Posterior tibial nerve stimulation: is ultrasound guided needle placement more accurate?

INTRODUCTION To compare the accuracy of the transcutaneous ultrasound (US) in detecting the tibial nerve (TN) as opposed to digital palpation in the performance of posterior tibial nerve stimulation (PTNS). MATERIALS AND METHODS: After Institutional Review Board (IRB) approval, 25 adults were enrolled to quantify the difference in position of the distal TN by the use of US as opposed to cutaneous palpation. The position of the TN was determined first by the palpation method and then by using a L12-4MHz high frequency Linear Array Transducer. The difference in position between the two methods was determined in both proximal-distal (PD [Knee-Sole]) and anterior-posterior planes (AP). Statistical analysis was completed with numeric variables summarized with the sample median, range, and interquartile range (IQR). Categorical variables were summarized with the number and percentage of patients. Comparisons between AP and PD distances were performed using a nonparametric Wilcoxon signed rank test. Box and whisker plots were used to display individual observations graphically. All analyses and graphics were performed using SAS statistical software (version 9.4M5, SAS Institute Inc., Cary, NC, USA). RESULTS: Twenty-five patients were studied. The median AP distance between US and digital palpation was 2 mm (range, 0-5 mm; IQR, 2-3 mm). The median PD distance between US and digital palpation was 4 mm (range, 0-9 mm; IQR, 3-5 mm). The median difference between the AP and PD distances was 2 mm (range, -3-7 mm; IQR, 0-4 mm, p < 0.001). CONCLUSION: The use of US identifies the nerve with statistically significant greater accuracy than palpation technique along the PD plane.

Salvage autologous fascial sling after failed synthetic midurethral sling: Greater than 3-year outcomes.

OBJECTIVE: To determine long-term surgical outcomes of salvage autologous fascial sling placement after a failed synthetic midurethral sling. METHODS: Women who had undergone autologous fascial sling placement without concomitant pelvic surgery for a failed synthetic midurethral sling utilizing mesh with a minimum follow up of 36 months were identified. Charts were reviewed, and patients were contacted by telephone. Success was determined by the Patient Global Impression of Improvement. Secondary measures included the Incontinence Severity Index questionnaire, patient recommendation of the autologous fascial sling and need for further incontinence surgery. RESULTS: A total of 35 patients met the criteria, and 21 were successfully contacted. Of those contacted, the median age at surgery was 67 years (range 53-81 years) and at the time of the survey was 75 years (range 63-84 years) with median follow up of 74 months (range 36-127 years). Preoperatively, 12 patients (57.1%) had urethral hypermobility and 13 patients (61.9%) had mixed urinary incontinence. Eight patients (38.1%) had concomitant sling excision with five of those combined with urethrolysis at the time of the salvage operation. Patient Global Impression of Improvement success was noted in 16 patients (76.2%). A total of 11 patients (52.4%) were dry or had slight incontinence by the Incontinence Severity Index. One patient required additional anti-incontinence surgery (4.8%). A total of 18 patients (85.7%) recommended the autologous fascial sling. No statistical impact was noted with sling excision (P = 0.62), mixed urinary incontinence (P = 0.61), age at surgery (P = 0.23), age at follow up (P = 0.15), length of follow up (P = 0.71) or first surgery type (transobturator tape vs retropubic; P = 1.00). CONCLUSIONS: Autologous fascial sling provides reasonable long-term success as a salvage operation for failed midurethral slings.

The impact of site of graduate medical education training and other factors on physician employee retention.

This study sought to determine if the site of graduate medical training or other factors impact the length of institutional employment. Physician hires for the home institution were catalogued from January 1, 1996, through December 31, 2006. In analyzing the 253 physician hires, we found no statistically significant advantage in employee retention associated with hiring "one's own" or with U.S. medical school graduates.

Voiding chain cystourethography: assessing a historical test's role in selection for urethrolysis.

