Retrospective Multicenter Observational Study of Immediate Voiding at End of Urinary Sphincter Surgery (REMOVE).

PURPOSE: Patients may remain catheterized after artificial urinary sphincter surgery to prevent urinary retention, despite a lack of evidence to support this practice. Our study aims to evaluate the feasibility of outpatient, catheter-free continence surgery using a multi-institutional database. We hypothesize that between catheterized controls and patients without a catheter, there would be no difference in the rate of urinary retention or postoperative complications. MATERIALS AND METHODS: We conducted a retrospective review of patients undergoing first-time artificial urinary sphincter placement from 2009-2021. Patients were stratified by postoperative catheter status into either no-catheter (leaving the procedure without a catheter) or catheter (postoperative indwelling catheter for ∼24 hours). The primary outcome, urinary retention, was defined as catheterization due to subjective voiding difficulty or documented postvoid residual over 250 mL. RESULTS: Our study identified 302 catheter and 123 no-catheter patients. Twenty (6.6%) catheter and 9 (7.3%) no-catheter patients developed urinary retention (P = .8). On multivariable analysis, controlling for age, cuff size, radiation history and surgeon, there was no statistically significant association between omitting a catheter and urinary retention (OR: 0.45, 95% CI: 0.13-1.58; P = .2). Furthermore, at 30 months follow-up, Kaplan-Meier survival analysis revealed that device survival was 70% (95% CI: 62%-76%) vs 69% (95% CI: 48%-82%) for the catheter and no-catheter group, respectively. CONCLUSIONS: In our multi-institutional cohort, overall retention rates were low (7%) in groups with a catheter and without. Obviating postoperative catheterization facilitates outpatient incontinence surgery without altering reoperation over medium-term follow-up.

The reporting quality of randomized controlled trials and experimental animal studies for urethroplasty.

OBJECTIVES: To assess the reporting quality of randomized controlled trials and experimental animal studies examining urethroplasty in reconstructive urological surgery literature. METHODS: We performed a comprehensive literature search to identify all urethroplasty-related RCTs examining humans as well as animal models. We used the Consolidated Standards of Reporting Trials (CONSORT) and the Animals in Research: Reporting in vivo Experiments (ARRIVE) guidelines to assess reporting quality. Two reviewers performed data abstraction independently and in duplicate. We then generated descriptive statistics including CONSORT (0-25) and ARRIVE (0-20) summary scores using the median and interquartile range. RESULTS: Twenty studies were ultimately included; 14 randomized controlled trials and 6 experimental animal studies. All studies were two-armed, parallel group studies. Median sample sizes (and interquartile range) of the human and animal studies were 48.5 (31.8-53.8) and 18 (15.3-27.5), respectively. The median CONSORT and ARRIVE scores were 10.0 (8.75-12.63) and 7.97 (6.79-8.64), respectively. Human randomized controlled trials did not consistently report the method of allocation concealment (6/14; 42.9%), blinding (2/14; 14.3%), or discuss the generalizability of the results (6/14; 42.9%). Animal studies infrequently reported why a given animal model was used (1/6; 16.7%), how they were allocated to groups (0/6; 0%) or what the experimental primary and secondary outcomes were (0/6; 0%). CONCLUSIONS: Urethroplasty literature is marked by a paucity of both randomized controlled trials and experimental design animal studies. The existing studies are inconsistently reported and are therefore of uncertain methodological quality.

Contemporary multicenter outcomes of continent cutaneous ileocecocystoplasty in the adult population over a 10-year period: A Neurogenic Bladder Research Group study.

