Genitourinary Blastomycosis in a Young Male Patient: A Case Report and Review of Diagnostic Challenges.

Disseminated blastomycosis is an endemic fungal infection that rarely manifests with genitourinary involvement. We present a unique case of a 28-year-old professional male gamer with a remote history of hemoptysis and cervical lymphadenopathy who presented with hematospermia, lower urinary tract symptoms (LUTS), and persistent groin abscesses after left orchiectomy at an outside hospital. He underwent drainage of groin abscess and prostate biopsy for an abnormal digital rectal exam which revealed disseminated blastomycosis requiring systemic, long-term antifungal treatment. We have also included a review of literature to note clinical patterns in presentations and highlight the diagnostic challenges that this infection presents.

Corpus spongiosum flap: a unique technique in the management of urosymphyseal fistula.

Urosymphseal fistulas are a debilitating but treatable consequence of the combination of radiotherapy and endoscopic interventions in prostate cancer patients. Treatment includes fistula excision with a tissue flap to prevent communication of involved structures and provide structural and vascular support. We introduce a unique surgical approach of mobilizing and utilizing a corpus spongiosum flap in urosymphyseal fistula repair. A retrospective study identified two patients who underwent repair with a pedicled corpus spongiosum flap at our institution. The corpus spongiosum had adequate length and vascularization and limited the need for extra-pelvic muscle flaps, thus maintaining muscle integrity in the abdomen and thighs. Following extirpative surgery, both patients had durable fistula closure, decreased pelvic pain, and resolution of lower urinary tract symptoms and osteomyelitis. These cases highlight the potential of the corpus spongiosum to be a reasonable alternative interpositional flap in genitourinary reconstruction.

Cancer risk in bladder diverticula: a large institutional analysis of risk and management.

PURPOSE: Bladder diverticula (BD) are usually asymptomatic, but may increase the risk of infections, stones, or malignancy, likely due to urinary stasis within the BD. We aim to characterize the risk of bladder cancer (BC) within diverticula. METHODS: Retrospective review was conducted of patients diagnosed with BD between 1994 and 2021 at a single institution. Cancer risk was characterized using descriptive statistics and multivariable logistic regression as appropriate. RESULTS: We identified 764 patients with mean age 68 years, the majority of whom were male (87%) and Caucasian (86%). Of this total, 13.3% (102/764) had a diagnosis of BC and 35.3% of this subset (36/102) had definitive cancer within the BD. Diverticulectomy or partial cystectomy was performed in 13.6% (104/764), 76% of whom were preoperatively presumed to have benign disease. Surgical patients were younger and had larger BD. Of the 79 patients who underwent diverticulectomy without preoperative suspicion for cancer, 5 were incidentally diagnosed with BC on final pathology. On multivariable logistic regression, male gender [odds ratio (OR) = 2.6, p = 0.03] and increasing age (OR = 1.02, p = 0.03) were independent risk factors for BC diagnosis. Indwelling catheter, recurrent urinary tract infections (UTIs), and bladder stones did not affect the risk of BC. CONCLUSIONS: The majority of patients with BD are not managed with surgery. BC is identified in a small but considerable proportion of patients with BD, with an even lower rate of incidentally diagnosed cancer among those undergoing BD surgery. Male gender and increasing age increased the risk of BC diagnosis.

Unusual Cause of Artificial Urinary Sphincter Malfunction: Device Entanglement Resulting in Urethral Constriction and Urinary Retention.

Urinary retention following placement of an artificial urinary sphincter (AUS) is not an uncommon complication. We describe a unique case of urinary retention due to AUS entanglement causing urethral constriction in a 72-year-old male. He presented to the emergency department postoperatively following AUS placement with pelvic pain and incomplete emptying. Eventual cystourethroscopy demonstrated severe extrinsic urethral constriction despite the deactivation of the AUS device. Surgical exploration revealed an unexpected looping of the occlusive cuff, causing urethral constriction. Although the precise cause is not clearly known, we suspect that it may have been related to the process of connecting the tubing at the level of the abdomen. Regardless of the underlying etiology, this case highlights a unique complication and supports an assessment of the cuff with direct perineal inspection prior to wound closure and/or with cystourethroscopy.

Management of Urosymphyseal Fistula and Pelvic Osteomyelitis: A Comprehensive Institutional Experience and Improvements in Pain Control.