OBJECTIVE: To analyze the benefit of voiding chain cystourethrography (VCC) [placing a radiographic opaque chain into the urethra and bladder and asking the patient to void under fluoroscopy] in the urodynamic evaluation of female bladder outlet obstruction (BOO). MATERIALS AND METHODS: Females with post anti-incontinence operation voiding dysfunction who underwent urodynamic evaluation augmented with VCC and later had urethrolysis were identified. Six diagnostic criteria for obstruction were applied to each patient: (1) VCC ( obstructed: chain was angulated and could not be voiding out) (2) Video urodynamic study (VUDS) (detrusor contraction combined with radiographic obstruction) (3) maximum flow (Qmax) ≤ 15 cc/sec, detrusor pressure (pDet)@ Qmax ≥ 20 cm H20 (4) Qmax ≤ 11 cc/sec, pDet@ Qmax ≥ 25 cm H20 (5) Qmax ≤ 12 cc/sec, pDet@ Qmax ≥ 25 cm H20 (6) Blaivas-Groutz (B-G) nomogram. Urethrolysis results were reviewed. Agreement in assessment of BOO criteria was assessed by estimating the proportion of pair-wise agreements along with an exact binomial 95% confidence interval (CI) and by estimating kappa along with a 95 % CI. RESULTS: Twenty-one patients were identified. Twenty of the 22 urethrolyses (91%) were clinically successful. Diagnosis of BOO was most common for VCC (86 %) and then B-G Nomogram (67 %). Agreement with the VCC was relatively poor for each of the five other methods (14% -62%) with the video urodynamic study (VUDS) being the best. Three patients with successful urethrolysis were diagnosed only by the VCC. All of kappa values regarding agreement with the VCC were low; the highest value of 0.15 was observed for VUDS. CONCLUSION: VCC may augment selection criteria for urethrolysis.

Conversion to Disposable Cystoscopes Decreased Post-procedure Encounters and Infections Compared to Reusable Cystoscopes.

INTRODUCTION: We evaluated for differences in post-procedure 30-day encounters or infections following office cystoscopy using disposable vs reusable cystoscopes. METHODS: Cystoscopies performed from June to September 2020 and from February to May 2021 in our outpatient practice were retrospectively reviewed. The 2020 cystoscopies were performed with reusable cystoscopes, and the 2021 cystoscopies were performed with disposable cystoscopes. The primary outcome was the number of post-procedural 30-day encounters defined as phone calls, patient portal messages, emergency department visits, hospitalizations, or clinic appointments related to post-procedural complications such as dysuria, hematuria, or fever. Culture-proven urinary tract infection within 30 days of cystoscopy was evaluated as a secondary outcome. RESULTS: We identified 1,000 cystoscopies, including 494 with disposable cystoscopes and 506 with reusable cystoscopes. Demographics were similar between groups. The most common indication for cystoscopy in both groups was suspicion of bladder cancer (disposable: 153 [30.2%] and reusable: 143 [28.9%]). Reusable cystoscopes were associated with a higher number of 30-day encounters (35 [7.1%] vs 11 [2.2%], P < .001), urine cultures (73 [14.8%] vs 3 [0.6%], P = .005), and hospitalizations attributable to cystoscopy (1 [0.2%] vs 0 [0%], P < .001) than the disposable scope group. Positive urine cultures were also significantly more likely after cystoscopy with a reusable cystoscope (17 [3.4%] vs 1 [0.2%], P < .001). CONCLUSIONS: Disposable cystoscopes were associated with a lower number of post-procedure encounters and positive urine cultures compared to reusable cystoscopes.

