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.

Implementation of a Perioperative Venous Thromboembolism Prophylaxis Program for Patients Undergoing Radical Cystectomy on an Enhanced Recovery After Surgery Protocol.

BACKGROUND: Novel venous thromboembolism (VTE) prophylaxis programs, including postdischarge pharmacologic prophylaxis, have been associated with decreased VTE rates. Such practices have not been widely adopted in managing radical cystectomy (RC) patients. OBJECTIVE: To evaluate the effect of a perioperative VTE prophylaxis program on VTE rates after RC. DESIGN, SETTING, AND PARTICIPANTS: Single-institution, nonrandomized, pre- and post-intervention analysis of 319 patients undergoing RC at Brigham and Women's Hospital between July 2011 and April 2017. Patient and outcome data were prospectively collected as part of the American College of Surgeons National Surgical Quality Improvement Program. INTERVENTION: Before June 2015, patients only received postoperative pharmacologic and mechanical VTE prophylaxis in the inpatient setting. Starting June 2015, a perioperative VTE prophylaxis program was implemented as part of an enhanced recovery after surgery (ERAS) protocol, including a 28-d course of postdischarge enoxaparin. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was 30-d postoperative VTE rate. Secondary outcomes were perioperative bleeding rates, 30-d complication, readmission, and mortality rates, and length of stay. Univariate analysis was performed comparing outcomes between pre- and post-intervention cohorts. RESULTS AND LIMITATIONS: Of the 319 patients who underwent RC, 210 (66%) were in the pre- and 109 (34%) in the post-intervention cohort. VTE rate was significantly lower in the post-intervention cohort (n=1, 0.9% vs n=13, 6.2%; p=0.04). Rates of perioperative bleeding (35% vs 33%; p=0.80) and 30-d readmissions related to bleeding (1% vs 3.7%; p=0.19) did not differ significantly. Single-institution data limits generalizability, and patient compliance with postdischarge enoxaparin was unknown. CONCLUSIONS: Implementation of a perioperative VTE prophylaxis program as part of an ERAS protocol that includes extended postdischarge pharmacologic prophylaxis was associated with decreased rate of VTE events after RC. Perioperative bleeding and readmissions related to bleeding did not increase with this intervention. PATIENT SUMMARY: This study evaluated whether clotting complication rates after radical cystectomy (RC) for bladder cancer can be reduced by implementing a new postoperative care pathway. This pathway reduced rates of clotting complications without increasing bleeding rates and should be considered for all patients undergoing RC.

Minimally Invasive Techniques in Urology.

Urologists were early adopters of minimally invasive, specifically robotic, techniques for cancer surgery. The current trends show increasing adoption of robotic surgery for renal, bladder, and prostate cancer. Several randomized controlled trials show that robotic urologic surgery has outcomes that are at least as good as, if not superior to, open surgery.

Contemporary perceptions of human papillomavirus and penile cancer: Perspectives from a national survey.

INTRODUCTION: We aimed to assess the contemporary knowledge of human papillomavirus (HPV) and its association with penile cancer in a nationwide cohort from the U.S. METHODS: We used the Health Information National Trends Survey (HINTS), a cross-sectional telephone survey performed in the U.S. initiated by the National Cancer Institute. The most recent iteration, HINTS 4 Cycle 4, was conducted in mail format between August 19 and November 17, 2014. Primary endpoints included knowledge of HPV and its causal relationship to penile cancer. Baseline characteristics included sex, age, education, race and ethnicity, income, residency, personal or family history of cancer, health insurance status, and internet use. Multivariable logistic regression assessed predictors of HPV and penile cancer knowledge. RESULTS: An unweighted sample of 3376 respondents was extracted from the HINTS 4, Cycle 4. Whereas 64.4% of respondents had heard of HPV, only 29.5% of these were aware that it could cause penile cancer. Men were significantly less likely to have heard of HPV than women (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.24-0.43). Older age; African-American, Asian, and "other race"; being married; from a lower education bracket; having a personal cancer history; and those without internet access were significantly less likely to have heard of HPV. None of our examined variables were independent predictors for the knowledge of the association of penile cancer and HPV. CONCLUSIONS: Our analysis of a large, nationally representative survey demonstrates that the majority of the American public is familiar with HPV, but lack a meaningful understanding between this virus and penile cancer. Primary care providers and specialists should be encouraged to intensify counselling about this significant association as a primary preventive measure of this potentially fatal disease.