BACKGROUND: Urosymphyseal fistula (USF) is an uncommon but painful and devastating condition typically occurring after radiotherapy for pelvic malignancy, with a delayed diagnosis and a risk of opioid dependence. OBJECTIVE: To characterize our institutional experience and determine the impact of intervention for USF on pain control and opioid use. DESIGN, SETTING, AND PARTICIPANTS: We evaluated data for 33 adult patients diagnosed with USF and managed at a quaternary institution between 2009 and 2021. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We assessed chronic opioid use, pain scores, prior therapy for pelvic malignancy, prior endoscopic procedures, microbiology and histology congruence, and postoperative complications. For comparative analyses we used a χ2 test or Fisher's exact test for categorical variables and a Wilcoxon signed-rank test for continuous variables. RESULTS AND LIMITATIONS: Nearly 94% of the patients had received prior pelvic radiotherapy and >80% occurred in 2016-2021 but were not diagnosed until a median of 10 mo (interquartile range [IQR] 3.5-19.5) following endoscopic procedure(s). Osteomyelitis was suspected in 78.8% of imaging reports and nearly 70% had a positive preoperative urine culture. Over 90% of patients underwent cystectomy, pubic bone debridement or resection, and a soft-tissue pedicle flap. Preoperative urine cultures were concordant with 60% of intraoperative tissue/bone cultures. Histologic osteomyelitis was identified in 85% and concordant with 80% of preoperative imaging. Clavien-Dindo grade ≥3 complications occurred in 15.6%. The median pain score decreased from 4 (IQR 0-8) preoperatively to 0 (IQR 0) postoperatively (p < 0.001). Chronic opioid use decreased from 39.4% to 21.2% (p = 0.02). CONCLUSIONS: Pelvic osteomyelitis may complicate USF and commonly manifests with severe, persistent pain. USF incidence may be increasing or at least increasingly recognized, but diagnosis is delayed. Definitive management results in significant improvements in pain perception and a decrease in chronic opioid use. PATIENT SUMMARY: We examined features of urinary fistulas, which are abnormal openings or connections between part of the urinary tract and another structure. Patients with a urinary fistula involving the pelvic bones can present with severe pain, but diagnosis of the condition is often delayed. Removal of some pelvic bone with bladder removal or repair can result in a decrease in long-term pain and in the use of opioid drugs for pain relief.

Urosymphyseal fistulas in women: identification and characterization of a previously undescribed phenomenon.

Urosymphyseal fistula (USF) is a very uncommon but catastrophic condition which typically occurs in the setting of previous radiation treatment for prostate cancer. As a result, USF has only been described in male populations. For the first time, we characterize this phenomenon in a series consisting of four women managed at our quaternary institution. We found that most patients presented with pubic pain and all were diagnosed with USF on CT or MRI. Imaging commonly demonstrated features suggesting osteomyelitis which was confirmed on histology. Patients experienced significant decreases in peri-operative pain scores following extirpative surgery with urinary diversion, bone debridement/resection and tissue interposition. This case series highlights the rarity of USF in women in order to help promote increased recognition and timely management.

Effect of Obesity and Overweight Status on Complications and Survival After Minimally Invasive Kidney Surgery in Patients with Clinical T2-4 Renal Masses.

Objective: To evaluate the effect of obesity and overweight on surgical, functional, and survival outcomes in patients with large kidney masses after minimally invasive surgery. Materials and Methods: Within a multicenter multinational dataset, patients found to have ≥cT2 renal mass and treated with minimally invasive (laparoscopic or robotic) kidney surgery (radical or partial nephrectomy) during the period 2003 to 2017 were abstracted. They were stratified according to the body mass index classes as normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2). Mixed models and Cox proportional hazard regression tested differences in complication rates, estimated glomerular filtration rate (eGFR) change over time, overall mortality (OM), and disease recurrence (DR) rates. Results: Of 812 patients, 30.6% were normal weight, 42.7% were overweight, and 26.7% obese. Overweight (odds ratio 0.82, 95% confidence interval [CI]: 0.51-1.31, p = 0.406) and obese patients (OR: 0.81, 95% CI: 0.44-1.47, p = 0.490) experienced similar complication rates than normal weight. Moreover, no statistically significant differences in eGFR were found for overweight (p = 0.129) or obese (p = 0.166) patients compared to normal weight. However, higher OM rates were recorded in overweight (hazard ratio [HR] 3.59, 95% CI: 1.03-12.51, p = 0.044), as well as in obese, patients (HR 7.83, 95% CI: 2.20-27.83, p = 0.002). Similarly, higher DR rates were recorded in obese (HR 2.76, 95% CI: 1.40-5.44, p = 0.003) patients. Conclusions: Obese and overweight patients do not experience higher complication rates or worse eGFR after minimally invasive kidney surgery, which therefore can be deemed feasible and safe also in this subset of patients. Nevertheless, obese and overweight patients seem to carry a higher risk of OM, and therefore, they should undergo a strict follow-up after surgery.