Dorsal vaginal graft urethroplasty for female urethral stricture disease.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Female urethral stricture disease has been described for almost 200 years. The symptoms of female stricture disease may range from clinically insignificant to severe and debilitating with the exact aetiology being unclear. No strict criteria for diagnosis have been established with the diagnosis often relying on a combination of presenting symptoms and objective findings. Initial therapy for female urethral stricture disease has often rested on urethral dilatations and self-intermittent catheterisation with surgery reserved for patients that failed conservative measures. Female urethroplasty currently is a topic of increasing attention with multiple surgical approaches described including use of both grafts (vaginal wall, buccal mucosal membrane, lingual mucosa, and labia minus) and flaps (vaginal vestibule, anterior vagina, and lateral vagina). We describe our approach to female urethroplasty using a suprameatal (dorsal) approach (described by Tsivian and Sidi) with an autologous vaginal epithelium inlay graft. The technique and modern approaches to female urethroplasty are contrasted and discussed. The success of the approach including continence rates and lack of need for long-term self-intermittent catheterisation is noted. OBJECTIVE: • To review the technique and outcomes of using a dorsal vaginal graft to perform urethroplasty for the treatment of urethral strictures in women. PATIENTS AND METHODS: • This is a retrospective chart review of 11 women who were treated with a dorsal vaginal graft urethroplasty by one surgeon. • All women underwent preoperative evaluation that included history, physical examination, fluoro-urodynamics and urethral calibration. • After surgery interviews, physical examinations, and urinary flow and postvoid residual urine volumes (PVRs) were obtained. RESULTS: • In all, 11 women who had undergone dorsal vaginal graft urethroplasty were identified for review. The mean (range) age was 60.6 (39-75) years. The mean (range) follow-up was 22.7 (6-46) months. • There were no cases of new onset stress urinary incontinence. The mean PVRs before and after surgery were 187.1 mL and 75.8 mL, respectively (P = 0.003). The mean urinary flows before and after surgery were 7.3 mL/s and 21.8 mL/s, respectively (P = 0.001). • No patient has required repeat surgery. • Self-reporting satisfaction scores using the Patient Global Impression of Improvement showed that four patients scored 1 (very much better), three scored 2 (much better), two patients scored 3 (a little better), and one scored 4 (no change). Only one patient scored a 5 (worse). CONCLUSION: • Dorsal graft urethroplasty with vaginal mucosa may be considered as a first-line option for definitive management of female urethral stricture disease. No consensus exists for the surgical treatment of female urethral stricture disease.

Robotic assisted laparoscopic repair of vesico-vaginal fistula: the extravesical approach.

The optimal method of vesico-vaginal fistula (VVF) repair remains undetermined. Almost all previous descriptions of laparoscopic/robotic fistula repair involve utilizing a vertical cystotomy to identify the fisula. Avoidance of an intravesical approach to vesico-vaginal fistula repair may decrease patient morbidity. Patient selection, patient positioning, fistula recognition, port placement, intra-operative dissection techniques, flap formation, and repair are outlined in this video of robotic repair of vesico-vaginal fistula utilizing an extravesical approach. The extravesical robotic repair has been successfully utilized in two patients with VVF following hysterectomy. This manuscript and video demonstrates that vesico-vaginal fistulae can be repaired with a robotic assisted extravesical approach avoiding the morbidity of a large cystotomy.

Influence of Preoperative and Postoperative Factors on Prolonged Length of Stay and Readmission After Minimally Invasive Radical Prostatectomy.

Background: The mean length of stay (LOS) after minimally invasive radical prostatectomy (MI-RP) is <2 days. Our main objective was to utilize the National Surgical Quality Improvement Program (NSQIP) database to evaluate preoperative factors that may contribute to prolonged hospital stay and readmission. Materials and Methods: Utilizing the NSQIP database, records for surgery with the Current Procedural Terminology code 55866 (prostatectomy) between 2007 and 2017 were evaluated. Chi-square and t-tests were used to assess the effects of preoperative factors on prolonged LOS and rates of hospital readmission within 30 days. Odds ratios (ORs), p-values, and confidence intervals were determined using multivariable logistic regression. Results: A total of 40,764 patients underwent MI-RP between 2007 and 2017. Of these, 11.7% reported an LOS of >2 days, whereas 3.9% of patients were readmitted to the hospital within 30 days. Preoperative congestive heart failure within 30 days of surgery was shown to be strongly associated with both prolonged LOS (OR = 6.16) and readmission (OR = 3.28). Bleeding requiring transfusion was demonstrated to be the most significant postoperative factor for prolonged LOS (OR = 23.9), whereas unplanned intubation was shown to be the most significant postoperative factor for readmission (OR = 57.1). Body mass index (BMI) >30 was associated with both prolonged LOS and increase in readmission. Conclusions: Upon NSQIP database analysis, cardiopulmonary factors and BMI were demonstrated to have negative impacts on postoperative quality indicators. Patients with comorbidities should be counseled preoperatively concerning their individual risk factors. Mitigation of these factors is important in ensuring optimal outcomes.