AIMS: Evidence is sparse on the long-term outcomes of continent cutaneous ileocecocystoplasty (CCIC). We hypothesized that obesity, laparoscopic/robotic approach, and concomitant surgeries would affect morbidity after CCIC and aimed to evaluate the outcomes of CCIC in adults in a multicenter contemporary study. METHODS: We retrospectively reviewed the charts of adult patients from sites in the Neurogenic Bladder Research Group undergoing CCIC (2007-2017) who had at least 6 months of follow-up. We evaluated patient demographics, surgical details, 90-day complications, and follow-up surgeries. the Mann-Whitney U test was used to compare continuous variables and χ² and Fisher's Exact tests were used to compare categorical variables. RESULTS: We included 114 patients with a median age of 41 years. The median postoperative length of stay was 8 days. At 3 months postoperatively, major complications occurred in 18 (15.8%), and 24 patients (21.1%) were readmitted. During a median follow-up of 40 months, 48 patients (42.1%) underwent 80 additional related surgeries. Twenty-three patients (20.2%) underwent at least one channel revision, most often due to obstruction (15, 13.2%) or incontinence (4, 3.5%). Of the channel revisions, 10 (8.8%) were major and 14 (12.3%) were minor. Eleven patients (9.6%) abandoned the catheterizable channel during the follow-up period. Obesity and laparoscopic/robotic surgical approach did not affect outcomes, though concomitant surgery was associated with a higher rate of follow-up surgeries. CONCLUSIONS: In this contemporary multicenter series evaluating CCIC, we found that the short-term major complication rate was low, but many patients require follow-up surgeries, mostly related to the catheterizable channel.

Frequency of patient-reported UTIs is associated with poor quality of life after spinal cord injury: a prospective observational study.

STUDY DESIGN: Cross-sectional survey of the Neurogenic Bladder Research Group (NBRG) registry; a multicenter prospective observation study. OBJECTIVES: To assess how patient-reported urinary tract infections (PRUTIs) in spinal cord injury (SCI) affect quality of life (QOL). SETTING: Multiple United States hospitals. METHODS: 1479 participants with SCI were asked about neurogenic bladder-related QOL. Eligibility: age ≥ 18 years with acquired SCI. PRUTI frequency over the last year was classified as 0, 1-3, 4-6, or >6. Four UTI QOL domains were assessed: (1) UTIs limited daily activities, (2) UTIs caused increased muscle spasms, (3) UTIs would not go away, and (4) UTIs made me avoid going out. Multivariable regression identified variables associated with poor QOL. RESULTS: PRUTI frequency was 0 in 388 patients (26%), 1-3 in 677 (46%), 4-6 in 223 (15%), and more than 6 in 190 (13%). Increasing PRUTI rate was independently associated with worse QOL for all four questions. Compared with those with 0 PRUTIs, participants reporting >6 were more likely to limit daily activities (OR 9.0 [95% CI 8.1-21.2] p < 0.0001), experience increased muscle spasms (OR 12.4 [95% CI 7.5-20.6] p < 0.0001), perceive a UTI would not go away (OR 30.1 [95% CI 15.0-60.4] p < 0.0001), and avoid going out because of UTIs (OR 7.2 [95% CI 4.2-12.4] p < 0.0001). CONCLUSIONS: An increasing rate of PRUTIs is independently associated with worse QOL. Thorough evaluation and treatment may improve QOL in this population.

Bladder changes after catheterizable channel creation in adults with cerebral palsy who are in chronic urinary retention.

AIMS: Cerebral palsy (CP) is characterized by motor impairments as a result of brain injury during development. Patients can have neurogenic bladder dysfunction and are often unable to catheterize through their native urethra. Catheterizable channel (CC) creation can facilitate clean intermittent catheterization (CIC). We have observed that patients with large capacity, low-pressure bladders can develop de novo neurogenic detrusor overactivity (NDO) postoperatively. We sought to better characterize this finding. METHODS: We reviewed the charts of patients 17 years or older with CP seen between 2006 and 2017. Patients undergoing creation of any type of CC without augmentation cystoplasty, due to adequate storage on pre-operative urodynamics (UDS), were included. Pre- and post-operative UDS were reviewed. Frequency of incontinence and use of anticholinergics or intravesical injections of onabotulinum toxin A (Btx) were reviewed. RESULTS: Eight patients with CP underwent CC creation without augmentation. Preoperatively, six of eight patients were in chronic retention with two others performing CIC. Following CC creation, patients in retention required additional NDO management with anticholinergics, mirabegron, or onabotulinumtoxin A. Among those with complete UDS data, 67% demonstrated lower maximum cystometric capacity postoperatively. Median follow-up was 25 months. CONCLUSIONS: CC creation facilitates CIC in adults with CP who are in chronic retention due to pseudodyssynergia. Despite preoperative UDS suggesting an adequate capacity, low-pressure bladder, such patients often manifest de novo NDO and worsening incontinence upon initiation of CIC after surgery. These findings should be considered when determining whether to perform augmentation at the time of CC in adults with CP.