Urinary dysfunction in transgenic sickle cell mice: model of idiopathic overactive bladder syndrome.

Voiding abnormalities are common among the sickle cell disease (SCD) population, among which overactive bladder (OAB) syndrome is observed at rates as high as 39%. Although detrusor overactivity is the most common cause of OAB, its molecular pathophysiology is not well elucidated. The nitric oxide (NO) signaling pathway has been implicated in the regulation of lower genitourinary tract function. In the present study, we evaluated the role of the NO signaling pathway in voiding function of transgenic SCD mice compared with combined endothelial and neuronal NO synthase gene-deficient mice, both serving as models of NO deficiency. Mice underwent void spot assay and cystometry, and bladder and urethral specimens were studied using in vitro tissue myography. Both mouse models exhibited increased void volumes; increased nonvoiding and voiding contraction frequencies; decreased bladder compliance; increased detrusor smooth muscle contraction responses to electrical field stimulation, KCl, and carbachol; and increased urethral smooth muscle relaxation responses to sodium nitroprusside compared with WT mice. In conclusion, our comprehensive behavioral and functional study of the SCD mouse lower genitourinary tract, in correlation with that of the NO-deficient mouse, reveals NO effector actions in voiding function and suggests that NO signaling derangements are associated with an OAB phenotype. These findings may allow further study of molecular targets for the characterization and evaluation of OAB.

Lower Genitourinary Foreign Bodies: An Institutional Experience and Description of a Novel, Minimally-invasive Extraction Technique for Anterior Urethral Objects.

OBJECTIVE: To describe our experience with management of lower genitourinary foreign bodies (FBs); to introduce our novel, but simple and minimally-invasive retrieval method compared with standard techniques for anterior urethral FBs; and to propose a derived, practical management algorithm. METHODS: We reviewed all male patients presenting with inserted urethral and/or bladder FBs between January2000 and October 2018. Patient characteristics and number of episodes were identified. Episodes were stratified by FB type, FB location, diagnostic modality, and removal method. We performed a subgroup analysis of anterior urethral FB management techniques comparing retrieval outcomes using our novel Retrieval of Anterior urethral Materials Safely (RAMS) technique which utilizes urethral hydrodistension via retrograde injection of lidocaine jelly to expel FBs vs forceps extraction. Cost analyses were performed, and a management algorithm was then derived. RESULTS: We identified 116 episodes. Eighty-seven of 116 (75%) episodes involved items located within the anterior urethra. A subset of episodes (14/116, 12%) was managed using the RAMS technique. There was no difference in FB extraction success rates between RAMS (13/14, 92.9%) and forceps extraction (37/40, 92.7%), P = 1.00. FBs were successfully removed using RAMS when utilized for nonembedded FBs located entirely within the anterior urethra. Among FBs located within the anterior urethra, the median total hospital cost was nearly 10 times less with utilization of RAMS compared with cystoscopic extraction ($379.09 v s$3,214.21, P <.05). CONCLUSION: Because an overwhelming majority of FBs are located within the anterior urethra, the RAMS technique represents a simple, cost-conscious, and minimally-invasive strategy with low risk and potentially high-yield for initial extraction in the emergency department.

Robotic versus laparoscopic radical nephrectomy: a large multi-institutional analysis (ROSULA Collaborative Group).