Histologic Analysis of Urethral Stricture in 9 Patients Following Dorsal Vaginal Graft Urethroplasty.

OBJECTIVE: To present the pathologic analysis of female urethral strictures obtained during reconstructive urethroplasty. METHODS: Nine separate female urethral tissue specimens were obtained during dorsal vaginal graft urethroplasty by a single surgeon (S.P.P.). Samples were serially sectioned and fixed in 10% formalin 6 to 12 hours before routine processing in paraffin blocks. Serial 5-µm sections were subjected to H&E, Masson trichrome, and elastin staining. End point analysis included evaluation for epithelial hyperplasia and cell type, mucosal edema, degree of fibroblast/inflammatory cell infiltrate, and elastin fiber density and distribution. RESULTS: Nine specimens were examined. Six specimens had epithelial linings of stratified squamous epithelium overlying fibrosis (67%), 1 had mixed squamous and urothelial epithelium, and 2 had only urothelial epithelium. Two specimens (29%) showed acute injury with prominent squamous papillary hyperplasia, focal erosion, and patchy mucosal hemorrhage. Areas of urethral stricture were variably thickened, with increased, densely packed collagen fibers and associated mucosal lymphocytic inflammation ranging from mild and patchy to focally dense with lymphoid aggregates. The highest elastin fiber density appeared to be associated with vessels and overlying muscle bundles in the submucosa. CONCLUSIONS: Further elucidation of histopathologic characteristics may illuminate more appropriate therapeutic pathways for female urethral stricture disease management.

The evaluation and treatment of nocturia: a consensus statement.

What's known on the subject? and What does the study add? Nocturia is currently defined by the International Continence Society (ICS) as the complaint that an individual has to wake at night one or more times to void. It is, however, an underreported, understudied, and infrequently recognized problem in adults. Many factors may contribute to nocturia which are treatable, yet patients do not seek care or the condition may not be identified by providers. This paper aims to help healthcare providers better serve patients who are experiencing nocturia by summarizing current research, clinical approaches, and treatment options. The results of the conference provide a balanced evaluation of the full treatment armamentarium capable of meeting the needs of patients with the manifold causes of nocturia such as nocturnal polyuria, overactive bladder, or benign prostatic hyperplasia.

An Organization Model to Assist Individual Physicians, Scientists, and Senior Health Care Administrators With Personal and Professional Needs.

Working as a physician, scientist, or senior health care administrator is a demanding career. Studies have demonstrated that burnout and other forms of distress are common among individuals in these professions, with potentially substantive personal and professional consequences. In addition to system-level interventions to promote well-being globally, health care organizations must provide robust support systems to assist individuals in distress. Here, we describe the 15-year experience of the Mayo Clinic Office of Staff Services (OSS) providing peer support to physicians, scientists, and senior administrators at one center. Resources for financial planning (retirement, tax services, college savings for children) and peer support to assist those experiencing distress are intentionally combined in the OSS to normalize the use of the Office and reduce the stigma associated with accessing peer support. The Office is heavily used, with approximately 75% of physicians, scientists, and senior administrators accessing the financial counseling and 5% to 7% accessing the peer support resources annually. Several critical structural characteristics of the OSS are specifically designed to minimize potential stigma and reduce barriers to seeking help. These aspects are described here with the hope that they may be informative to other medical practices considering how to create low-barrier access to help individuals deal with personal and professional challenges. We also detail the results of a recent pilot study designed to extend the activity of the OSS beyond the reactive provision of peer support to those seeking help by including regular, proactive check-ups for staff covering a range of topics intended to promote personal and professional well-being.

Impact of Minimally Invasive Benign Prostatic Hyperplasia Therapies on 30- and 90-Day Postoperative Office Encounters.

