Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice.

BACKGROUND: The definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs. AIM: To evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries. METHODS: A database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared. MAIN OUTCOME MEASURE: The primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups. RESULTS: A total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P < .001) and surgical (68 vs 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs 4.4% [hospital], P = .02), corroborated by logistic regression analysis (odds ratio 0.39, P = .03). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). The primary reason for mandated hospital-based surgery was medical (51.4%), though requirement as a result of insurance directive (39.7%) was substantial. CLINICAL IMPLICATIONS: IPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer. STRENGTHS & LIMITATIONS: The strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding. CONCLUSION: ASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk. Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020;17:1025-1032.

Robotic transanal minimally invasive rectal mucosa harvest.

INTRODUCTION: Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction. There may be insufficient BMG for applications requiring large grafts, such as urethral stricture after gender-affirming phalloplasty. Rectal mucosa in lieu of BMG avoids oral impairment, while potentially affording less postoperative pain and larger graft dimensions. Transanal minimally invasive surgery (TAMIS) using laparoscopic instruments has been described. Due to technical challenges of harvesting a sizable graft within the rectal lumen, we adopted a new robotic approach. We demonstrate the feasibility and safety of a novel technique of Robotic TAMIS (R-TAMIS) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty. METHODS: Six patients (ages 28-60) presenting with urethral stricture and one vaginal stricture underwent robotic rectal mucosal harvest. The procedure, which was first studied on an inanimate bovine colon model, was performed under general anesthesia in lithotomy position using the GelPOINTTM Path Transanal Access. Mucosa was harvested robotically after submucosal hydrodissection. Graft size harvested correlated with surface area needed for urethral or vaginal reconstruction. Following specimen retrieval, flexible sigmoidoscopy confirmed hemostasis. The graft was placed as an onlay for urethroplasty. RESULTS: There were no intraoperative or postoperative complications. Mean graft size was 11.4 × 3.0 cm. All reconstructions had excellent graft take. All patients recovered without morbidity or mortality. They reported minimal postoperative pain and all regained bowel function on postoperative day one. Patients with prior BMG harvests subjectively self-reported less postoperative pain and greater quality of life. There have been no long-term complications at a median follow-up of 17 months. CONCLUSIONS: To our knowledge, this is the first use of R-TAMIS for rectal mucosa harvest. Our preliminary series indicates this approach is feasible and safe, constituting a promising minimally invasive technique for urethral reconstruction. Prospective studies evaluating graft outcomes and donor site morbidity with more long-term follow-up are needed.

Impact of Surgeon Case Volume on Reoperation Rates after Inflatable Penile Prosthesis Surgery.

PURPOSE: We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery. MATERIALS AND METHODS: The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications. RESULTS: A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p <0.001), 2.4 (p <0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively. CONCLUSIONS: Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.

Sub-Coronal Inflatable Penile Prosthesis Placement With Modified No-Touch Technique: A Step-by-Step Approach With Outcomes.

INTRODUCTION: The surgical treatment of disorders of male sexual function requires specific exposure to correct the underlying problem safely and efficiently. Currently, sub-coronal exposure is used for treatment of phimosis, Peyronie's disease plaque (PDP), and semirigid penile prosthesis insertion. Infra-pubic and scrotal incisions are used for inflatable penile prosthesis (IPP) placement. However, men who present with several disorders might require multiple procedures and surgical incisions. AIM: To report a prospective review of our surgical experience and outcomes with a single sub-coronal incision for IPP placement with a modified no-touch technique. This approach allows for access to the entire corporal body for multiple reconstructive procedures. METHODS: Two hundred men had IPPs placed through a sub-coronal incision using our modified no-touch technique. The penis was degloved to the level of the penoscrotal junction and the dartos muscle was everted and secured to the drapes. This allowed exclusion of the scrotal and penile skin from the operative field. After artificial erection, the patient's corpora were inspected for PDP and other abnormalities. Penoscrotal IPP models were placed in all cases with insertion proximal to the penoscrotal junction. After placement of the IPP, the abnormalities were repaired. MAIN OUTCOME MEASURES: Feasibility of the procedure, operative times, complication rate, utilization of accessory, reconstructive procedures, and post-operative penile length. RESULTS: Of the 200 men who had IPP placement, 92 had PDP that was treated, 106 (53%) consented to circumcision, 24 (12%) had their reservoir placed ectopically, and 31 (16%) had a prosthesis exchanged through the sub-coronal technique. Mean operative time was 73 minutes (39-161 minutes). CONCLUSION: Specialists in the surgical treatment of disorders of male sexual function can perform multiple procedures safely and easily through a modified no-touch single sub-coronal incision. This approach allows access to the entire corporal body, providing excellent visibility and allowing the surgeon to perform multiple penile reconstructive surgeries through a single incision.