OBJECTIVE: To compare the outcomes of robotic radical nephrectomy (RRN) to those of laparoscopic radical nephrectomy (LRN) for large renal masses. METHODS: This was a retrospective analysis of RRN and LRN cases performed for large (≥ cT2) renal masses from 2004 to 2017 and collected in the multi-institutional international database (ROSULA: RObotic SUrgery for LArge renal masses). Peri-operative, functional, and oncologic outcomes were compared between each approach. Descriptive analyses were performed and presented as medians with interquartile ranges. Inverse probability of treatment weighting-adjusted multivariable analyses were used to identify predictors of peri-operative complications. Kaplan-Meier analysis and Cox regression models were used to assess survival outcomes. RESULTS: A total of 941 patients (RRN = 404, LRN = 537) were identified. There was no difference in terms of gender, age, and clinical tumor size. Over the study period, RRN had an annual increase of 11.75% (95% CI [7.34, 17.01] p < 0.001) and LRN had an annual decline of 5.39% (95% CI [-6.94, -3.86] p < 0.001). Patients undergoing RRN had higher BMI (27.6 [IQR 24.8-31.1] vs. 26.5 [24.1-30.0] kg/m2, p < 0.01). Operative duration was longer for RRN (185.0 [150.0-237.2] vs. 126 [90.8-180.0] min, p < 0.001). Length of stay was shorter for RRN (3.0 [2.0-4.0] vs. 5.0 [4.0-7.0] days, p < 0.001). RRN cases presented more advanced disease (higher pathologic staging [pT3-4 52.5 vs. 24.2%, p < 0.001], histologic grade [high grade 49.3 vs. 30.4%, p < 0.001], and rate of nodal disease [pN1 5.4 vs. 1.9%, p < 0.01]). Surgical approach did not represent an independent risk factor for peri-operative complications (OR 1.81 95% CI [0.97-3.39], adjusted p = 0.2). The main study limitation is the retrospective design. CONCLUSIONS: This study represents the largest known multi-center comparison between RRN and LRN. The two procedures seem to offer similar peri-operative outcomes. Notably, RRN has been increasingly utilized, especially in the setting of more advanced and surgically challenging disease without increasing the risk of peri-operative complications.

Optimization of renal function preservation during robotic partial nephrectomy.

Over the past few years, the role of robotic-assisted partial nephrectomy (RPN) has exponentially grown. Multiple recognized factors contribute to postoperative renal function in patients undergoing RPN. The aim of this review is to identify these potential factors, and to evaluate strategies that may help optimize the goal of renal function preservation. A nonsystematic literature review was performed to retrieve the most recent evidence on factors contributing to renal function post-RPN. Analyzed elements include baseline factors (tumor complexity and patient characteristics), intraoperative (surgical) factors (control of the renal hilum and type of ischemia, resection technique, renorrhaphy technique), and pharmacotherapeutics. In conclusion, the advantages of robotic surgery in the setting of partial nephrectomy (PN) are becoming well established. Maximal preservation of renal function remains a priority goal of the procedure, and it is influenced by a plethora of factors. Adequate patient selection using radiomics, control of comorbidities, utilization of evidence-based intraoperative techniques/strategies, and postoperative care are key components of postoperative preservation of renal function. Further investigations regarding these factors and their effects on long-term renal function are necessary and will continue to aid in guiding appropriate patient care.

Impact of Perioperative Blood Transfusions on the Outcomes of Patients Undergoing Kidney Cancer Surgery: A Systematic Review and Pooled Analysis.

The aim of the present study is to systematically review current evidence regarding the association between perioperative blood transfusions (PBT) and oncological outcomes of patients with renal cell carcinoma undergoing nephrectomy procedures. A computerized bibliographic search was conducted to identify pertinent studies. The Population, Intervention, Comparator, Outcome (PICO) study design approach was used to define study eligibility according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria. Only 7 studies were deemed fully eligible for analysis. Most series included both open and laparoscopic cases. The rate of PBT varied between 9.6% and 76.6%, and the median number of transfused units was 2 for most of the studies. At pooled analysis, a statistically significant association was found between PBT and disease recurrence (HR, 1.79; 95% CI, 1.32-2.41; P < .001), cancer-specific mortality (HR, 1.62; 95% CI, 1.29-2.05; P ≤ .001), and all-cause mortality (HR, 1.45; 95% CI, 1.25-1.69; P < .001). Current evidence suggests that indeed the use of PBT may be associated with worse oncologic outcomes in patients with renal cell carcinoma undergoing nephrectomy procedures. Although presents findings should be interpreted within the intrinsic limitations of this type of pooled analysis, they emphasize the need for evidence-based strategies to minimize the use of PBT during kidney cancer surgery.