Trends in penile prosthesis implantation and analysis of predictive factors for removal.

PURPOSE: This study aims to analyze patient demographics, hospital characteristics, and clinical risk factors which predict penile prosthesis removal. We also examine costs of penile prosthesis removal and trends in inflatable versus non-inflatable penile prostheses implantation in the USA from 2003 to 2015. METHODS: Cross-sectional analysis from Premier Perspective Database was completed using data from 2003 to 2015. We compared the relative proportion of inflatable versus non-inflatable penile prostheses implanted. We separated the prosthesis removal group based on indication for removal-Group 1 (infection), Group 2 (mechanical complication), and Group 3 (all explants). All groups were compared to a control group of patients with penile implants who were never subsequently explanted. Multivariate analysis was performed to analyze patient and hospital factors which predicted removal. Cost comparison was performed between the explant groups. RESULTS: There were 5085 penile prostheses implanted with a stable relative proportion of inflatable versus non-inflatable prosthesis over the 13-year study period. There were 3317 explantations. Patient factors associated with prosthesis removal were non-black race, Charlson Comorbidity Index, diabetes, and HIV status. Hospital factors associated with removal included non-teaching status, hospital region, year of removal, and annual surgeon volume. Median hospitalization costs of all explantations were $10,878. Explantations due to infection cost $11,252 versus $8602 for mechanical complications. CONCLUSIONS: This large population-based study demonstrates a stable trend in inflatable versus non-inflatable prosthesis implantation. We also identify patient and hospital factors that predict penile prosthesis removal which has clinical utility for patient risk stratification and counseling.

An American Association for the Surgery of Trauma (AAST) prospective multi-center research protocol: outcomes of urethral realignment versus suprapubic cystostomy after pelvic fracture urethral injury.

BACKGROUND: Pelvic fracture urethral injuries (PFUI) occur in up to 10% of pelvic fractures. It remains controversial whether initial primary urethral realignment (PR) after PFUI decreases the incidence of urethral obstruction and the need for subsequent urethral procedures. We present methodology for a prospective cohort study analyzing the outcomes of PR versus suprapubic cystostomy tube (SPT) after PFUI. METHODS: A prospective cohort trial was designed to compare outcomes between PR (group 1) and SPT placement (group 2). Centers are assigned to a group upon entry into the study. All patients will undergo retrograde attempted catheter placement; if this fails a cystoscopy exam is done to confirm a complete urethral disruption and attempt at gentle retrograde catheter placement. If catheter placement fails, group 1 will undergo urethral realignment and group 2 will undergo SPT. The primary outcome measure will be the rate of urethral obstruction preventing atraumatic passage of a flexible cystoscope. Secondary outcome measures include: subsequent urethral interventions, post-injury complications, urethroplasty complexity, erectile dysfunction (ED) and urinary incontinence rates. RESULTS: Prior studies demonstrate PR is associated with a 15% to 50% reduction in urethral obstruction. Ninety-six men (48 per treatment group) are required to detect a 15% treatment effect (80% power, 0.05 significance level, 20% loss to follow up/death rate). Busy trauma centers treat complete PFUI approximately 1-6 times per year, thus our goal is to recruit 25 trauma centers and enroll patients for 3 years with a goal of 100 or more total patients with complete urethral disruption. CONCLUSIONS: The proposed prospective multi-institutional cohort study should determine the utility of acute urethral realignment after PFUI.

The urological management of children with spinal cord injury.

BACKGROUND: The urologic management of children with spinal cord injury (SCI) differs from that of the adult insofar as the care involves a developing organ system and will be ongoing for years. Preservation of renal function as well as prevention of urinary tract infection in concert with both bladder and bowel continence are the essential guiding principles. METHODS: This is a non-systematic review of the literature and represents expert opinion where data are non-existent. This review focuses on special considerations in children with spinal cord injuries. RESULTS: SCI in children is less frequent than in adults and affects mainly older children and teenagers. The etiology of SCI in children is usually motor vehicle accidents. The cervical spine is often injured. The urologic evaluation is similar to that for adults but may involve more frequent radiologic and urodynamic assessment to monitor renal function as the child grows. CONCLUSIONS: Treatment may be divided into medical vs. surgical and mirrors the approach to children who have a neurogenic bladder due to spina bifida. Bladder management should be associated with bowel management to achieve the goals of continence and social acceptability.