Patient subjective assessment of urinary tract infection frequency and severity is associated with bladder management method in spinal cord injury.

STUDY DESIGN: The Neurogenic Bladder Research Group (NBRG) registry is a multicenter prospective observational study. This manuscript is retrospective based on a cross-sectional survey. OBJECTIVES: To assess patient subjective assessment of urinary tract infection (UTI) frequency and severity are associated with the degree of use of catheters or incontinence products. SETTING: Multiple hospitals across the United States. METHODS: Eligibility included: age > 18 years and acquired SCI. Over 1.5 years, 1479 eligible participants were enrolled. We excluded those with surgical reconstruction or diversion of the bladder. In total, 1282 participants were grouped by bladder management: (1) indwelling catheter (IDC), (2) clean intermittent catheterization (CIC), (3) external devices (pads/condom), and (4) volitional voiding (Void). UTI frequency was classified as 0, 1-3, 4-6, or > 6 over the prior year. UTI severity was determined by hospitalization for UTI in the prior year. Multivariate regression compared these factors across groups. RESULTS: UTIs were least frequent in Void followed by pads/condom, CIC, and IDC (all p ≤ 0.001). UTI severity followed a similar pattern. Controlling for covariates, the adjusted odds of UTI frequency (Void = reference) were 2.28 (1.38-3.76) for pads/condom, 3.42 (2.25-5.18) for CIC, and 4.3 (2.59-6.70) for IDC (all p ≤ 0.001). CONCLUSIONS: Patient subjective assessment of UTI frequency is highest with IDC, followed by CIC, pads/condom, and lowest with spontaneous voiding. The odds of hospitalization for UTI were three times higher for IDC than spontaneous voiding. UTI risk should be considered when counseling patients about bladder management options. These associations do not imply causation but warrant further investigation in a prospective manner. SPONSORSHIP: Patient-Centered Outcomes Research Institute (PCORI) Award (CER14092138).

Extended Duration Enoxaparin Decreases the Rate of Venous Thromboembolic Events after Radical Cystectomy Compared to Inpatient Only Subcutaneous Heparin.

PURPOSE: Venous thromboembolic events are a significant source of morbidity after radical cystectomy. At our institution subcutaneous heparin was historically given to patients undergoing radical cystectomy immediately before incision and throughout the inpatient stay. In an effort to decrease the overall rate of venous thromboembolism and post-discharge venous thromboembolism, a regimen including extended duration enoxaparin was initiated for patients undergoing radical cystectomy. MATERIALS AND METHODS: In January 2013 thromboprophylaxis was modified for patients undergoing radical cystectomy by replacing a regimen of subcutaneous heparin before induction and then every 8 hours until discharge home with enoxaparin daily for postoperative prophylaxis continued until 28 days after discharge. Data from our institutional radical cystectomy database for patients undergoing surgery from January 2011 to May 2014 were reviewed. The primary outcome was clinically symptomatic postoperative venous thromboembolism. Secondary outcomes included timing of venous thromboembolism and blood transfusions. Multivariate logistic regression was used to control for differences between cohorts. RESULTS: Of the 402 patients 234 underwent radical cystectomy before the change and 168 after. The enoxaparin regimen decreased the rate of venous thromboembolism (12% vs 5%, p=0.024) with the main benefit on post-discharge venous thromboembolism (6% vs 2%, p=0.039). Overall 17 of 37 (46%) venous thromboembolisms occurred after discharge home. Multivariate analysis confirmed that the enoxaparin regimen was independently associated with reduced odds of venous thromboembolism (OR 0.33, 95% CI 0.14-0.76, p=0.009). Intraoperative and postoperative transfusion rates were similar between cohorts. CONCLUSIONS: Thromboprophylaxis with extended duration enoxaparin decreased the rate of venous thromboembolism after radical cystectomy compared to inpatient only subcutaneous heparin with no increased risk of bleeding.

Redefining the implications of nasogastric tube placement following radical cystectomy in the alvimopan era.