Potential Association of Weight-Based Gentamicin with Increased Acute Kidney Injury in Urologic Prosthetic Surgery.

BACKGROUND: Despite the known nephrotoxicity of gentamicin, in 2008 the American Urological Association recommended a weight-based gentamicin dose of 5 mg/kg for antimicrobial prophylaxis during urologic prosthetic surgery. AIM: To identify and characterize rates of acute kidney injury (AKI) in urologic prosthetic surgery, both before and after the implementation of weight-based gentamicin dosing. METHODS: We performed a single-institution retrospective study of patients receiving perioperative gentamicin during implant, revision, salvage, or explant of inflatable penile prostheses, malleable penile prostheses, or artificial urinary sphincters between the years 2000 and 2017. Patients were stratified into 2 groups, based on administration of either weight-based gentamicin (5 mg/kg or 2-3 mg/kg in cases of poor renal function) or standard-dose gentamicin (80 mg). Patient characteristics and perioperative outcomes were identified. Patients with available preoperative and postoperative (≤7 days) serum creatinine values were included. AKI was defined by Kidney Disease: Improving Global Outcomes criteria. Comparative analyses were performed between groups. MAIN OUTCOME MEASURE: Our primary outcome was incidence of AKI, with secondary outcomes including device infection rate and length of stay. RESULTS: Of the 415 urologic prosthetic surgeries performed during the study period, 124 met inclusion criteria with paired preoperative and postoperative serum creatinine values. 57 received weight-based gentamicin (median dose 5.06 mg/kg, interquartile range [IQR] 3.96-5.94) and 67 received standard-dose gentamicin (median dose 1.07 mg/kg, IQR 1.04-1.06), P < .001. There were no significant differences in preoperative renal function or comorbidities between groups; however, the weight-based group was older (median age 64.0 years, IQR 60.0-68.5) compared with the standard-dose group (median age 61.0 years, IQR 55.0-66.0), P = .01, and comprised fewer explant cases (1.8%, 1 of 57) than the standard-dose group (13.4%, 9 of 67), P = .02. The AKI rate was significantly higher in the weight-based group (15.8%, 9 of 57) compared with the standard-dose group (3.0%, 2 o67), P = .02. Device infection rate was similar between groups (5.3%, 3/56 vs 5.2%, 3 of 58), P = 1.00. CLINICAL IMPLICATIONS: Our data suggest weight-based perioperative gentamicin prophylaxis may be associated with an increased AKI risk, without noticeably improving infection rates. STRENGTH & LIMITATIONS: Strengths of our study include the Veterans Affairs population analyzed, as well as rigorous inclusion criteria that allowed for a sensitive assessment of postoperative renal function. Limitations include the retrospective design and small sample size. CONCLUSION: Weight-based gentamicin dosing may warrant closer perioperative monitoring of renal function, and merits larger investigations to further elucidate risks and benefits. Moore RH, Anele UA, Krzastek SC. Potential Association of Weight-Based Gentamicin with Increased Acute Kidney Injury in Urologic Prosthetic Surgery. J Sex Med 2019;16:137-144.

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T2 Renal Tumors: A Multicenter Analysis (ROSULA Collaborative Group).