Predicting Renal Parenchymal Loss after Nephron Sparing Surgery.

PURPOSE: We analyze the relationship among various patient, operative and tumor characteristics to determine which factors correlate with renal parenchymal volume loss after nephron sparing surgery using a novel 3-dimensional volume assessment. MATERIALS AND METHODS: We conducted a retrospective review of an institutional database of patients who underwent nephron sparing surgery from 1992 to 2014 for a localized renal mass. Tumors were classified according to the R.E.N.A.L. nephrometry system. Using 3-dimensional reconstruction imaging software, preoperative and postoperative renal parenchymal volume was calculated for the ipsilateral and contralateral kidney. RESULTS: A total of 158 patients were analyzed. Mean patient age was 58.7 years and mean followup was 40.1 months. Mean preoperative tumor volume was 34.0 cc and mean tumor dimension was 3.4 cm. Mean R.E.N.A.L. nephrometry score was 6.2, with 60.1%, 34.2% and 5.7% of tumors classified as low, medium and high complexity, respectively. Mean change in renal parenchymal volume after nephron sparing surgery was -15.3% for the ipsilateral kidney and -6.8% for total kidney volume. On univariate analysis ischemia time, tumor size, R.E.N.A.L. nephrometry score, complexity grouping and the individual nephrometry components of tumor size, percent exophytic, anterior/posterior, depth and tumor proximity to the renal artery or vein were associated with greater renal parenchymal volume loss. On multivariate analysis only ischemia time, tumor size, posterior location and percent exophytic were independently associated with more renal parenchymal volume loss. CONCLUSIONS: Using precise 3-dimensional volumetric analysis we found that ischemia time, tumor size and endophytic/exophytic properties of a localized renal mass are the most important determinants of renal parenchymal volume loss.

Utilization and perioperative complications of laparoscopic cryoablation vs. robotic partial nephrectomy for localized renal tumors.

OBJECTIVE: To compare the utilization, perioperative complications and predictors of LCA versus RPN in the treatment of localized renal tumors. METHODS: From the Nationwide Inpatient Sample we identified patients undergoing RPN or LCA for the treatment of localized renal tumors from October 2008 through 2010. Patient and hospital-specific factors which predict postoperative complications and use of LCA were investigated. RESULTS: 14,275 patients with localized renal tumors were identified: 70.3% had RPN and 29.7% had LCA. LCA was more common in older patient and at hospitals without robotic consoles. No difference was identified in perioperative complications (0.2% vs. 0.2%), transfusion (5.1% vs. 6.2%), length of stay (2.9 vs. 3.0 days) or median cost ($41,753 vs. $44,618) between the groups, LCA vs. RPN. On multivariate analysis sicker patients were more likely to have LCA (OR 1.34, p=0.048) and sicker patients had greater postoperative complications (OR 3.30, p<0.001); LCA did not predict more complications (OR 1.63, p=0.138) and LCA was performed at hospitals without RCs (OR 0.02, p<0.001). Limitations include observational study design, inability to assess disease severity, operative time, or body mass index, which may affect patient selection and outcomes. CONCLUSIONS: More patients had RPN vs. LCA; surgical technique was not predictive of postoperative complications. As technology develops to treat localized renal tumors, it will be important to continue to track outcomes and costs for procedures including RPN and LCA.

Reliability and validity of the Overactive Bladder Symptom Score in Spanish (OABSS-S).

