Artificial Urinary Sphincter Cuff Downsizing Improves Continence and Patient Satisfaction in Cases of Sub-cuff Atrophy.

PURPOSE: The management of artificial urinary sphincter sub-cuff atrophy remains controversial, and clinical outcomes are underreported. We intend to examine the impact of cuff downsizing in cases of isolated sub-cuff atrophy. MATERIALS AND METHODS: We reviewed our prospectively collected, institutionally approved quality improvement database for this study from 2011 to 2022. Institutional Review Board approval was obtained for the analysis. Sub-cuff atrophy in patients with post-prostatectomy incontinence was diagnosed with a clinical presentation of recurrent urinary leakage, serial pelvic films, cystoscopy, and patient evaluation. Outcomes were assessed with pad use, subjective measures, and American Urological Association Symptom Score scores. RESULTS: During the study interval, 871 encounters for artificial urinary sphincter placement were identified, 229 for revision or replacement, of which cuff downsizing for isolated cases of sub-cuff atrophy occurred in 34. Downsizing took place after a median of 6.5 years after initial artificial urinary sphincter placement. Of the patients, 97% reported subjective improvement and 93% experienced a decrease in daily incontinence pad use, with a mean±SD decrease of 2.2±1.45 pads (P < .01). American Urological Association Symptom Score bother scores decreased from pre-downsizing values by a mean±SD of 1.5±1.4 (P = .01). After a median follow-up of 1.8 years after downsizing, 24 (70.6%) of downsized cuffs remained in place, 2 (5.9%) were further downsized, 2 (5.9%) required replacement for mechanical failure, 4 (11.8%) underwent removal for erosion, and 2 (5.9%) underwent replacement for a herniated pressure regulating balloon. CONCLUSIONS: When diagnosed using objective criteria, cuff downsizing improves continence and patient satisfaction in cases of sub-cuff atrophy.

Leadership Training in Medicine-12 Years of Experience From the Feagin Leadership Program.

INTRODUCTION: Increasingly, physicians find themselves in demanding leadership positions. However, leadership education for medical trainees remains lacking with most physicians reporting that they are ill-equipped to tackle the challenges of leadership. Here, we set out to describe the Feagin Leadership Program (FLP) and assess its reception and impact on trainees over the past 12 years. MATERIALS AND METHODS: During the 1-year FLP, selected scholars from Duke University, Wake Forest University, and the University of North Carolina participate in five leadership sessions, individual coaching, a leadership forum, and a multidisciplinary team-based capstone project. A 28-question survey with six optional free-response questions was distributed to the Feagin Alumni Network, and descriptive statistics were assessed. RESULTS: Since its founding, 212 scholars have graduated from the FLP and 117 (55%) alumni have gone on to surgical specialties. A survey was distributed among all Feagin alumni. A total of 56 (26%) surveys were completed. Forty-three percent (n = 24) had held at least one leadership position since completing the FLP. When asked about the impact of their experience, 96% (n = 54) said that the program encouraged them to pursue a position of leadership within their field, 95% (n = 53) stated that it prepared them for such a position, and 93% (n = 52) stated that the program positively influenced their decision to be involved with current or future positions of leadership. CONCLUSIONS: Over the last 12 years, the FLP has demonstrated a high perceived impact on personal growth, leadership proficiency, and the decision to pursue leadership positions in medicine. The current dearth of leadership education for surgical trainees can best be addressed with models such as the FLP, with adoption benefiting medical trainees, the medical community, and patients they serve.

Buccal Reharvest for Urethroplasty After Graft Site Closure is Safe and Does Not Affect Long-Term Oral Health.

