not receive their initial screen from 2015 to 2020 were evaluated. Using the U.S. Department of Agriculture Rural-Urban Continuum Codes (RUCC), patients were assigned a 1-9 code based on the population of their zip code, with 1 being the most urban and 9 being the most rural and outcomes between these patients were compared. RESULTS: There were 34,928 patients initially identified. Patients that had follow-up testing after a failed NBHS had a slightly higher RUCC than those that did not follow-up, 2.3 versus 2.2, respectively (p < 0.001). There was a significant difference between those that refused screening, with a mean RUCC of 4.2, and those that had a failed initial screen having a mean RUCC of 2.1 (p < 0.001). Similarly, those with equipment failure had a higher mean RUCC, 2.8, compared to those that had screening completed (p < 0.001). CONCLUSIONS: More rural areas are more likely to refuse a newborn hearing screen as well as have equipment failure options. There was no difference in rurality scores of those that had a follow-up screen after a failure and those that did not. LEVEL OF EVIDENCE: IV Laryngoscope, 134:2937-2940, 2024.

Outcomes After Exoscopic Versus Microscopic Type 1 Tympanoplasty.

OBJECTIVE: To analyze the outcomes of exoscopic versus microscopic type 1 tympanoplasty. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care otology-neurotology practice. PATIENTS: Adult subjects with a diagnosis of tympanic membrane perforation from 2018 to 2022. INTERVENTION: Exoscopic or microscopic tympanoplasty with cartilage + perichondrium or perichondrium/fascia graft. MAIN OUTCOME MEASURES: Primary outcomes were graft success rate (1 wk, 3 wk, 3 mo, and 6 mo postoperatively) and operative time. Secondary outcomes included audiometric outcomes of postoperative air-bone gap (ABG), change in ABG, pure tone average (PTA), speech reception threshold (SRT), and word recognition score (WRS) at 6-month follow-up and complication rates of cerebrospinal fluid leak, facial nerve injury, persistent tinnitus, and persistent vertigo. RESULTS: Seventy-one patients underwent type 1 tympanoplasty by a single surgeon. Thirty-six patients underwent exoscopic tympanoplasty, and 35 patients underwent microscopic tympanoplasty. Cartilage and perichondrium were utilized in 27 subjects (75.0%) in the exoscopic group and in 25 subjects (71.4%) in the microscopic group (p = 0.7, Cramer's V = 0.04). Graft success rate was as follows (exoscope versus microscope): 100% (36/36) versus 100% (35/35) at 1 week (p = 1.0, Cramer's V = 0.0), 97.2% (35/36) versus 100% (35/35) at 3 weeks (p = 1.0, Cramer's V = 0.1), 97.2% (35/36) versus 94.3% (33/35) at 3 months (p = 1.0, Cramer's V = 0.07), and 91.7% (33/36) versus 91.4% (32/35) at 6 months (p = 0.7, Cramer's V = 0.0). Operative time was 57.7 minutes for the exoscopic group and 65.4 minutes for the microscopic group (p = 0.08, 95% CI [-16.4, 0.9], Cohen's d = 0.4). There were no serious complications. All preoperative and postoperative audiometric outcomes were comparable. CONCLUSIONS: The outcomes after exoscopic versus microscopic type 1 tympanoplasty are comparable.

Recent surgical advances and continued controversies in medically refractory Meniere's disease.

PURPOSE OF REVIEW: Meniere's disease is caused by hydropic changes in the endolymphatic system, and manifests as a collection of vertigo, hearing loss, tinnitus, and aural fullness. Although high-quality clinical practice guidelines exist for the diagnosis and initial management of Meniere's disease, there is no strong consensus for treatment of medically refractory Meniere's disease. This review summarizes treatment options and highlights controversies surrounding surgical treatment of Meniere's disease. RECENT FINDINGS: Intratympanic steroid and intratympanic gentamicin injections continue to be widely used as in-office therapies in medically refractory Meniere's disease. Despite historical controversy surrounding the use of endolymphatic sac (ELS) surgery, the use of ELS decompression has been widely adopted by the international neurotologic community due to high vertigo control rate, coupled with low risk of audiovestibular loss. Wider decompression of the sac and surgical manipulation of the endolymphatic duct may impact outcome and are the subject of discussion. An emerging surgical technique called Triple Semicircular Canal Occlusion (TSCO) holds promise as a partially ablative procedure with high vertigo control rate in Meniere's disease. Cochlear implants may be placed in active Meniere's disease patients, or during an ablative surgery such as labyrinthectomy. SUMMARY: For the medically refractory Meniere's disease patient, treatment options include intratympanic steroid injection, endolymphatic sac decompression, medical or surgical labyrinthectomy, and vestibular nerve section. TSCO holds promise as an emerging partially ablative procedure. Cochlear implants maintain an important role in the rehabilitation of hearing loss associated with Meniere's disease.

Retrosigmoid Approach for Sporadic Vestibular Schwannoma: Patient Selection, Technical Pearls, and Hearing Results.