PURPOSE: To validate the Spanish translation of the Overactive Bladder Symptom Score (OABSS) questionnaire. MATERIALS AND METHODS: The OABSS was translated into Spanish (OABSS-S) and back translated. The OABSS-S was self-administered to subjects, following internal IRB and ISPOR Good Practices guidelines. Spanish speaking patients >18 years of age were recruited from primary care clinics. Content validity was achieved by having the first 25 subjects complete the questionnaire in privacy; afterwards they were interviewed and the clarity of each question was discussed with the patient. All subjects recruited, including the first 25, were divided into two groups by the presence of OAB as determined by a previously validated intake question. Subjects completed the OABSS-S in privacy on two occasions within 10 days. Patients were excluded if their symptoms changed between the first and second administration of the questionnaire. Internal consistency was determined with Cronbach's alpha. Test-retest was determined by Spearman's rho. Discriminant validity was assessed between each group using one-way ANOVA and the Tukey post hoc test. RESULTS: One hundred and seventeen of 128 enrolled subjects completed this study (mean age 55; SD 18). Of 117, 74 (63%) were women 29 with OAB and 45 without OAB. There were 43 men (37%), 18 with OAB and 25 without OAB. A high level of consistency was observed among the seven items answered at visit 1 and 2, with a Cronbach's raw alpha statistic of 0.92. No differences in OABSS-S with age or gender were noted. However, subgroup analysis showed patients in the OAB group were significantly older and post-test analysis showed they had higher scores both for each individual question as well as overall symptom severity scores. Spearman's rank order correlation coefficients showed that there was significant difference between the seven items of the OABSS-S; a strong association (Spearman's rho) was also observed between the total seven-item score at visits 1 and 2 for the total score of all subjects r = 0.84, with OAB: r = 0.81, and without OAB: r = 0.83. Comparison of average total scores obtained for all patients at visits 1 and 2 was not significant (10.47 ± 6.53 vs. 11.02 ± 0.66). Discriminant validity testing revealed that there were significant differences in the responses between all diagnostic groups at visits 1 and 2: with OAB versus without OAB; total versus with OAB; total versus without OAB. CONCLUSION: The Spanish version of the OABSS is valid and reliable and will allow health care providers to easily and quickly assess a Spanish-speaking patient's symptoms.

Population-based determinants of radical prostatectomy surgical margin positivity.

STUDY TYPE: Prognosis (cohort). LEVEL OF EVIDENCE: 2b. What's known on the subject? and What does the study add? Prior population and single-centre studies have assessed incidence of positive surgical margins. The current study derived population-based positive surgical margin cut-offs in order to help identify underperforming surgeons who may benefit from further courses and/or self study to improve outcomes. OBJECTIVE: To characterize factors associated with positive surgical margins (PSMs) and derive population-based PSM cutoffs to evaluate surgeon performance in radical prostatectomy (RP). PATIENTS AND METHODS: SEER-Medicare data were used to identify 4247 men diagnosed with prostate cancer during 2004-2005 who underwent RP up to 2006. We performed logistic regression to assess the impact of tumour characteristics, surgeon volume and surgical approach on the likelihood of PSMs for pT2 and PT3a disease. Moreover, we derived 25th and 10th percentile cutoffs from binomial distribution equations. RESULTS: Overall, 19.4% of men experienced PSMs with a pT2 vs pT3a PSM rate of 14.9% vs 42% (P<0.001). Extrapolating from our population-based results, a surgeon incurring more than three PSMs in 10 cases of pT2 disease performed below the 25th percentile. There was a trend for fewer PSMs with minimally invasive vs open RP (17.4% vs 20.1%, P=0.086), and the PSM rate also decreased over the study period from 21.3% in 2004 to 16.6% in 2006 (P=0.028) with significant geographic variation (P<0.001). In adjusted analyses, temporal and geographic variation in PSM persisted, and men with high (odds ratio 3.68, 95% CI 2.82-4.81) and intermediate (odds ratio 2.52, 95% CI 2.03-3.13) vs low-risk disease were at greater odds to experience PSMs. Notably, neither surgical approach nor surgeon volume was significantly associated with PSMs. CONCLUSION: Our population-based PSM benchmarks allow identification of under-performing outliers who may seek courses or video self-study to improve outcomes. There was significant temporal and geographic variation in PSMs but neither surgeon volume nor surgical approach was associated with PSMs.

Trends in the care of radical prostatectomy in the United States from 2003 to 2006.