OBJECTIVE: To understand the effects of reharvest on safety and long-term oral health in patients requiring buccal mucosa reharvest from a previously harvested and closed site for management of recurrent urethral stricture disease. METHODS: We conducted an IRB approved retrospective chart review from 2014 to 2019 of all patients who underwent buccal graft urethroplasty at our referral based academic medical center. Surgical data was collected, and the validated Oral Health Impact Profile (OHIP-14) survey was administered to each patient. Descriptive statistics were performed and compared between patients who underwent a buccal graft reharvest and patients who underwent standard first time buccal harvest. Buccal graft beds were closed on both initial and reharvest. RESULTS: Four patients underwent a total of 5 ipsilateral buccal graft reharvests and 6 patients underwent first time buccal harvest. Median length of follow-up for all patients was 6 months (1-35 mo) and the median length of all grafts was 6 cm (5-6 cm) with no difference in the reharvest and first-time cohorts. For patients that underwent buccal reharvest, their median post-operative OHIP-14 score was 0 (0-9 pts) out of a possible 56 points. This compared to a median postoperative OHIP-14 score of 0 (0-10 pts) for patients who underwent first time buccal harvests with oral complications limited to one post-operative hematoma in the first-time cohort. CONCLUSION: Buccal grafts can safely be reharvested from a previous site with minimal concern for long-term oral health outcomes.

Small Diameter Penile Implants: A Survey on Current Utilization and Review of Literature.

BACKGROUND: Inflatable penile prostheses (IPPs) with smaller diameter cylinders have been in use for over 30 years, yet the literature is sparse on their utilization patterns amongst prosthetic surgeons. AIM: To understand current usage of small diameter penile implants (SDPI) among prosthetic surgeons. METHODS: IRB approval was obtained to conduct a survey of prosthetic surgeons. A 23-question online survey was distributed via email to physician members of the Sexual Medicine Society of North America (SMSNA) and Society of Urologic Prosthesis Surgeons (SUPS). The survey included questions regarding surgeon experience and volume, frequency of SDPI utilization, indications for SDPI, surgical strategy in the setting of SDPI (approach, use of concordant modeling/grafting), reservoir and pump management, and perceived infection risk and patient satisfaction. MAIN OUTCOME MEASURE: SDPI were utilized by the vast majority of respondents in certain clinical situations such as corporal fibrosis or anatomically small corpora, and surgeons have had a favorable experience with these as a final destination implant or as a place-holder until reimplantation with a normal diameter device. RESULTS: Fifty individuals responded to the survey, 48 of whom routinely utilized SDPI. The most common indication for SDPI placement was corporal fibrosis from prior infection, followed by anatomically small corpora and priapism. The most common maximal dilation diameter was 10 mm (47%), an additional 23% of respondents utilized SDPI with 11 mm dilation. 75.4% of respondents sometimes or always intended to upsize to standard diameter cylinders in the future. 68.8% of surgeons routinely counseled patients on the possibility of reduced grith and rigidity with SDPI. Patient satisfaction was perceived to be comparable to standard diameter cylinders in 56.3% of respondents, while the remaining 43.6% believed it to be lower than traditional cylinders. Utilization of SDPI can be an important tool for prosthetic surgeons faced with difficult cases due to corporal fibrosis or small corpora. This survey provides new insight into patterns of SDPI utilization by surgeons. A limitation of the study is that patient satisfaction is indirectly addressed through surgeons' perception and experience, further research will be necessary to include patient questionnaires regarding device satisfaction. CONCLUSION: SDPI are necessary in certain scenarios that preclude the use of normal diameter cylinders. These implants may offer satisfactory erections, but can also be upsized to standard diameter cylinders in the future. Campbell SP, Kim CJ, Allkanjari A et al. Small Diameter Penile Implants: A Survey on Current Utilization and Review of Literature. Sex Med 2022;10:100458.

Specialized proresolution mediators in the bladder: annexin-A1 normalizes inflammation and bladder dysfunction during bladder outlet obstruction.