PURPOSE: Alvimopan has decreased ileus and need for nasogastric tube (NGT) after radical cystectomy (RC). However, the natural history of ileus versus intestinal obstruction in patients receiving alvimopan is not well defined. We sought to examine the implications of NGT placement before and after the introduction of alvimopan for RC patients. METHODS: Retrospective review identified 278 and 293 consecutive patients who underwent RC before and after instituting alvimopan between June 2009 and May 2014. Baseline characteristics and postoperative outcomes were compared by alvimopan status. Multivariate logistic regression was performed to assess the impact of alvimopan on rates of NGT placement and reoperation for bowel complications. RESULTS: The cohorts had similar age, stage, approach, and BMI. Patients receiving alvimopan had decreased ileus (16 vs 32 %, p < 0.01) but similar rates of reoperation for bowel complications (2.8 vs 2.7 %). On multivariate analysis, alvimopan was associated with lower risk of NGT placement (OR 0.30, p < 0.01). For patients requiring NGT placement, there was an increased rate of reoperation among patients receiving alvimopan compared with those who did not (28 vs 11 %, p = 0.03). Patients receiving alvimopan who needed NGT had significantly increased median length of stay (22 vs 7 days), need for TPN (66 vs 5.3 %), and readmission for ileus (10.3 vs 2.3 %) compared with those who did not require NGT. CONCLUSIONS: Alvimopan significantly reduced the incidence of ileus and NGT placement following RC. NGT placement was associated with an increased need for reoperation for bowel complications in the setting of alvimopan.

Comparison of Perioperative and Early Oncologic Outcomes between Open and Robotic Assisted Laparoscopic Prostatectomy in a Contemporary Population Based Cohort.

PURPOSE: We compared rates of positive surgical margins, use of postoperative radiation therapy, and perioperative outcomes between robotic assisted laparoscopic and open radical prostatectomy in a contemporary population based cohort. MATERIALS AND METHODS: In the National Cancer Data Base from 2010 through 2011 patients who underwent robotic assisted laparoscopic prostatectomy (73,131) and open radical prostatectomy (23,804) for nonmetastatic prostate adenocarcinoma were identified. Covariates included age, race, Charlson comorbidity index, prostate specific antigen, biopsy Gleason score, clinical stage, final Gleason score, pathological T stage, lymph node dissection, nodal status, facility type, hospital volume and year of surgery. Multivariable logistic regression was used to identify factors associated with positive surgical margins, use of adjuvant/salvage radiation therapy, prolonged length of stay, readmission and 30-day mortality. Outcomes were also compared in 1:1 propensity matched cohorts. RESULTS: Analysis of propensity matched cohorts showed robotic assisted laparoscopic prostatectomy reduced the risk of positive surgical margins (OR 0.88, 95% CI 0.83-0.93, p <0.01), the use of radiation therapy (OR 0.71, 95% CI 0.63-0.80, p <0.01) and 30-day mortality (OR 0.28, 95% CI 0.13-0.60, p <0.01). The protective effect of robotic assisted laparoscopic prostatectomy for positive surgical margins was found in patients with pT2 disease only (pT2-OR 0.85, 95% CI 0.79-0.91, p <0.01; pT3-OR 0.94, 95% CI 0.86-1.04, p=0.2). Similar results were obtained using multivariable regression. CONCLUSIONS: In a contemporary large national cohort, robotic assisted laparoscopic prostatectomy was independently associated with clinically meaningful reductions in positive surgical margins, postoperative radiation therapy and 30-day mortality compared to open radical prostatectomy. The oncologic benefit was primarily in patients with organ confined disease. Limitations were those associated with any observational study, namely the potential for bias due to unmeasured confounders.

Bladder Cancer Mortality in the United States: A Geographic and Temporal Analysis of Socioeconomic and Environmental Factors.