OBJECTIVE: • o determine differences in surgical outcomes by surgical approach during a period of rapid adoption of minimally invasive surgical approaches in radical prostatectomy. PATIENTS AND METHODS: • We identified 19 542 men undergoing minimally invasive (MIRP), perineal (PRP), and retropubic (RRP) radical prostatectomy from 2003 to 2006 from the MarketScan® Medstat database, a national employer-based administrative database. • We assessed for temporal trends in perioperative complications, use of postoperative cystography and anastomotic strictures by surgical approach. RESULTS: • Between 2003 and 2006, MIRP use increased 33.6% vs 31.8% and 1.7% decreases in RRP and PRP, respectively. During the 4-year study, median length of stay for MIRP decreased from 2.0 to 1.0 day (P = 0.004) and overall perioperative complications decreased from 13.8 to 10.7%, (P = 0.023). • These findings were driven by reductions in genitourinary complications (3.3 to 2.5%, P = 0.049), miscellaneous surgical complications (3.6 to 2.3%, P = 0.006) and intestinal injury (1.5 to 0.1%, P= 0.009). • Median length of stay for RRP decreased from 3.2 to 2.9 days, (P < 0.001), overall perioperative complications decreased from 18.1 to 14.6%, (P = 0.007), because of reductions in both wound/bleeding complications (2.0 to 1.1%, P = 0.002) and heterologous blood transfusions. • Men undergoing MIRP vs RRP were less likely to have perioperative complications (12.5 vs 17.1%, P < 0.001), blood transfusions (1.5 vs 8.9%, P < 0.001) and anastomotic strictures (6.3 vs 12.8%, P < 0.001), and they had shorter mean lengths of stay (1.8 vs 3.1 days, P < 0.001) during the study period. CONCLUSION: • The increased use of MIRP corresponds with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. Further study is needed to assess the impact of tumour characteristics and surgeon volume on these perioperative outcomes as well as effects on long-term cancer control.

Utilization of pharmacotherapy for erectile dysfunction following treatment for prostate cancer.

INTRODUCTION: Pharmacotherapies improve sexual function following treatments for localized prostate cancer; however, patterns of care remain unknown. Aim. To ascertain post-treatment utilization of pharmacotherapies for erectile dysfunction (ED) using a population-based approach. METHODS: We identified 38,958 men who underwent definitive treatment for localized prostate cancer during 2003-2006 from the MarketScan Medstat data. MAIN OUTCOME MEASURES: We compared the use of ED pharmacotherapy at baseline (up to 3 months prior) and up to 30 months following radical prostatectomy (RP) or radiotherapy (RT) for localized prostate cancer by utilizing National Drug Classification codes for phosphodiesterase-5 inhibitors (PDE5I), intracavernosal injectable therapies (IT), urethral suppositories and vacuum erection devices (VED). In adjusted analyses, we controlled for the effect of age, comorbidity, type of treatment, health plan and use of adjuvant hormone therapy on the use of pharmacotherapies. Results. Men undergoing RP vs. RT were younger with less co-morbid conditions. Utilization of PDE5I was up to three times greater for men undergoing RP vs. RT, 25.6% vs. 8.8%, (P < 0.0001) in the first post-treatment year, and usage of these agents was greatest for men undergoing minimally-invasive RP procedures. A higher percentage of men also used IT, suppositories and VED after RP vs. RT (P < 0.001). However, more men in the RT group received adjuvant hormonal therapy (39.53% vs. 5.25% for RP, P < 0.01). In adjusted analyses, men undergoing RP vs. RT were more than two times likely (OR 2.1, 95% CI 1.98, 2.26) to use PDE5I post-treatment while men on adjuvant hormonal therapy were less likely to use PDE5I (OR 0.74, 95% CI 0.70-0.79, P < 0.0001). CONCLUSION: Men undergoing RP vs. RT, particularly minimally-invasive RP, are more likely to employ IT, suppositories, VED, and PDE5I pharmacotherapy post-treatment.

Inflatable Penile Prosthesis Implantation in the Ambulatory Setting: A Systematic Review.