OBJECTIVE: To compare the frequency of postoperative encounters in the 30-day and 90-day postoperative periods for various bladder outlet obstruction surgical therapies. MATERIALS AND METHODS: All patients who underwent transurethral resection of the prostate (TURP), GreenLight laser photovaporization of the prostate (GL-PVP) (American Medical Systems Inc.), and holmium laser enucleation of the prostate (HoLEP) from January 1, 2012 to December 31, 2014 were followed for 6 months postoperatively. All postoperative encounters such as patient calls or questions, catheter exchanges or removals, and hospital-based readmissions or emergency department visits were recorded in the electronic medical record. RESULTS: Two hundred and ninety-one consecutive patients underwent outlet procedures during the study period: TURP (N = 199; mean age, 71 years; mean body mass index [BMI], 28.5), HoLEP (N = 60; mean age, 68 years; mean BMI, 28.1), or GL-PVP (N = 32; mean age, 72 years; mean BMI, 29.3). No statistically significant difference was observed for age, BMI, preoperative American Urological Association symptom score, or preoperative maximum flow velocity between the 3 groups. Thirty-day postoperative encounters differed significantly between the 3 surgery types (P < .001). Specifically, there were fewer encounters within 30 days of surgery for TURP compared to both HoLEP (≥1 encounter: TURP = 48.7%, HoLEP = 66.7%; P = .006) and GL-PVP (≥1 encounter: TURP = 48.7%, GL-PVP = 93.7%; P < .001). The number of encounters within 90 days postoperatively was also significantly lower for TURP patients (P < .001). CONCLUSION: TURP results in fewer postoperative encounters in both the 30-day and 90-day postoperative periods compared to HoLEP and GL-PVP. Laser prostate therapies may place increased burden on clinic staff during the 30-day and 90-day postoperative periods.

Does indigo carmine prevent early artificial urinary sphincter cuff erosion?

INTRODUCTION: Urethral erosion following artificial urinary sphincter (AUS) placement is hypothesized to be secondary to unrecognized intra-operative urethral injury. Intra-urethral indigo carmine solution (ICS), a blue dye, following urethral mobilization should identify intra-operative urethrotomy and prevent early post-operative cuff erosion. METHODS: Retrospective review was completed of all men undergoing AUS (AMS 800 device) insertion between January 2000 and January 2005 for post prostatectomy stress incontinence at one institution. Operative reports were examined for use of intra-operative injection of ICS as well as documentation of urethral injury. Post-operative course was reviewed for evidence of early cuff erosion. All patients were followed a minimum of 6 months post-operatively. RESULTS: Seventy-eight men underwent AUS placement during the investigative period. Forty-one men received intra-operative ICS injection following urethral mobilization and 37 men did not. ICS identified one intra-operative urethral injury. No urethral injuries were noted in the non-injection group. The ICS group suffered 3 (7.3%) early urethral erosions; the control group had one early urethral erosion (2.7%). CONCLUSION: Intra-operative ICS use is easy, safe, and able to identify urethral injury. However, its use did not preclude the incidence of early cuff erosion. This may postulate the existence of early urethral cuff erosion as a separate entity not dependent on intra-operative urethrotomy.

The use of passive visual stimuli to enhance compliance with handwashing in a perioperative setting.

BACKGROUND: To encourage handwashing, we analyzed the effect that a passive visual stimulus in the form of a picture of a set of eyes had on self-directed hand hygiene among health care staff. METHODS: This was a prospective, single-blind study using a repeated measure design. Four dispensers of alcohol foam located in positions identified as #1, #2, #3, and #4 were used to deliver a single uniform volume of alcohol foam in an automated fashion. Pictures of eyes were placed on dispensers #1 and #3 but not dispensers #2 and #4 for 1 time period. The visual stimulus was rotated with each study time period. At the end of each study period, the volumes dispensed were examined to determine if the visual stimulus had a statistically significant influence on the volume dispensed. RESULTS: There were a total of 6 time periods. The average volume dispensed in stations with eyes was 279 cc versus that in the stations without eyes, which was 246 cc, and this was a statistically significant difference (P = .009). CONCLUSION: The correct visual stimuli may enhance compliance with hand hygiene in health care settings.

Mayo Adhesive Probability Score Is Associated With Localized Renal Cell Carcinoma Progression-free Survival.