Bladder outlet obstruction (BOO) is ultimately experienced by ≈90% of men, most commonly secondary to benign prostatic hyperplasia. Inflammation is a critical driver of BOO pathology in the bladder and can be divided into two critical steps: initiation and resolution. Although great strides have been made toward understanding the initiation of inflammation in the bladder [through the NLR family pyrin domain containing 3 (NLRP3) inflammasome], no studies have examined resolution. Resolution is controlled by five classes of compounds known as specialized proresolving mediators (SPMs), all of which bind to one or more of the seven different receptors. Using immunocytochemistry, we showed the presence of six of the known SPM receptors in the bladder of control and BOO rats; the seventh SPM receptor has no rodent homolog. Expression was predominantly localized to urothelia, often with some expression in smooth muscle, but little to none in interstitial cells. We next examined the therapeutic potential of the annexin-A1 resolution system, also present in control and BOO bladders. Using the peptide mimetic Ac2-26, we blocked inflammation-initiating pathways (NLRP3 activation), diminished BOO-induced inflammation (Evans blue dye extravasation), and normalized bladder dysfunction (urodynamics). Excitingly, Ac2-26 also promoted faster and more complete functional recovery after surgical deobstruction. Together, the results demonstrate that the bladder expresses a wide variety of potential proresolving pathways and that modulation of just one of these pathways can alleviate many detrimental aspects of BOO and speed recovery after deobstruction. This work establishes a precedent for future studies evaluating SPM effectiveness in resolving the many conditions associated with bladder inflammation.NEW & NOTEWORTHY To our knowledge, this is the first study of proinflammation-resolving pathways in the bladder, which is the basis of a new pharmacological genus-dubbed "resolution pharmacology" aimed at reducing inflammation without creating an immunocompromised state. Inflammation plays a causative or exacerbating role in numerous bladder maladies. We documented proresolution receptors in the rat bladder and the effectiveness of a specialized proresolving mediator, annexin-A1, in alleviating detrimental aspects of bladder outlet obstruction and speeding recovery after deobstruction.

Urinary Pubic Symphysis Fistula Leads to Histopathologic Osteomyelitis in Prostate Cancer Survivors.

OBJECTIVE: To assess the histologic findings in the pubic bone resected during extirpative surgery for urinary pubic symphysis fistula (UPF). The concurrent presence of osteomyelitis and the need for bone resection at time of extirpative surgery for UPF has been debated. We hypothesized that UPF results in histopathologically confirmed osteomyelitis, underscoring the importance of bone resection at the time of surgery. METHODS: An IRB-approved retrospective review of all patients undergoing surgery for UPF from 2012 to 2019 was performed. Demographic data were recorded. A single pathologist performed histopathologic examination of bone tissue in each case. Logistic regression and Fisher exact test were used to assess association of osteomyelitis with clinical factors. RESULTS: We identified 36 patients who underwent major extirpative surgery for UPF with bone pathology available for review. Bone histopathology findings confirmed presence of osteomyelitis in the majority (n = 32, 88.9%). This was characterized as chronic osteomyelitis in 15 (41.7%), acute osteomyelitis only in 1 (2.8%) and combined chronic, and acute osteomyelitis in 16 (44.4%). Osteonecrosis was seen in 11 cases (33.6%). There was no correlation between presence of osteomyelitis and age, timing from radiotherapy to diagnosis of UPF, type of radiotherapy, or history of endoscopic bladder outlet procedures. CONCLUSION: Osteomyelitis is present on histology of the pubic bone resected during surgery for UPF in the majority of cases (88.9%). Osteonecrosis is also common. These findings underscore the critical importance of pubic bone resection at time of UPF surgery to adequately treat the diseased bone.

Update on Intraoperative Cultures, Biofilms, and Modifiable Factors During Revision of Clinically Non-Infected Penile Implants.