INTRODUCTION: Erectile dysfunction is a common problem that may be definitively treated with the implantation of an inflatable penile prosthesis (IPP). The preponderance of available data on IPP surgery derives from institutional studies, most notably from academic centers or large single-surgeon series, where the majority of procedures are performed in a hospital setting. Because insurance companies and health systems look to reduce health care costs, IPP surgery in outpatient freestanding ambulatory surgery centers (ASC) is becoming more prevalent. AIM: To review the utility of surgery in an ASC setting and to explore its role in the modern practice of urology, focusing on IPP implantation. METHODS: A critical review was performed of the literature on ambulatory surgery, with specific focus on IPP surgery, using the PubMed database. Key search terms and phrases included erectile dysfunction, penile prosthesis, ambulatory surgery, ambulatory surgery center, outpatient surgery. MAIN OUTCOME MEASURE: The main outcome measure was the use of IPP implantation in an ASC. RESULTS: In contemporary surgical practice, the implementation of ambulatory surgery in free-standing centers is increasing. The principal benefits include reducing cost and improving efficiency. Studies on the modern use of IPPs support the prospect of implantation in an ambulatory setting, which can achieve similar outcomes to surgeries classically performed in the inpatient hospital setting. Novel approaches to anesthesia, surgical, and nursing care have revolutionized IPP surgery so that it can now be safely and effectively performed in the ambulatory setting. CONCLUSION: The role of ambulatory IPP implantation has increased, with the majority of cases being performed outside the hospital. Although there will always be a need for hospital-based surgery, such as significant medical comorbidities, more studies demonstrating the safety and feasibility of ambulatory surgery are needed. For those men who would otherwise be candidates for ambulatory surgery but whose insurance mandates hospital-based treatment, such studies proving utility, safety, and reduced cost could inspire policy change and broaden the ambulatory practice of IPP surgery. Segal RL, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis Implantation in the Ambulatory Setting: A Systematic Review. Sex Med Rev 2020;8:338-347.

Comparative effectiveness of minimally invasive vs open radical prostatectomy.

CONTEXT: Minimally invasive radical prostatectomy (MIRP) has diffused rapidly despite limited data on outcomes and greater costs compared with open retropubic radical prostatectomy (RRP). OBJECTIVE: To determine the comparative effectiveness of MIRP vs RRP. DESIGN, SETTING, AND PATIENTS: Population-based observational cohort study using US Surveillance, Epidemiology, and End Results Medicare linked data from 2003 through 2007. We identified men with prostate cancer who underwent MIRP (n = 1938) vs RRP (n = 6899). MAIN OUTCOME MEASURES: We compared postoperative 30-day complications, anastomotic stricture 31 to 365 days postoperatively, long-term incontinence and erectile dysfunction more than 18 months postoperatively, and postoperative use of additional cancer therapies, a surrogate for cancer control. RESULTS: Among men undergoing prostatectomy, use of MIRP increased from 9.2% (95% confidence interval [CI], 8.1%-10.5%) in 2003 to 43.2% (95% CI, 39.6%-46.9%) in 2006-2007. Men undergoing MIRP vs RRP were more likely to be recorded as Asian (6.1% vs 3.2%), less likely to be recorded as black (6.2% vs 7.8%) or Hispanic (5.6% vs 7.9%), and more likely to live in areas with at least 90% high school graduation rates (50.2% vs 41.0%) and with median incomes of at least $60,000 (35.8% vs 21.5%) (all P < .001). In propensity score-adjusted analyses, MIRP vs RRP was associated with shorter length of stay (median, 2.0 vs 3.0 days; P<.001) and lower rates of blood transfusions (2.7% vs 20.8%; P < .001), postoperative respiratory complications (4.3% vs 6.6%; P = .004), miscellaneous surgical complications (4.3% vs 5.6%; P = .03), and anastomotic stricture (5.8% vs 14.0%; P < .001). However, MIRP vs RRP was associated with an increased risk of genitourinary complications (4.7% vs 2.1%; P = .001) and diagnoses of incontinence (15.9 vs 12.2 per 100 person-years; P = .02) and erectile dysfunction (26.8 vs 19.2 per 100 person-years; P = .009). Rates of use of additional cancer therapies did not differ by surgical procedure (8.2 vs 6.9 per 100 person-years; P = .35). CONCLUSION: Men undergoing MIRP vs RRP experienced shorter length of stay, fewer respiratory and miscellaneous surgical complications and strictures, and similar postoperative use of additional cancer therapies but experienced more genitourinary complications, incontinence, and erectile dysfunction.