Aquaporin-graphene interface: relevance to point-of-care device for renal cell carcinoma and desalination.

The aquaporin superfamily of hydrophobic integral membrane proteins constitutes water channels essential to the movement of water across the cell membrane, maintaining homeostatic equilibrium. During the passage of water between the extracellular and intracellular sides of the cell, aquaporins act as ultra-sensitive filters. Owing to their hydrophobic nature, aquaporins self-assemble in phospholipids. If a proper choice of lipids is made then the aquaporin biomimetic membrane can be used in the design of an artificial kidney. In combination with graphene, the aquaporin biomimetic membrane finds practical application in desalination and water recycling using mostly Escherichia coli AqpZ. Recently, human aquaporin 1 has emerged as an important biomarker in renal cell carcinoma. At present, the ultra-sensitive sensing of renal cell carcinoma is cumbersome. Hence, we discuss the use of epitopes from monoclonal antibodies as a probe for a point-of-care device for sensing renal cell carcinoma. This device works by immobilizing the antibody on the surface of a single-layer graphene, that is, as a microfluidic device for sensing renal cell carcinoma.

Comparative Effectiveness of Transurethral Resection Techniques in the Inpatient Setting for Benign Prostatic Hyperplasia.

INTRODUCTION: Monopolar transurethral resection is the conventional surgical standard of care for bladder outlet obstruction due to benign prostatic enlargement. Bipolar resection and GreenLight™ photovaporization have emerged as options with favorable safety profiles. The literature comparing these modalities is limited by sample size and absence of cost data. We compared costs and short-term safety of monopolar, bipolar and laser vaporization techniques in an all-payer inpatient discharge database. METHODS: A total of 20,323 men 40 to 80 years old with a diagnosis of benign prostatic hyperplasia who underwent an outlet procedure between 2003 and 2013 were identified in the Premier Research Database. Using propensity weighted logistic regression we assessed treatment trends and perioperative safety outcomes. RESULTS: Monopolar resection remained the most commonly performed procedure between 2003 and 2013. However, its use decreased by 20% (p <0.001). Whereas there were no differences between bipolar and monopolar resection with regard to operative time (p >0.99), length of stay (p=0.82) and 90-day complication rates (p=0.34), GreenLight photovaporization was associated with prolonged operative time (+12 minutes, 95% CI 10.25 to 13.75, p <0.001) and shorter length of stay (OR 0.51, 95% CI 0.37 to 0.7, p <0.001) compared to monopolar resection. Bipolar resection ($982, 95% CI 509-1,456; p <0.001) and GreenLight photovaporization ($1,536; 95% CI 1,296-1,775; p <0.001) were associated with greater 90-day direct hospital costs than monopolar resection. GreenLight photovaporization was associated with decreased odds of dilutional hyponatremia, stricture formation and prostatitis relative to monopolar resection. CONCLUSIONS: We found a modest perioperative safety benefit with bipolar resection and GreenLight photovaporization relative to monopolar resection. However, both procedures were associated with higher costs.

Routine Urethrography After Buccal Graft Bulbar Urethroplasty: The Impact of Initial Urethral Leak on Surgical Success.