OBJECTIVE: To assess the association of the Mayo Adhesive Probability (MAP) score and progression-free survival (PFS) in patients with renal cell carcinoma (RCC). The MAP score is derived from cross-sectional imaging measurements of perinephric fat thickness and stranding. MATERIALS AND METHODS: We identified 456 patients from a prospective registry who were treated surgically for localized RCC between 2002 and 2014. One reviewer calculated a preoperative MAP score (0-5) for each patient. Kaplan-Meier curves were utilized to estimate PFS. Cox proportional hazard models were used to estimate the association of MAP score with risk of progression univariately and after adjusting for covariates such as age, body mass index (BMI), and size, stage, grade, necrosis scores. RESULTS: Patients with higher MAP scores (4-5) were more likely to be male, to be older, to have higher BMI, and to have larger tumors (all P <.01). Of our total cohort, 405 patients had MAP scores and follow-up data to assess PFS. Dichotomizing MAP scores into high (MAP 4-5) and low (MAP 0-3) yields a hazard ratio of 2.16 for the 4-5 group vs 0-3 (95% confidence interval: 1.15-4.06, P = .017). Adjustment for BMI did not alter the association (BMI-adjusted hazard ratio [HR] = 2.20 [1.07-4.52], P = .032). Of interest, the association with MAP and PFS remains for pT1 RCC patients (n = 287, HR = 3.46 [1.06-11.24], P = .039). CONCLUSION: High MAP scores (4-5) are associated with decreased PFS in patients surgically treated for clinically localized RCC compared with patients with lower MAP scores (0-3). RCC aggressiveness may be associated with perinephric fat thickness and stranding.

Comparison of OnabotulinumtoxinA Intradetrusor Injection Needle Performance with Modern Flexible Cystoscopes.

INTRODUCTION: Intradetrusor injection of onabotulinumtoxinA (BTX-A) can be performed with rigid or flexible cystoscopy. The primary aim of this study was to analyze irrigant flow rate and total angle of deflection for the intradetrusor injection needles used for flexible cystoscopic injection of BTX-A to see if any needle provided a technical advantage. METHODS: Three commercially available intradetrusor injection needles were evaluated using two modern flexible cystourethroscopes. The three needles analyzed were the NBI070 (Coloplast, Minneapolis, MN), DIS200 (Laborie, Williston, VT), and NM-101C-0427/MAJ-565/MAJ-655 (Olympus, Center Valley, PA). Angles of deflection and irrigant flow rates were calculated with an empty working channel and each injection needle in the working channel of the two flexible cystoscopes. RESULTS: With the working channel empty, the Karl Storz 11272CU1 (KS) and Olympus CYF-V2 (O) cystoscopes had a total range of deflection of 341 degrees and 281 degrees, respectively. Total range of deflection with the KS cystoscope was reduced to 275 degrees, 250 degrees, and 311 degrees for the Coloplast NBI070, Laborie DIS200, and Olympus NM-101C-0427 needles, respectively. Total range of deflection with the O cystoscope was reduced to 195 degrees, 157 degrees, and 257 degrees for Coloplast NBI070, Laborie DIS200, and Olympus NM-101C-0427 needles, respectively. Average flow rates with an empty working channel were 5.7 mL/s and 5.5 mL/s for the KS and O cystoscopes, respectively. Mean flow rate with the KS cystoscope was reduced to 1.0 mL/s, 0.1 mL/s, and 0.7 mL/s for Coloplast NBI070, Laborie DIS200, and Olympus NM-101C-0427 needles, respectively. Mean flow rate with the O scope was reduced to 0.5 mL/s, 0.1 mL/s, and 0.4 mL/s for Coloplast NBI070, Laborie DIS200, and Olympus NM-101C-0427 needles, respectively. CONCLUSION: Among commercially available intradetrusor BTX-A injection needles, the Olympus NM-101C-0427 allows for the greatest total range of deflection and has the greatest elasticity and flexibility. Coloplast NBI070 allows for the best flow rate.

Urologic-Induced Complications of Prophylactic Ureteral Localization Stent Placement for Colorectal Surgery Cases.