New aspects of the classification of nocturia.

Nocturia, one of the most bothersome urologic symptoms, has been poorly classified and understood. Multiple factors may cause nocturia, such as behavioral or environmental factors and pathologic conditions, including cardiovascular disease, diabetes mellitus, lower urinary tract obstruction, anxiety or primary sleep disorders, and sleep apnea. Nocturia caused by any combination of these and other conditions may be attributed to nocturnal polyuria, diminished nocturnal or global bladder capacity, global 24-hour polyuria, or a combination of these factors. Distinction among these classes of nocturia is made by a simple arithmetic analysis of the 24-hour voiding diary. Nocturia has been poorly studied and only recently classified according to its etiology and pathogenesis. After reviewing the current state of knowledge, we present a scheme for rational diagnosis of patients suffering from loss of sleep due to nocturnal micturition. This article reviews the current state of knowledge and presents algorithms for the diagnosis and classification of nocturia.

Robotic Y-V Plasty for Recalcitrant Bladder Neck Contracture.

OBJECTIVE: To demonstrate the technique and the outcomes of robot assisted Y-V plasty bladder neck reconstruction (RYVBNR). METHODS: We present our technique for treatment of recalcitrant bladder neck contracture (BNC) in 7 patients who underwent RYVBNR at our institution between March 2016 and September 2017. Indication for the procedure was incomplete emptying, recurrent urinary tract infections, and dysuria. On follow-up, patients were assessed for clinical success by absence of infections, symptoms, and cystoscopic evaluation. Robotic assisted dissection is performed to open the space of Retzius and mobilize the bladder. The cystoscope is passed to the level of the BNC, and Firefly technology is used to localize the BNC. The BNC is incised anteriorly, and a V-shaped bladder flap is advanced into the BNC in a Y-V plasty fashion. We place a perioperative closed suction drain, which is removed before discharge, and a 22 Fr catheter, which that will be removed in the office at approximately 2 weeks. RESULTS: Six men developed recalcitrant BNCs and 1 developed a recalcitrant vesicourethral anastomotic stenosis. All patients had previously undergone an endoscopic procedure. Median time for last attempt at endoscopic management to robot-assisted bladder neck repair was 4.7 months. The average number of prior attempts at endoscopic management was 2. All patients underwent RYVBNR without conversion to open surgery. The median operative time was 240 minutes, estimated blood loss was 67 mL, and length of stay was 1 day. There were no intraoperative complications. Catheters were removed in the office at a median time of 15 days. At a median follow-up of 8 months, all cases were successful with no evidence of recurrence. Only 2 patients had persistent urinary incontinence at 1 pad per day. CONCLUSION: RYVBNR with a Y-V plasty is a feasible and effective technique for managing a difficult reconstructive problem.

Robotic Ureteral Reconstruction Using Buccal Mucosa Grafts: A Multi-institutional Experience.

BACKGROUND: Minimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation. OBJECTIVE: To evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers. DESIGN, SETTING, AND PARTICIPANTS: This retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016. SURGICAL PROCEDURE: RBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS: The onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0cm (range 2.0-8.0), operative time was 200min (range 136-397), estimated blood loss was 95ml (range 25-420), and length of stay was 2 d (range 1-15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%. CONCLUSIONS: RBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures. PATIENT SUMMARY: We studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction.

Lengthening strategies for Peyronie's disease.

Loss of penile length is a common complaint of men with Peyronie's disease (PD), both before and after corrective intervention, which has a significant negative effect on patient quality of life. We sought to identify and describe the methods by which penile length can be preserved or increased. We conducted an extensive, systematic literature review, based on a search of the PUBMED database for articles published between 1990 and 2015. Articles with the key words "Peyronie's disease", "penile length" and/or "penile lengthening" were reviewed if they contained subjective or objective penile length outcomes. Only English-language articles that were related to PD and penile size were included. We found no evidence in the literature that medical therapy alone increases penile length. Classic inflatable penile prosthesis (IPP) placement, plication procedures, and the Nesbit procedure appear likely to maintain or decrease penile length. Plaque incision (PI) and grafting appears likely to maintain or increase penile length, but is complicated by risk of post-operative erectile dysfunction (ED). There are several surgical procedures performed concomitantly with IPP placement that may be suitable treatment options for men with comorbid ED, and consistently increase penile length with otherwise good outcomes concerning sexual function. These include the subcoronal penile prosthesis (scIPP), Egydio circumferential technique, the sliding technique, the modified sliding technique (MoST), and the multiple slice technique (MuST). In addition, adjuvant therapies such as penile traction therapy (PTT), post-operative inflation protocols, suspensory ligament relaxation, lipectomy, and adjuvant medical therapy for glans engorgement appear to increase subjective and/or objective penile length for men at high risk of decreased penile length after PD surgery. Considering the psychological burden of length loss in men with PD, providers with adequate volume and expertise should attempt, if possible, to maintain or increase penile length for men undergoing surgical intervention. There are several evidence-based, safe, and effective ways to increase penile length for these men and multiple emerging adjuvant therapies that may help ensure adequate length.