PURPOSE: We assessed the association of temporal, socioeconomic and environmental factors with bladder cancer mortality in the United States. Our hypothesis was that bladder cancer mortality is associated with distinct environmental and socioeconomic factors with effects varying by region, race and gender. MATERIALS AND METHODS: NCI (National Cancer Institute) age adjusted, county level bladder cancer mortality data from 1950 to 2007 were analyzed to identify clusters of increased bladder cancer death using the Getis-Ord Gi* statistic. Socioeconomic, clinical and environmental data were assessed using geographically weighted spatial regression analysis adjusting for spatial autocorrelation. County level socioeconomic, clinical and environmental data were obtained from national databases, including the United States Census, CDC (Centers for Disease Control and Prevention), NCHS (National Center for Health Statistics) and County Health Rankings. RESULTS: Bladder cancer mortality hot spots and risk factors for bladder cancer death differed significantly by gender, race and geographic region. From 1996 to 2007 smoking, unemployment, physically unhealthy days, air pollution ozone days, percent of houses with well water, employment in the mining industry and urban residences were associated with increased rates of bladder cancer mortality (p <0.05). Model fit was significantly improved in hot spots compared to all American counties (R(2) = 0.20 vs 0.05). CONCLUSIONS: Environmental and socioeconomic factors affect bladder cancer mortality and effects appear to vary by gender and race. Additionally there were temporal trends of bladder cancer hot spots which, when persistent, should be the focus of individual level studies of occupational and environmental factors.

The impact of days off between cases on perioperative outcomes for robotic-assisted laparoscopic prostatectomy.

PURPOSE: To examine the effect of days off between cases on perioperative outcomes for robotic-assisted laparoscopic prostatectomy (RALP). METHODS: We analyzed a single-surgeon series of 2036 RALP cases between 2003 and 2014. Days between cases (DBC) was calculated as the number of days elapsed since the surgeon's previous RALP with the second start cases assigned 0 DBC. Surgeon experience was assessed by dividing sequential case experience into cases 0-99, cases 100-249, cases 250-999, and cases 1000+ based on previously reported learning curve data for RALP. Outcomes included estimated blood loss (EBL), operative time (OT), and positive surgical margins (PSMs). Multiple linear regression was used to assess the impact of the DBC and surgeon experience on EBL, OT, and PSM, while controlling for patient characteristics, surgical technique, and pathologic variables. RESULTS: Overall median DBC was 1 day (0-3) and declined with increasing surgeon case experience. Multiple linear regression demonstrated that each additional DBC was independently associated with increased EBL [ß = 3.7, 95% CI (1.3-6.2), p < 0.01] and OT [ß = 2.3 (1.4-3.2), p < 0.01], but was not associated with rate of PSM [ß = 0.004 (-0.003-0.010), p = 0.2]. Increased experience was also associated with reductions in EBL and OT (p < 0.01). Surgeon experience of 1000+ cases was associated with a 10% reduction in PSM rate (p = 0.03) compared to cases 0-99. CONCLUSIONS: In a large single-surgeon RALP series, DBC was associated with increased blood loss and operative time, but not associated with positive surgical margins, when controlling for surgeon experience.

Trends in Simple Prostatectomy for Benign Prostatic Hyperplasia.

The definitive treatment for symptomatic large volume (>80 mL) benign prostatic hyperplasia (BPH) is simple prostatectomy (SP). This can be performed by utilizing a retropubic, suprapubic, or a combined approach. The latter two approaches allow for the management of concomitant bladder diverticulum or stones through the same incision. Each approach affords unique technical strengths and weaknesses that must be considered in light of patient characteristics and concomitant pathology. SP allows for removal of the entire prostatic adenoma while obviating some of the neurovascular and continence issues that can arise from radical prostatectomy. Concerns with SP include its relatively high perioperative morbidity, notably bleeding. Therefore, there is increasing interest in less invasive options, including enucleation procedures and minimally invasive SP. This review presents an update regarding trends and outcomes of SP, as well as the effectiveness and popularity of alternative treatments.

Outcomes following Thulium vapoenucleation of large prostates.

INTRODUCTION: Thulium laser VapoEnucleation of the prostate (ThuVEP) is an evolving surgical technique for BPH. Most studies have focused on outcomes in small to médium sized prostates and have originated from Europe and Asia. We sought to describe our experience with ThuVEP for very large prostates in a North American cohort. MATERIALS AND METHODS: From December 2010 to October 2014, 25 men underwent Thu-VEP using the CyberTM® (Quantastem, Italy) thulium laser, all with prostate volume >75mL. Data collected included patient demographics, comorbidities, intraoperative parameters, complications, and post-operative outcomes including maximum flow rate (Qmax), post-void residual (PVR), International Prostate Symptom Score (IPSS), and quality of life score (QoL) in one year of follow-up. Statistical analysis was done using Wilcoxon signed-rank test. RESULTS: At baseline, mean age was 70±9 years and prostate size was 163±62g. Most patients (84%) were in retention and 10 (40%) patients were on anticoagulation. Seven (28%) patients went home the day of surgery (mean hospital stay: 1.2±1.2d). There were 2 intraoperative complications (8%), both cystotomies related to morcellation. Nine patients (36%) experienced a complication, all within 30 days. There were no Clavien III complications. Significant improvements were seen in Qmax, PVR, IPSS, and QoL score at each time interval to 12-months following surgery (all p<0.05). Of 21 patients initially in retention, all were voiding at last follow-up. CONCLUSIONS: Our findings suggest that ThuVEP is an effective treatment for BPH in patients with large prostates with sustained results for one year.