PURPOSE: A prophylactic ureteral localization stent (PULSe) placed by urologists aids in intraoperative localization and detection of suspected ureteral injury during complex colorectal surgery (CRS) cases. We evaluated the incidence and management of urologic-induced complications secondary to PULSe placement during CRS cases at a single center. MATERIALS AND METHODS: We performed a retrospective review of all patients who underwent cystoscopy and PULSe placement at the time of CRS over a 12-month period. Bilateral 5 French ×70-cm TigerTail® (Bard Medical Division, Covington, GA) PULSe devices were placed without assistance of routine fluoroscopy. RESULTS: Ninety-nine patients (mean age, 58.1 years; range, 17-88 years) underwent bilateral PULSe placement, with a male:female ratio of 44:55 and a mean body mass index of 26.8 (17.0-38.6) kg/m(2). Mean pre- and postprocedural creatinine levels were 0.91 and 1.01 mg/dL, respectively. Twenty-two of 99 (22%) cases utilized a guidewire to aid in placement of PULSe. Four Clavien grade IIIb complications occurred: mucosal edema, reflex anuria, ureteral perforation, and ureteral obstruction secondary to significant clot burden. Three of the grade IIIb complications were managed endoscopically with double-J stent placement. The ureteral perforation case required percutaneous nephrostomy tube placement. Subgroup analysis of the four grade IIIb complications revealed a mean age of 62.3 years, body mass index of 26.98 kg/m(2), and pre- and postprocedural creatinine levels of 0.95 and 4.83 mg/dL, respectively. Only one of the four grade IIIb complications utilized a guidewire prior to PULSe placement. CONCLUSIONS: The incidence of Clavien grade III urologic-induced complications during PULSe placement is approximately 2% (4/188). Mandatory adoption of fluoroscopy and guidewires may be required to minimize complications of PULSe placement.

Acute urinary retention after transperineal template-guided prostate biopsy.

PURPOSE: Urinary retention occurs in 5%-36% of patients with prostate cancer after implantation of radioactive seeds for brachytherapy. We used transperineal biopsy as a model to determine the influence of needle trauma on urinary retention. METHODS AND MATERIAL: We retrospectively reviewed medical records of 157 men with high risk of prostate cancer who underwent systematic ultrasound-guided biopsy of the prostate with the transperineal template technique and an 18-gauge automated biopsy device. RESULTS: Eighteen of 157 patients (11.5%; 95% confidence interval, 6.9%-17.5%) had urinary retention within 48 hours after biopsy. Median age was 68.5 years in patients with retention vs. 67.0 years in patients without (p = 0.319); median calculated prostate volume, 76.5 vs. 51.5 mL (p = 0.015); and median number of biopsy cores, 22.0 vs. 20.0 (p = 0.038). Age distribution differed between groups (p = 0.047), with more younger men in the no-retention group. On multivariate analysis, only number of biopsy cores significantly predicted urinary retention (p = 0.003). Four patients required transurethral resection; 1 had an indwelling catheter until radical prostatectomy; and 13 were catheter-free within 1-5 days. CONCLUSIONS: Needle trauma alone may cause urinary retention in men undergoing transperineal procedures. The number of needle incursions and prostate size are predictors of postprocedure urinary retention.

Robotic-assisted bladder diverticulectomy: tips and tricks.

INTRODUCTION: The da Vinci Surgical System has become extremely popular in the field of urology for procedures requiring complex reconstructive maneuvers, such as radical prostatectomy and pyeloplasty. A natural extension of these procedures is the use of the da Vinci system for complex urinary tract reconstruction deep in the pelvis, such as bladder diverticulectomy. TECHNICAL CONSIDERATIONS: In our report and accompanying Video, we have demonstrated some technical tips and tricks with regard to patient selection, preoperative imaging, patient positioning, port placement, intraoperative diverticulum recognition/excision, and cystotomy repair that the surgeon might find beneficial for successful completion of robotic-assisted bladder diverticulectomy. CONCLUSIONS: The tips and tricks we have presented might aid in the successful completion of robotic bladder diverticulectomy.