INTRODUCTION: Penile implants have a limited lifespan, and as the population using inflatable penile prostheses ages, revision surgery has become increasingly common. Devices are frequently cultured during non-infectious revision surgeries, providing a burgeoning of evidence of positive cultures without clinical infection. However, the clinical significance of these cultures remains unclear. OBJECTIVES: We aim to review the current literature on culture results from revision surgery for clinically non-infected devices and summarize the available data to formulate a synopsis of clinically significant organisms and their significance and modifiable approaches to prosthesis surgery. METHODS: A literature review was performed on 1 March, 2020 in PubMed and Google Scholar. Search terms centered on penile prosthesis revision surgery, cultures, and infection. Titles and abstracts were reviewed for topical relevance with emphasis placed on literature from the last 20 years. Most publications comprised small case series aside from a single meta-analysis. RESULTS: Since 1995, seven series have been published examining culture positivity at the time of revision surgery for clinically non-infected devices. Isolated organisms are most commonly from the Staphylococcus genus with Staphylococcus epidermidis being the most frequently isolated organism on clinically non-infected devices. Reported culture positivity rates at the time of revision range between 9.8% and 80%. CONCLUSION: Current literature pertaining to the clinical significance of culture positivity at the time of revision surgery for clinically non-infected penile prostheses is lacking; however, multiple series do report high rates of culture positivity. This does appear to confer a higher rate of subsequent infection and a lower revision-free survival. Staphylococcus epidermidis is the most commonly isolated organism followed by other members of the Staphylococcus genus. Further studies are needed to determine the impact of modifiable variables or techniques on asymptomatic culture positivity and the ideal technologies for biofilm prevention. Nosé BD, Grimberg DCD, Lentz AC. Update on Intraoperative Cultures, Biofilms, and Modifiable Factors During Revision of Clinically Non-Infected Penile Implants. Sex Med Rev 2021;9:160-168.

The Absence of a Validated English-Language Survey to Assess Prosthesis Satisfaction: A Prospective Cohort Using the Sexual Quality of Life After Penile Prosthesis.

BACKGROUND: Prior assessments of sexual quality of life (SQoL) after penile prosthesis implantation have been performed without validated implant-specific tools. The Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire was designed and validated in Italian to specifically evaluate SQoL after a penile prosthesis is placed. AIM: We aim to better characterize prosthesis-specific SQoL after inflatable penile prosthesis placement using the English translation of the QoLSPP questionnaire. METHODS: A total of 395 consecutive patients received an inflatable penile prosthesis between January 1, 2009 and November 27, 2017, and 270 had functional emails to whom the QoLSPP questionnaire was sent. 90 surveys were completed by 75 first-time implantees and 15 patients who underwent removal/replacement surgery. Responses were considered positive if ≥ 3. Among first-time implantees, subpopulation analysis was carried out by age at survey completion (<55 years, 55-65 years, and ≥66 years), age of penile prosthesis at survey completion (<1 year, 1-5 years, and >5 years), device model (Coloplast Titan, AMS 700 CX, and AMS LGX), history of a psychiatric diagnosis, etiology of erectile dysfunction, total device length > or ≤ 21 cm, diabetes status, and body mass index < /≥ 30. Responses were analyzed in R using t-tests for continuous variables and Chi-squared tests (Fisher's for small counts) for categorical variables. OUTCOMES: The main outcome measure of this study was sexual quality of life assessed by QoLSPP. RESULTS: Patients completed the survey on average 3.15 years from their most recent prosthesis placement. 84% of first-time implantees had positive responses. Among them, there were no significant differences in the proportion of positive responses by device type, age, history of a psychiatric diagnosis, total implanted device length, etiology of erectile dysfunction, diabetes, or body mass index statuses (all P > .05). There was no difference in SQoL between first-time implantees and those who underwent removal/replacement surgery (P = 1.0). CLINICAL IMPLICATIONS: Patients experience a positive impact on their SQoL following implantation of a penile prosthesis. STRENGTHS & LIMITATIONS: Our study is the first to apply the English language QoLSPP which demonstrates high prosthesis specific SQoL but is limited by size and a lack of a validated English language tool. CONCLUSIONS: The positive impact on patients' SQoL with penile prosthesis is 84% when assessed by the English QoLSPP questionnaire. While these results mirror those reported from Italy, the English-speaking patient population is plagued with a lack of a validated tool to assess satisfaction, a void the academic and prosthetic community must fill to better understand the impact prostheses have on their patients. Carlos EC, Nosé BD, Barton GJ, et al. The Absence of a Validated English-Language Survey to Assess Prosthesis Satisfaction: A Prospective Cohort Using the Sexual Quality of Life After Penile Prosthesis. J Sex Med 2020;17:2307-2310.

Extirpative Cultures Reveal Infectious Pubic Bone Osteomyelitis in Prostate Cancer Survivors With Urinary-Pubic Symphysis Fistulae (UPF).

