A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury.

BACKGROUND: Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI. METHODS: Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction. RESULTS: There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784). CONCLUSION: In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The Outcomes of Pelvic Fracture Urethral Injuries Stratified by Urethral Injury Severity: A Prospective Multi-institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury. METHODS: Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score. RESULTS: There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (P < 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (P < 0.001). CONCLUSION: In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed.

Case report: Bladder to lumbar spinal hardware fistula managed via partial cystectomy and removal of offending piece of spinal hardware.

A bladder to lumbar hardware fistula has never been reported. We report the case of a 67 year old male who presented with a bladder to lumbar spinal hardware fistula approximately four years following an L4-S1 anterior lumbar internal fixation. It was identified through the use of CT cystogram. His case was managed first with cystoscopy and interrogation of the fistula with a Glidewire followed by partial cystectomy and removal of some of the offending spinal hardware.

Genitourinary Prosthetic Use among Prostate Cancer Survivors Treated with Radical Prostatectomy.

INTRODUCTION: Erectile dysfunction and urinary incontinence are well-known side effects of radical prostatectomy that, when refractory to medical therapy, can be addressed by major genitourinary prosthetic surgery (urethral slings, artificial urinary sphincters, penile prostheses). Although these procedures have been evaluated in single institution studies, population based analyses regarding their use have been sporadic. Thus, we characterized post-prostatectomy genitourinary prosthetic surgery in a contemporary, population based cohort of men with private insurance. METHODS: Using MarketScan® Commercial Claims data we identified men who underwent radical prostatectomy between 2009 and 2010 based on coding. Our primary outcome was receipt of genitourinary prosthetic device based on codes documented in claims from 2009 through 2015. Other factors of interest included patient age, comorbidity and geographic region. RESULTS: We identified 23,813 men who underwent radical prostatectomy in 2009 and 2010 (mean [SD] age 55.5 [9.1] years). Overall 731 men (3.07%) underwent genitourinary prosthetic surgery, including 243 (1.0%) for male slings, 111 (0.5%) for artificial urinary sphincter and 377 (1.6%) for penile prostheses. Median time to the first prosthetic surgery was 21.7 months (SD 12.9, range 1.2 to 54.5). Men undergoing prosthetic surgery for post-prostatectomy complications were older (57.1 vs 55.5 years, p=0.001) and more likely to be diabetic (31.9% vs 22.6%, p <0.001) than the remainder of the cohort. There was no significant difference in treatment with surgery based on overall comorbidity or geographic region (all p >0.05). CONCLUSIONS: Overall treatment with genitourinary prosthetic surgery for incontinence (1.5%) or erectile dysfunction (1.6%) was rare following radical prostatectomy. However, diabetic and older men demonstrated a greater likelihood of device placement..

Endometrioid adenocarcinoma in the native ureter of a renal transplant patient: case report and review of the literature.

Endometriosis is characterized by endometrial-like tissue outside the uterus, primarily on the pelvic peritoneum, ovaries, and rectovaginal septum, and, in rare cases, within the urinary tract (1-3%). Although endometriosis is a benign condition, malignant transformation of endometriosis is a well-described phenomenon. Malignancies arising in endometriosis are uncommon at extragonadal pelvic sites. A case of endometrioid adenocarcinoma in the native ureter of a postmenopausal renal transplant patient presented with painless gross hematuria and hydroureteronephrosis. The patient had a history of total abdominal hysterectomy and bilateral salpingo-oophrectomy 14 years prior for menorrhagia and had since been on unopposed estrogen replacement therapy. Workup revealed a filling defect in the native left mid-ureter secondary to a large 2.5-cm ureteral tumor. Endoscopic biopsies of the native left ureteral mass showed endometrioid adenocarcinoma, grade II-III. The patient ultimately underwent an open native left nephroureterectomy and temporary diverting colostomy. Final pathology confirmed endometrioid adenocarcinoma, grade II-III, arising in a background of endometriosis with negative perirectal lymph nodes. This case of ureteral endometrioid adenocarcinoma highlights the importance of obtaining a careful history and maintaining a high index of suspicion for malignant degeneration, especially in the context of hyperestrogenism.