Utilization of the Robotic Surgical Platform for Radical Nephrectomy: A National Comparison of Trends for Open, Laparoscopic and Robotic Approaches.

INTRODUCTION: The robotic platform in surgery has been widely adopted as it facilitates complex surgical reconstructions such as renorrhaphy during partial nephrectomy. Although the robotic approach to radical nephrectomy has higher costs and a lack of perioperative and oncologic evidence, the use of robotic platforms for radical nephrectomy is increasing. We evaluated a national database to explain the increased use of robotic radical nephrectomy despite a lack of perioperative and oncologic evidence. METHODS: The current retrospective cohort study used NIS (Nationwide Inpatient Sample) to identify patients who underwent radical nephrectomy from the last quarter of 2008 through 2010. We investigated hospital and patient specific factors associated with the robotic approach to radical nephrectomy, including hospital volume of robotic partial nephrectomy and robot-assisted radical prostatectomy. RESULTS: Of the 124,462 radical nephrectomies 4.7% were performed robotically. The median cost of robotic radical nephrectomy was $1,324 to $2,759 higher than that of open and laparoscopic radical nephrectomy. No differences in complications, length of stay, blood transfusion rates or mortality were found between laparoscopic and robotic radical nephrectomy. However the rate of open and laparoscopic radical nephrectomy decreased during the study period while the use of robotic radical nephrectomy increased almost fourfold. At hospitals in the middle or highest tertile of robotic partial nephrectomy the procedure was more likely to be performed. Patients younger than 60 years were less likely to undergo the surgery than those older than 80 years (p <0.001). Robotic radical nephrectomy was less likely to be done at large and medium medical centers (p <0.05). The hospital volume of robot-assisted radical prostatectomy did not predict that of robotic radical nephrectomy. CONCLUSIONS: Although increased median costs and equivalent outcomes (perioperative and oncologic) question the benefit of robotic radical nephrectomy, its use is increasing. Robotic radical nephrectomy is more likely to be done at medium-high volume robotic centers for partial nephrectomy. This nationwide overtreatment and inefficiency may reflect the use of robotic radical nephrectomy as a training tool to facilitate the robotic learning curve and the proliferation of robotic partial nephrectomy.

Use of Partial Nephrectomy after Acquisition of a Surgical Robot: A Population Based Study.

INTRODUCTION: The advent of robotics may promote the dissemination of partial nephrectomy, and allow patients to experience survival and functional benefits compared to radical nephrectomy. Therefore, we assessed the impact of hospital acquisition of a robotic surgery platform on the rate of partial nephrectomy recorded in a nationwide database. METHODS: We identified 53,364 patients with a diagnosis of localized renal cell carcinoma who underwent extirpative surgery from 2006 to 2012 using the Perspective database. Procedures were categorized based on extent of surgery (radical nephrectomy vs partial nephrectomy), approach (open, laparoscopic, robotic) and hospital ownership of a surgical robot. Changes in the proportion of partial nephrectomies performed over time and the effect of acquiring a surgical robot on the proportion of partial nephrectomies performed were assessed with multivariable logistic regression. RESULTS: Overall 40,147 (75.2%) radical nephrectomies and 13,217 (24.8%) partial nephrectomies were performed between 2006 and 2012. The proportion of hospitals using a surgical robot for renal cancer surgery increased from 1.8% in the first quarter of 2006 to 47.7% by the end of 2012. Partial nephrectomy use ranged from 19.1% to 31.2%. More robotic hospitals performed partial nephrectomy than nonrobotic hospitals (29.6% vs 18.0%, p <0.001). After acquisition of a surgical robot the partial nephrectomy rate increased from 16.4% to 34.3% (p <0.001). Hospitals with a robot were more likely to use partial nephrectomy than radical nephrectomy (OR 1.464, CI 1.39-1.54, p <0.001). CONCLUSIONS: While laparoscopic partial nephrectomy remains a challenging operation, this study demonstrates that hospital ownership of a surgical robot is associated with increased use of partial nephrectomy in the treatment of localized renal masses.