The retrosigmoid corridor provides the most broadly applied approach for resection of sporadic vestibular schwannoma. It may be utilized for any size tumor and for patients with intact hearing with the intention of hearing preservation. For larger tumors, the skull base surgeon must weigh the benefits the retrosigmoid approach against those of the translabyrinthine route. For smaller tumors where hearing preservation is a goal, the retrosigmoid approach is contrasted to the middle fossa route. Hearing preservation is most likely for patients with small and medially located intracanalicular tumors with minimal extension into the cerebellopontine angle, and excellent preoperative hearing.

Analysis of Imaging Results for Semisitting Compared with Supine Positioning in the Retrosigmoid Approach for Resection of Cerebellopontine Angle Vestibular Schwannomas.

OBJECTIVE: To compare the completeness of resection of vestibular schwannomas using three-dimensional segmented volumetric analysis of pre- and postoperative magnetic resonance imaging (MRI) of patients undergoing supine and semisitting positioning for the retrosigmoid approach. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary medical center. PATIENTS: Patients with vestibular schwannomas undergoing surgical resection via the retrosigmoid approach. INTERVENTIONS: Tumor resection via the retrosigmoid approach with different patient positioning: standard supine versus semisitting. MAIN OUTCOME MEASURES: Preoperative versus postoperative three-dimensional segmented volumetric MRI analysis of vestibular schwannomas. RESULTS: A total of 43 patients (15 supine and 28 semisitting) underwent retrosigmoid craniotomy for resection of vestibular schwannomas. For the conventional supine and semisitting positioning, mean preoperative tumor volumes were 12.65 and 8.73 cm 3 ( p = 0.15), respectively. Postoperative mean tumor volumes for the supine and semisitting positions were 2.09 and 0.48 cm 3 ( p = 0.13), respectively. There were 11 cases of postoperative sigmoid sinus thrombosis, 3 in the conventional supine group and 8 in the semisitting groups, and there were 6 cases of postoperative cerebrospinal fluid leaks, all in the semisitting group. The mean House-Brackmann scores for the supine and semisitting groups were 2.9 and 2.3, respectively. There was no statistically significant difference between groups in the rates of these or any other postoperative complications. CONCLUSIONS: The semisitting position for the suboccipital retrosigmoid approach for vestibular schwannoma resection does not compromise the ability to adequately resect the tumor as seen by volumetric MRI results. Further studies are needed to establish the safety of this position compared with the traditional supine approach.

Pott's puffy tumor in a 23-month-old: Youngest known case of a rare disease.

This case report describes a child who developed Pott's puffy tumor and was treated at the Children's Mercy Hospital in Kansas City. In addition to a discussion of a case, a review of the literature was completed on this topic describing the typical embryology and development of the frontal sinus, and the epidemiology, diagnosis, and treatment of Pott's puffy tumor. The patient was a 23-month-old boy who developed Pott's puffy tumor after recovery from influenza. The patient presented to the hospital with progressing edema of the unilateral eye that spread bilaterally within a few days. A CT scan demonstrated pansinusitis, developed frontal sinuses, right periorbital cellulitis, and medial forehead subperiosteal abscess. Functional endoscopic sinus surgery and transcutaneous abscess drainage were urgently performed and the patient made a full recovery following a course of ertapenem and levofloxacin. The presence of a developed frontal sinus in a 23-month-old is an unexpected radiologic finding. This case represents the youngest patient reported in the literature to develop this rare complication of frontal sinusitis.

Factors associated with postoperative urinary retention in patients undergoing penile prosthesis implantation.

Placement of penile prosthesis had been well described in the outpatient setting, however, one barrier to same-day discharge is postoperative urinary retention (POUR). POUR remains a condition encountered during ambulatory surgical procedures and has yet to be characterized in patients undergoing penile prosthesis. We characterized POUR in a cohort of penile prosthesis recipients along with risk factors and management. Patients undergoing penile prosthesis implantation from 2014 through 2020 without pre-existing retention were included. All patients underwent a void trial immediately following penile prosthesis in the post-anesthesia care unit. POUR was strictly defined as (1) any patient requiring catheter replacement after prosthesis, (2) a rising post-void residual, or (3) inability to void after 6 h regardless of whether a catheter was placed. Independent procedures, demographic, intraoperative, and postoperative risk factors for POUR were assessed. 317 men were included of whom 27.1% experienced POUR. Men experiencing POUR and those not in retention were essentially indistinguishable with respect to previously described risk factors for POUR. Only use of both α-blockers and 5-α-reductase inhibitors was significantly associated with a greater risk of POUR, a finding maintained on adjusted analysis (adjusted odds ratio 10.1, 95% confidence interval 2.1 to 49.8). POUR resolved without intervention in 3.5%, a single episode of clean intermittent catheterization (CIC) in 7.0% of patients, and repeated CIC or indwelling catheter placement with a successful delayed void trial in 88.4% of patients. Rate of prosthesis infection in patients who experienced POUR did not significantly differ from those who did not experience POUR (4.7% vs. 2.2% p = 0.26). Our findings suggest that POUR is experienced in as many as 1 in 4 men undergoing penile prosthesis placement, most of whom must be managed with indwelling catheterization or repeated CIC. Those with indicators of symptomatic prostate enlargement are at significantly greater risk of urinary retention.