OBJECTIVE: To determine the long-term impact of extravasation at initial post-urethroplasty urethrogram, we present a novel classification system and report the association of leak severity with outcome. MATERIALS AND METHODS: A total of 91 patients underwent buccal graft urethroplasties of the bulbar urethra from 2007 to 2015. Median time to urethrogram was 23 days. All leaks were characterized by length and width. Cutoffs for length and width were calculated using receiver operating characteristic curves. Each urethrogram was graded 0-3 (0 = no leak) with 1 point given for any leak, length ≥1.03 cm, and width ≥0.32 cm. Failure was stricture recurrence on cystoscopy. One-year failures were compared using Fisher test. Kaplan-Meier curves were constructed to measure the impact of variables on recurrence. RESULTS: Mean age was 46.1 years. Of 91 urethroplasties, 31 had extravasation on initial imaging. With median follow-up of 11 months, 15 patients had stricture recurrence, 6 of whom had leak on initial urethrogram. For patients with at least 1 year of follow-up, there was no difference at 1 year for failures, as to any leak (P = .220), length (P = 1.000), width (P = 1.000), or grade (P = .823). Grade 3 was associated with higher failure rates compared with grades ≤2 using Kaplan-Meier curves (P = .031), with the curves significantly diverging around the 1-year mark. Similarly, length ≥1.03 cm was associated with higher failure rates compared with <1.03 cm beyond 1 year (P = .044). CONCLUSION: Although there is no indication that leaks at 3 weeks are associated with short-term failure, leak length and width appear to be a predictor of longer term recurrence (>1 year).

30-Day Adverse Events Following Cystectomy for Bladder Cancer Versus Benign Bladder Conditions.

INTRODUCTION: Cystectomy is a first line treatment for muscle invasive bladder cancer and a last resort option for several benign bladder conditions. It is currently unknown how the perioperative outcomes of cystectomy for cancer differ from those of cystectomy for benign conditions. METHODS: Using the National Surgical Quality Improvement Program database we extracted data on cystectomy between 2006 and 2013. Bivariate comparison of baseline characteristics was performed and multivariate logistic regression analyses were conducted to assess the effect of cystectomy indication on 30-day outcomes. RESULTS: Overall 3,166 and 248 cystectomies were performed for cancer and benign conditions, respectively. Patients in the noncancer group were younger (median age 62.5 vs 70.0 years), had worse American Society of Anesthesiologists scores (3-4, 81.5% vs 73.8%) and functional health status (19.0% vs 1.6%), and more frequently had preoperative sepsis (3.2% vs 1.1%) and paresis (4.8% vs 0.3%) compared to patients in the cancer group (all values p ≤0.013). On adjusted analyses patients without cancer were more likely to experience prolonged length of stay (OR 2.14, 95% CI 1.60-2.86) and to be discharged to a special care facility (OR 3.08, 95% CI 2.13-4.47) compared to patients with cancer (all values p <0.001). CONCLUSIONS: Cystectomy performed for benign conditions is associated with higher odds of prolonged length of stay and adverse discharge disposition, which may be the result of worse baseline functional status and comorbid conditions. Adapting postoperative pathways after cystectomy in consideration of patients' baseline characteristics might be one approach to mitigate such outcome differences.

Blunt Abdominal Trauma from Motor Vehicle Collisions from 2007 to 2011: Renal Injury Probability and Severity in Children versus Adults.

PURPOSE: There are sparse data directly comparing the probability of renal injury in children and adults. The kidney of the child is believed to be more susceptible to blunt injury for a variety of anatomical reasons. In a large cohort we tested the hypothesis that the pediatric kidney is more susceptible to any renal injury and to higher grade injury. MATERIALS AND METHODS: We queried the NTDB® (National Trauma Data Bank®) on all hospital admissions following motor vehicle collisions in a pediatric population (age less than 21 years) and a referent adult population (age 30 to 50 years). Of 111,172 children who were admitted after motor vehicle collisions 1,093 had renal injury. RESULTS: Of the 111,172 children admitted to the hospital following motor vehicle collisions 59,385 had abdominal trauma and 1,093 had renal injury. In a multivariate logistic model adjusting for overall ISS (Injury Severity Score), region, year, driver/passenger status, presence of restraint or an airbag, we found that children had 48% higher odds of renal injury compared to adults ages 30 to 50 years (OR 1.48, 95% CI 1.32-1.66, p <0.001). Furthermore, children were at 33% higher risk for high grade renal injury (OR 1.33, 95% CI 1.05-1.69, p = 0.919). The effect remained when restricting analysis to patients with concomitant liver and spleen injuries (p <0.001). CONCLUSIONS: In a large national cohort of children, blunt renal injury following motor vehicle collisions is rare but substantially more common than in adults. The odds of high grade renal injury are approximately 50% higher in children. A greater index of suspicion and a lower threshold for renal imaging is prudent for children with blunt abdominal trauma from motor vehicle collisions.