Utilization and timing of blood transfusions following open and robot-assisted radical prostatectomy.

INTRODUCTION AND OBJECTIVES: Radical prostatectomy (RP) is associated with a high risk of intraoperative blood loss and subsequent blood transfusions. The shift in surgical technique from open radical prostatectomy (ORP) to robot-assisted radical prostatectomy (RARP) has resulted in lower operative blood loss, and reduced the need for transfusions. We analyzed the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database to compare real-world, contemporary trends in utilization and timing of blood transfusion following ORP and RARP. METHODS: We identified men undergoing both RARP and ORP and then queried for patients who received a blood transfusion in the perioperative period. The outcomes of interest were need and timing of perioperative blood transfusion (PBT), which was categorized into early (postoperative day [POD] ≤1) or late (POD ≥2). Logistic regression analysis was used to identify variables associated with the need and timing for PBT. RESULTS: A total of 16,144 men who underwent RP were identified from 2007 to 2012. The overall PBT rate was 3.1%. Highest rate of transfusions occurred on day of surgery for patients undergoing ORP, and first POD for patients undergoing RARP. On multivariate analysis significant predictors of blood transfusion included history of bleeding disorder (OR: 2.8, p=0.002), preoperative dyspnea (odds ratio [OR]: 1.7, p=0.03), starting hematocrit <42% (OR: 1.9, p<0.001), open approach (OR: 0.09, p<0.001), year of surgery (OR: 0.5, p<0.001), resident involvement (OR: 1.6, p=0.003), and operative time (OR: 4.4, p<0.001). The only predictor of receiving a blood transfusion on POD 2 or later was having the procedure performed through a robot-assisted approach (OR: 3.7, p<0.001). CONCLUSIONS: In this study we found that the rate of perioperative transfusions is lower than previously published. A clear separation in timing of transfusion exists based on the utilized surgical approach. It is prudent that surgeons performing RARP be aware of the low, but present risk of a delayed blood transfusion.

Venous thromboembolism after major urologic oncology surgery: a focus on the incidence and timing of thromboembolic events after 27,455 operations.

OBJECTIVE: To investigate the incidence and timing of venous thromboembolism (VTE) and identify risk factors for venous thromboembolism among patients undergoing major surgery for urologic malignancies. VTE events are stratified by occurrence in the inpatient vs outpatient settings. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Statistical Classification of Diseases, Ninth Revision codes to identify patients undergoing major surgery for urologic malignancies between 2005 and 2012. The incidence of overall 30-day VTE, postdischarge VTE, and post-VTE death was calculated for each surgical procedure. Logistic regression analysis was used to identify risk factors for VTE, adjusting for covariates including age, race, gender, smoking status, medical comorbidities, performance of pelvic lymph node dissection, and operative time. RESULTS: The study identified 27,455 patients who underwent an operation for malignancy--radical nephrectomy, partial nephrectomy, nephroureterectomy, radical prostatectomy, or radical cystectomy. The incidence and timing of VTE varied substantially across the procedures of interest. Overall, VTE occurred after radical cystectomy in 113 of 2065 of patients (5.5%), whereas only 19 of 2624 (0.7%) and 12 of 1690, respectively, of patients undergoing minimally invasive radical or partial nephrectomy procedures suffered a VTE event within 30-days of surgery. Among patients suffering a VTE after radical prostatectomy, 147 of 178 of venous thromboembolic events (82.6%) occurred after hospital discharge. CONCLUSION: This study demonstrates the significant burden of VTE beyond the time of hospital discharge. Identification of high-risk patients should prompt consideration of extended-duration VTE prophylaxis in the outpatient setting.