BACKGROUND: While partial nephrectomy (PN) represents the standard surgical management for cT1 renal masses, its role for cT2 tumors is controversial. Robot-assisted PN (RAPN) is being increasingly implemented worldwide. OBJECTIVE: To analyze perioperative, functional, and oncological outcomes of RAPN for cT2 tumors. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of a large multicenter, multinational dataset of patients with nonmetastatic cT2 masses treated with robotic surgery (ROSULA: RObotic SUrgery for LArge renal mass). INTERVENTION: Robotic-assisted PN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patients' demographics, lesion characteristics, perioperative variables, renal functional data, pathology, and oncological data were analyzed. Univariable and multivariable regression analyses assessed the relationships with the risk of intra-/postoperative complications, recurrence, and survival. RESULTS AND LIMITATIONS: A total of 298 patients were analyzed. Median tumor size was 7.6 (7-8.5) cm. Median RENAL score was 9 (8-10). Median ischemia time was 25 (20-32) min. Median estimated blood loss was 150 (100-300) ml. Sixteen patients had intraoperative complications (5.4%), whereas 66 (22%) had postoperative complications (5% were Clavien grade ≥3). Multivariable analysis revealed that a lower RENAL score (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.21-0.65, p=0.02) and pathological pT2 stage (OR 0.51, 95% CI 0.12-0.86, p=0.001) were protective against postoperative complications. A total of 243 lesions (82%) were malignant. Twenty patients (8%) had positive surgical margins. Ten deaths and 25 recurrences/metastases occurred at a median follow-up of 12 (5-35) mo. At univariable analysis, higher pT stage was predictive of a likelihood of recurrences/metastases (p=0.048). While there was a significant deterioration of renal function at discharge, this remained stable over time at 1-yr follow-up. The main limitation of this study is its retrospective design. CONCLUSIONS: RAPN in the setting of select cT2 renal masses can safely be performed with acceptable outcomes. Further studies are warranted to corroborate our findings and to better define the role of robotic nephron sparing for this challenging indication. PATIENT SUMMARY: This report shows that robotic surgery can be used for safe removal of a large renal tumor in a minimally invasive fashion, maximizing preservation of renal function, and without compromising cancer control.

Report of Three Cases of AKI Following Weight-Based Gentamicin Prophylaxis for IPP Implantation: Potential Concerns for Patients with Preexisting Conditions.

Despite the known nephrotoxicity of gentamicin, in 2008 the American Urological Association published guidelines recommending single high-dose weight-based gentamicin prophylaxis of 5 mg/kg for procedures involving urologic prostheses. These guidelines are based on the theoretical renal safety and improved antimicrobial activity of a single large dose of gentamicin. However, the risk of nephrotoxicity after weight-based gentamicin prophylaxis specifically in penile prosthetic surgery has never been established with evidence-based studies. This is of special concern in light of the known high rates of preexisting conditions in this specific population. Therefore, in order to expose potential safety issues, we present three cases of postoperative acute kidney injury following weight-based gentamicin prophylaxis after implantation of inflatable penile prostheses.

Sexual Function and Quality of Life Before and After Penile Prosthesis Implantation Following Radial Forearm Flap Phalloplasty.

OBJECTIVE: To provide sexual function and quality of life outcomes in patients with severe penile deficiency who underwent radial forearm flap phalloplasty with and without penile prosthesis implantation. PATIENTS AND METHODS: Patients with history of severe penile deficiency who underwent microsurgical radial forearm flap phalloplasty with and without penile prosthesis implantation between 2007 and 2014 were identified. They completed a set of web-based validated questionnaires including the International Index of Erectile Function, the Pediatric Penile Perception Score, the Sexual Quality of Life for Men, and several items addressing general quality of life. Outcomes were compared between groups. RESULTS: Nine of the 12 identified patients who had prosthesis after phalloplasty and 4 out of the 7 phalloplasty-only patients completed the survey, resulting in an overall response rate of 68%. Among the phalloplasty-prosthesis patients, 66% reported current sexual activity and 78% reported regular masturbation, whereas 1 of the 4 phalloplasty-only patients reported both. Prosthesis patients scored notably higher in all domains of the International Index of Erectile Function except for sexual desire. In contrast, they demonstrated similar scores of penile perception, as well as general and sexual quality of life. CONCLUSION: Among patients who have undergone flap phalloplasty, the subsequent placement of penile prosthesis appears to effectively allow for both intercourse and masturbation, resulting in measurable improvements in orgasmic function, intercourse satisfaction, and overall sexual satisfaction. Despite these important benefits, prosthesis placement does not appear to result in improvements in penile perception scores, or general or sexual quality of life.

Sexual Health Outcomes in Adults with Complete Male Epispadias.