OBJECTIVE: To examine the infectious features of patients with urinary pubic symphysis fistula (UPF) and their association with osteomyelitis. METHODS: We conducted a review of our quality improvement database for 36 patients with UPF undergoing bone resection and extirpative surgery from October 2012 to January 2019. An assessment of bone and urine cultures was carried out along with surgical, radiologic, and demographic data. We analyzed descriptive statistics and used Fisher Exact Tests and unpaired Welch t tests to assess for associations with positive bone cultures. RESULTS: In our cohort, 33 patients (91.7%) had positive bone cultures with the 3 most common organisms being candida (22.0%), enterococcus (18.0%), and pseudomonas (10.0%). There was a correlation between positive preoperative urine culture and positive bone culture (P <.01), with 63.0% of those with positive urine cultures growing the same organism on bone culture. CONCLUSION: In this series, 91.7% of patients undergoing extirpative surgery for UPF at our institution have positive bone cultures at time of pubic bone debridement. Additionally, we demonstrate a statistically significant correlation between positive urine cultures and positive bone cultures in these patients. This supports the need for a multidisciplinary approach including infectious disease, orthopedic surgery and reconstructive urology in order to address this complex clinical condition.

Counter incision is a safe and effective method for alternative reservoir placement during inflatable penile prosthesis surgery.

BACKGROUND: Alternative reservoir placement is increasingly popular during inflatable penile prosthesis (IPP) surgery to prevent intraperitoneal positioning, bowel, bladder, or vascular injury in patients with prior pelvic surgeries. Counter incision (CI) can be used for submuscular reservoir placement in high risk patients, however series exploring the safety remain limited. METHODS: A database of IPP surgeries was queried for use of a CI during reservoir placement to compare 90-day clinical outcomes in a retrospective case-control study. Primary outcome was device infections, with secondary outcomes including reservoir herniation, hematoma, device malfunction rates, and operative times. Groups were compared using Kruskal-Wallis and Chi-Squared tests, with multivariate logistic regression models to identify predictors of infectious complications. RESULTS: A total of 534 cases met criteria, of which 51 (9.6%) used a CI for reservoir placement. The CI cohort included significantly more removal and replacements, 45.1% vs. 20.9% (P<0.001). Thirty-one CI patients (61.0%) had undergone prior prostatectomy compared to 134 (27.7%) non-CI patients (P=0.001). The most common reasons for CI were prior prostatectomy and inguinal hernia repair. Median operative time was 17 minutes longer in the CI group (74 vs. 57 minutes, P<0.001). Device infection rates were similar (2.0% vs. 4.1%, P=0.71), as were rates of hematoma (5.9% vs. 2.7%, P=0.19), and device malfunction (0.0% vs. 1.4% P=1.00). CONCLUSIONS: Complication rates were similar between CI and non-CI cohorts, even in a subset where approximately half the cases were removal and replacements. For physicians not comfortable with alternative placement through a penoscrotal or infrapubic incision, this offers a reasonable alternative and permits use of three-piece devices in patients with a hostile pelvis.

Intrinsic Plasma Cell Differentiation Defects in B Cell Expansion with NF-κB and T Cell Anergy Patient B Cells.

B cell Expansion with NF-κB and T cell Anergy (BENTA) disease is a novel B cell lymphoproliferative disorder caused by germline, gain-of-function mutations in the lymphocyte scaffolding protein CARD11, which drives constitutive NF-κB signaling. Despite dramatic polyclonal expansion of naive and immature B cells, BENTA patients also present with signs of primary immunodeficiency, including markedly reduced percentages of class-switched/memory B cells and poor humoral responses to certain vaccines. Using purified naive B cells from our BENTA patient cohort, here we show that BENTA B cells exhibit intrinsic defects in B cell differentiation. Despite a profound in vitro survival advantage relative to normal donor B cells, BENTA patient B cells were severely impaired in their ability to differentiate into short-lived IgDloCD38hi plasmablasts or CD138+ long-lived plasma cells in response to various stimuli. These defects corresponded with diminished IgG antibody production and correlated with poor induction of specific genes required for plasma cell commitment. These findings provide important mechanistic clues that help explain both B cell lymphocytosis and humoral immunodeficiency in BENTA disease.