Comparison of Patients Undergoing PVP Versus TURP for LUTS/BPH.

Transurethral resection of the prostate (TURP) and photoselective vaporization of the prostate (PVP) are currently the two most commonly performed procedures for the treatment of benign prostatic hyperplasia (BPH). While each procedure has been shown to be efficacious, TURP or PVP may be preferred in certain clinical scenarios. A number of factors may influence the choice of which patients undergo PVP or TURP. This decision may take into account patient characteristics, such as age, co-morbidities, predominance of irritative symptoms, and/or ongoing anticoagulation. Additionally, balancing desired outcomes with possible risks is critical. Considerations should include possible effects on sexual function, rates of reoperation, cost, and need for tissue specimen in those at risk for prostate cancer. The primary objective of this article is to summarize the comparative research of PVP and TURP and the implications on differences between patients who undergo either procedure.

Complex ureteral stricture from chronic schistosomiasis requiring ileal ureter interposition: a case report.

Background: Schistosomiasis is most notably associated with squamous cell carcinoma of the bladder, and it is estimated that approximately 10% of people infected will develop a urologic complication. Ureteral pathology is rare and has only been described in a handful of case reports. Increasing awareness of this condition is needed given a recent increase in sub-Saharan immigrant population in the United States (US), as prompt recognition is key to providing optimal care. Case Description: A 40-year-old Kenyan immigrant presented to the emergency department with left-sided flank pain and was found to have left hydronephrosis and three mid-ureteral calcifications. He underwent ureteroscopy where the left ureter appeared blind-ending just proximal to the iliac vessels. A percutaneous nephrostomy tube was placed, and renal pelvis urine was analyzed for mycobacterium tuberculosis and acid fast bacilli which were negative. Antegrade ureteroscopy demonstrated a second, proximal ureteral stricture with a pinpoint lumen. Antegrade and retrograde pyelography revealed a 3 cm mid-ureteral stricture with no contrast passage. Given the stricture length, multifocality, and unclear pathology, we opted to perform ureterectomy with ileal interposition. Final pathology revealed schistosomiasis with calcifications. The patient received two doses of Praizquantel and his stent was removed 6 weeks postoperatively. He is doing well without complications. Conclusions: There is a wide range of urologic complications caused by schistosomiasis infection, and this case highlights an extreme case. Although many patients will present with a fixed urologic complaint, they remain at risk for additional urologic pathology in the future without antihelminthic therapy. This highlights the need for an accurate diagnosis and a high index of suspicion for at-risk populations.

A Systematic Review of Randomized Controlled Trials Comparing Buccal Mucosal Graft Harvest Site Non-Closure versus Closure in Patients Undergoing Urethral Reconstruction.

PURPOSE: To assess the effects of buccal mucosal graft site non-closure versus closure on postoperative oral morbidity for male undergoing augmentation urethroplasty for urethral stricture. MATERIALS AND METHODS: We included randomized controlled trials. Inclusion criteria were male over the age of 18 with urethral stricture disease requiring reconstruction with buccal mucosal graft harvest. Primary outcomes of the review were postoperative oral pain, need for secondary oral procedures and cosmetic defects. RESULTS: We included 5 studies with 346 randomized patients with urethral strictures, of whom 260 completed the trials. In terms of primary outcomes, non-closure graft site may reduce oral pain on postoperative day #1 (standard mean difference [SMD] 0.24 lower; 95% confidence interval [CI] 0.61 lower to 0.12 higher; low certainty evidence [CoE]) but we are uncertain how this impacts pain on postoperative days 3 to 6 (SMD 0.35; 95% CI 0.12 to 0.81 higher; very low CoE). We are also very uncertain as to how it affects the need for secondary oral procedures (risk ratio [RR] 0.22; 95% CI 0.01 to 4.28; very low CoE). Non-closure may increase the risk of cosmetic defects (RR 2.40; 95% CI 0.93 to 6.22; low CoE). CONCLUSIONS: This review describes the trade-off for buccal mucosal graft site non-closure versus closure for various patient-important outcomes; decision-making will likely hinge on the relative value individual patients and surgeons place on them. The supporting evidence was rated as low and very low, thereby signaling substantial underlying uncertainty and the need for better trials.