PURPOSE: Complete male epispadias is a rare congenital anomaly characterized by failed closure of the entire penopubic dorsal urethra. Epispadias repair is typically performed during infancy, and resultant genitourinary abnormalities can have a marked impact on adult life. We assess long-term post-reconstruction sexual health and fertility outcomes in adults with complete male epispadias. MATERIALS AND METHODS: A total of 132 patients 18 years or older with complete male epispadias who had undergone reconstruction were identified from a prospectively maintained, institutionally approved database. Patients who could be contacted were asked to complete a telephone survey regarding sexual function. Reconstructive history and clinical details were obtained by chart/database review. RESULTS: Of 132 patients with complete male epispadias 74 met inclusion criteria and 15 (20%) completed the questionnaire. Seven patients (47%) reported currently being in a relationship. Although 12 patients (80%) reported overall satisfactory sexual intercourse, 11 (73%) admitted to 1 or more problems with sexual function, including abnormal ejaculation (53%), diminished sensation (20%) and difficulty maintaining an erection (20%). When questioned regarding the importance of fertility on a scale of 0 to 5 using a Likert-type item the response of 10 patients (67%) was 4 points or greater. Five patients (33%) reported having impregnated a sexual partner. Although 4 patients (27%) had suspicion of fertility problems, only 2 (13%) reported having abnormal semen analyses. CONCLUSIONS: This is one of few studies examining post-reconstruction sexual health and function in adults with complete male epispadias. Although small, our study demonstrates that patients are able to engage in relationships, participate in sexual intercourse and impregnate their partners. These results highlight sexual concerns and outcomes that may be of use when counselling patients with complete male epispadias and their families.

Suprapubic cystostomy for the management of urethral injuries during penile prosthesis implantation.

INTRODUCTION: Urethral injury is an uncommon surgical complication of penile prosthesis (PP) surgery. Conventional dogma requires abortion of the procedure if the adjacent corporal body is involved or delayed implantation to avert device infection associated with urinary extravasation. Besides the setback of the aborted surgery, this management approach also presents the possible difficulty of encountering corporal fibrosis at the time of reoperation. AIM: We report an approach using primary urethral repair and temporary suprapubic cystostomy for the management of incidental urethral injuries in a cohort of patients allowing for successful completion of unaborted PP implantation. MATERIALS AND METHODS: We performed a retrospective analysis of all patients receiving PPs from 1990 to 2014 in which incidental urethral injuries were repaired and PP implantation was completed with suprapubic cystostomy (suprapubic tube [SPT] insertion). After allowing for urethral healing and urinary diversion via SPT for 4-8 weeks, the PP was activated. MAIN OUTCOME MEASURES: Successful management was determined by the absence of perioperative complications within 6 months of implantation. RESULTS: We identified four cases, all receiving inflatable PPs, managed with temporary suprapubic cystostomy. These patients sustained urethral injuries during corporal dissection (one patient), corporal dilation (one patient), and penile straightening (two patients). All patients were managed safely and successfully. CONCLUSION: Primary urethral repair followed by temporary suprapubic cystostomy offers a surgical approach to complete PP implantation successfully in patients who sustain urethral injury complications, particularly for complex PP surgeries. Anele UA, Le BV, and Burnett AL. Suprapubic cystostomy for the management of urethral injuries during penile prosthesis implantation.

External validation of a prediction model for penile prosthesis implantation for erectile dysfunction management.

INTRODUCTION: Penile prosthesis implantation (PPI) is the definitive surgical treatment for erectile dysfunction (ED), yet it is often delayed for a variety of reasons. From commercial and Medicare claims data, we previously developed a tool for determining a patient's likelihood of eventually receiving PPI. We validated this instrument's utility by comparing cohorts receiving surgical (PPI) versus non-surgical ED management at a single institution. MATERIAL AND METHODS: The prediction model was based on a logistic regression incorporating claims data on demographics, comorbidities and ED therapy. A risk score is calculated from the model as the product of relative risks for the individual variables. The current validation was a retrospective analysis of ED patients seen at this institution from January to December 2012. Inclusion criteria included ED diagnosis and either first-time PPI or non-surgical treatment (controls). Risk scores for patients receiving PPI were compared to those of non-surgical controls. RESULTS: We established a cohort of 60 PPI patients (mean age 54.4 ± 9.5) and compared them with 120 non-PPI patients (mean age 53.4 ± 11.2 years). The median score of the PPI cohort was 5.7 (IQR 2.8-9.9) versus the non-PPI cohort's 1.8 (IQR 0.9-5.5) (p < 0.0001). The area under the receiver operator characteristic curve for predicting eventual PPI was 0.72 (95% CI, 0.64-0.79) (p < 0.0001). CONCLUSION: The prediction model risk-stratified men who ultimately underwent PPI compared to non-surgically managed controls. This external validation study suggests that the prediction model may be used on an individual patient basis to support a recommendation of PPI for managing ED.