Contemporary Trends in the Management of Renal Trauma in the United States: A National Community Hospital Population-based Analysis.

OBJECTIVE: To better define the shift in the management of renal trauma throughout the United States, with a population-based assessment of community hospital practice patterns. To investigate how hospital, patient, and injury-specific factors influence management strategy by both urologists and nonurologists. MATERIALS AND METHODS: Using the Premier Hospital database, we performed a retrospective study of all patients with renal trauma between 2003 and 2013. We identified patients using International Classification of Diseases, Ninth Revision diagnosis codes (866.0x, 866.1x), determined management strategy by International Classification of Diseases, Ninth Revision procedure codes, and dichotomized grouping by surgeon specialty. We stratified hospitals by annual renal trauma volume categorized a priori into low, <10 cases per year; intermediate, 10-20 cases per year; and high, >20 cases per year. We performed descriptive statistics and univariate and multivariate regression analyses adjusting for survey weighting and for patient, hospital, and injury-specific characteristics. RESULTS: Our study cohort included a weighted sample size of 21,531 patients. Higher renal trauma hospitals (12.6%) were significantly less likely than low (26.4%) and intermediate (31.3%) volume hospitals to undergo surgical intervention for renal trauma on adjusted models. There was a statistically significant increase in nonoperative management from 65.2% in 2003 to 81.8% in 2013. CONCLUSION: National rates of surgical intervention for renal trauma are significantly higher than those frequently quoted by the literature, especially among low- and intermediate-volume renal trauma hospitals. Although operative rates are decreasing, further consideration may need to be given to centralization of care in higher-volume teaching hospitals to improve renal salvage.

Artificial Urinary Sphincters for Treatment of Urinary Incontinence in Elderly Males.

INTRODUCTION: We sought to examine the role of advanced age (defined as >70 years), impaired cognitive function, and decreased manual dexterity in the rates of re-operation (revision or replacement) of artificial urinary sphincters (AUS). METHODS: From 1988 to 2012, 213 men underwent virgin AUS placements. Failure was defined as a revision performed for stress incontinence and replacement/exploration performed for urethral erosion/infection or mechanical failure. Kaplan-Meier curves were constructed to compare failure rates with age and Cox proportional hazard models were used to test associations. RESULTS: Advanced age was not associated with overall failure (p = 0.48), erosion/infection failure (p = 0.65), recurrent/persistent incontinence failure (p = 0.08), or mechanical failure (p = 0.36). Controlling for age, patients with cognitive dysfunction or decreased manual dexterity showed a higher rate of overall failure (p = 0.01). CONCLUSIONS: AUS placement is an excellent option to treat stress urinary incontinence in elderly men with intact cognition and good manual dexterity. AUS placement should be performed with caution in patients with impaired cognitive function or decreased manual dexterity, and additional effort should be made to identify these conditions both before and after surgery.

Anterior Urethral Stricture Disease Negatively Impacts the Quality of Life of Family Members.

Purpose. To quantify the quality of life (QoL) distress experienced by immediate family members of patients with urethral stricture via a questionnaire given prior to definitive urethroplasty. The emotional, social, and physical effects of urethral stricture disease on the QoL of family members have not been previously described. Materials and Methods. A questionnaire was administered prospectively to an immediate family member of 51 patients undergoing anterior urethroplasty by a single surgeon (SBB). The survey was comprised of twelve questions that addressed the emotional, social, and physical consequences experienced as a result of their loved one. Results. Of the 51 surveyed family members, most were female (92.2%), lived in the same household (86.3%), and slept in the same room as the patient (70.6%). Respondents experienced sleep disturbances (56.9%) and diminished social lives (43.1%). 82.4% felt stressed by the patient's surgical treatment, and 83.9% (26/31) felt that their intimacy was negatively impacted. Conclusions. Urethral stricture disease has a significant impact on the family members of those affected. These effects may last decades and include sleep disturbance, decreased social interactions, emotional stress, and impaired sexual intimacy. Treatment of urethral stricture disease should attempt to mitigate the impact of the disease on family members as well as the patient.