The Management of Complications of Feminizing Gender Affirming Genital Surgery.

Penile inversion vaginoplasty is the most common technique used for gender affirming genital surgery in the treatment of gender dysphoria among transwomen. As vaginoplasty becomes more widely available, the management of associated complications has become its own field. There is a relative dearth of literature on surgery for complications following vaginoplasty. This review illustrates surgical technique and management options for patient reported complaints and complications following vaginoplasty. The goal of this manuscript is 2-fold (1) to introduce community surgeons to common postoperative issues they may encounter and (2) provide a systematic operative approach to complications for reconstructive surgeons who see transgender patients regularly.

Technique and Outcomes of Hand-Assist Laparoscopic Continent Cutaneous Ileocecocystoplasty.

BACKGROUND: Continent cutaneous ileocecocystoplasty (CCIC) involves reconfiguring the ileocecal segment for use as a bladder augment and continent catheterizable channel. CCIC requires release of the hepatic flexure of the colon, which necessitates a longer midline laparotomy than would be required for a standard bladder augmentation. This is associated with high rates of ventral and parastomal hernias. OBJECTIVES: To describe the technique of hand-assist laparoscopic CCIC and to compare outcomes to open CCIC. MATERIALS AND METHODS: We found pure laparoscopic colon mobilization difficult due to significant colonic distension in patients with neurogenic bladder and bowel. We modified our approach to hand-assisted laparoscopic mobilization for better retraction of the bowel. A 12-mm camera port is placed through the umbilicus, which later serves as the stoma site, and a 5-mm assist port is placed a handbreadth cephalad to the 12-mm port. A Pfannenstiel incision is made for use as the hand port. After colonic mobilization is completed the remainder of the procedure is performed in an open fashion through the Pfannenstiel incision. The primary outcome was 90-day Clavien grade 2 or greater complications. Secondary outcomes included revision rates, wound infection, urinary continence, operative time, and length of stay. Data was analyzed using Mann-Whitney U test and Fisher's exact test. RESULTS: Thirty-two laparoscopic and 21 open procedures were reviewed. Those who underwent open procedures were more likely to have undergone prior catheterizable channel or bladder augmentation (7 vs 1, P < .01). There were fewer 90-day complications in the laparoscopic group (18.8% vs 47.6%, P = .03). There was no difference in operative time, hospital length of stay, wound infections, need for subsequent channel revision, or long-term continence between groups. CONCLUSION: Hand-assist laparoscopic CCIC offers a minimally invasive alternative to open CCIC with fewer short-term complications and comparable long-term outcomes.

Testicular rupture following rubber bullet trauma case report.

Following civil unrest during 2020, physicians began to notice a variety of injuries resulting from crowd control weapons. While prior research emphasized ocular trauma, genitourinary complications of injuries have yet to be investigated. A previously healthy 27-year-old male presented to the emergency department due to sudden onset of severe left testicular pain following rubber bullet trauma. Physical exam showed extreme tenderness, abrasion, contusion, and edema of the left testicle with normal right testicle. Doppler ultrasound showed minimal blood flow to the superior pole with irregularity of the tunica albuginea. Surgery confirmed testicular rupture with a large tunical violation and extruded spermatic tubules. The testicle was thoroughly irrigated, non-viable tubules were debrided, and intraoperative ultrasound confirmed restoration of blood flow. Patient was discharged and instructed to follow-up should he face any fertility concerns in the future. Current crowd control guidelines state projectiles should be aimed at the lower abdomen or extremities; however, projectiles can cause testicular trauma which may lead to hypogonadism, infection, and psychological impact. Until there are changes to methods of crowd control, attendees should consider the use of athletic cups.