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BACKGROUND: Penile length loss is often observed in patients with erectile dysfunction and obesity. In patients with a prominent infrapubic fat pad, the excess fat can further reduce perceived penile length.1 As others have reported, concurrent suprapubic lipectomy and placement of a penile implant has been shown to be an effective way of exposing phallic length in this challenging patient population.2,3 OBJECTIVE: In this video, we present surgical technique and initial outcomes of concurrent suprapubic lipectomy and 3-piece inflatable penile prosthesis (IPP) placement in patients that have erectile dysfunction and lipodystrophy of the mons pubis. MATERIALS AND METHODS: We retrospectively reviewed an institutional review board-approved prosthetic database of male patients that underwent placement of a 3-piece IPP and concurrent suprapubic lipectomy from 2020 to 2023. Intraoperative complications and postoperative outcomes were collated and analyzed. To perform this operation, an elliptical incision is made around the suprapubic fat pad that extends to the base of the penis inferiorly. Laterally the incision is carried just medial to the inferior margin of the iliac crest. Sharp dissection and electrocautery are used to dissect the fat pad free. A layer of areolar tissue is preserved above the layer of the fascia to prevent seroma formation. For larger blood vessels, vascular clips are used to ensure adequate hemostasis. After removal of the fat pad, placement of the penile prosthesis can proceed as one would through an infrapubic approach. After the device is placed, the tissue flaps based on the external pudendal vessels are inspected for adequate vascularity. Penetrating towel clamps are used to approximate the skin edges from lateral to medial so that the midline closure can be approximated accurately. 0-PDS is used to anchor the flap superiorly into the lower edge of the abdominal fold. The incision is then closed in multiple layers of absorbable suture from lateral to medial. A skin stapler or suture is then used to approximate the skin and the penis is wrapped with a compressive dressing. RESULTS: Nine patients underwent the combined surgery. There were no intraoperative complications. In follow-up, 1 patient developed an infection-related complication that required device removal and immediate replacement. The remaining 8 did well postoperatively with improved dorsal phallic length with no infection or device-related complications. CONCLUSION: Concurrent suprapubic lipectomy and placement of a 3-piece IPP is a safe and reproducible technique for the treatment of suprapubic lipodystrophy, buried penis, and refractory ED.
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Disfunção Erétil , Lipectomia , Lipodistrofia , Prótese de Pênis , Humanos , Masculino , Disfunção Erétil/etiologia , Disfunção Erétil/cirurgia , Estudos Retrospectivos , Complicações IntraoperatóriasRESUMO
CONTEXT: Financial toxicity (FT) refers to the detrimental effects of financial strain caused by a cancer diagnosis on the well-being of patients and their families. It is highly prevalent among cancer patients and has been associated with inferior clinical outcomes. OBJECTIVE: To summarize the literature regarding FT among patients with prostate, bladder, and kidney cancer, and to propose a framework for future FT investigations. EVIDENCE ACQUISITION: Primary manuscripts and abstracts reporting FT as a primary or secondary outcome or a covariate in patients with prostate, bladder, or kidney cancer, published before May 2020, were retrieved using the PubMed, Scopus, Embase, CINAHL, and Cochrane databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Of 629 titles identified, 19, ten, and two studies met the inclusion criteria for prostate, bladder, and kidney cancer, respectively, and were included (24 unique articles). EVIDENCE SYNTHESIS: Significant heterogeneity was observed in covariates, methodology, and measure of FT. Factors commonly associated with FT included younger age at diagnosis, black race, low socioeconomic status, low education attainment, and rurality. FT was commonly associated with lower quality of life and nonadherence. FT was common among patients in countries with universal health coverage as well as those without, although the nature of these costs differed. CONCLUSIONS: Despite paucity of literature, it is suggested that FT is common among patients with prostate and bladder cancer, and remains uncharacterized in kidney cancer patients. Future work will benefit from the incorporation of a formal FT framework, utilization of validated FT instruments to characterize FT consistently, and inclusion of FT measures in outcomes reported by patients with genitourinary cancers. PATIENT SUMMARY: Financial toxicity affects many prostate, bladder, and kidney cancer patients; however, this toxicity is understudied. It is associated with decreased quality of life and lower medication and treatment adherence.
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Neoplasias Renais , Qualidade de Vida , Estresse Financeiro , Humanos , Masculino , Próstata , Bexiga UrináriaRESUMO
Heated intraperitoneal chemotherapy (HIPEC) is commonly performed at the time of tumor resection for metastatic intraabdominal tumors. Post operative complications, such as superficial wound infections or bowel leaks are common. They are largely thought to be secondary to poor wound healing due to chemotherapy-associated neutropenia. Scrotal eschars resulting in full-thickness skin necrosis have rarely been reported as a delayed complication after HIPEC. Here, we present the first case report of penile full-thickness skin necrosis after abdominal cytoreduction with HIPEC combined with ventral hernia repair and mesh placement.
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BACKGROUND: Non-guideline-directed care (NGDC) is seen in â¼30% of testicular cancer patients and has been identified as a significant predictor of relapse. However, the potential impact of mismanagement on patient quality of life (QoL) is yet to be established. OBJECTIVE: To explore the impact of NGDC on long-term QoL in testicular cancer survivors (TCSs). DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of TCSs, who completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) in person or via mail ≥6 mo after completion of treatment, was conducted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The validated questionnaire evaluates global health status (GHS); cognitive, social, physical, emotional, and role functioning; financial burden; and treatment-specific side effects. RESULTS AND LIMITATIONS: A total of 120 men with a median age of 31.5 (interquartile range: 24-42) yr completed the questionnaire. Thirty-four (28%) men received NGDC: overtreatment (44%), improper imaging (32%), and undertreatment (29%). Men with NGDC presented with a more advanced clinical stage (≥IIA: 64% vs 32%, p = 0.007) and were less likely to undergo surveillance (19% vs 37%, p = 0.016). Patients receiving guideline-directed care reported higher GHS (84.1 vs 77.5, p = 0.015), higher physical function scores (98.5 vs 91.2, p = 0.013), and fewer financial difficulties (5.8 vs 18.6, p = 0.006) than those receiving NGDC. Multivariable linear regression showed a significant association between NGDC and poorer GHS (p = 0.002). Limitations of the study include its retrospective nature, modest sample size due to a 21% response rate, and quality-of-life assessment at a single time point rather than serially over time. CONCLUSIONS: In addition to treatment delay, avoidable morbidity, and higher rates of relapse, NGDC leads to inferior global QoL, worse physical functioning, and more financial stress. PATIENT SUMMARY: We have previously shown how mismanagement of testicular cancer results in a higher rate of disease relapse. In this study, we emphasize how the lack of adherence to standard treatment guidelines can lead to worse quality of life outcomes and financial stress in testicular cancer survivors.
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Qualidade de Vida , Neoplasias Testiculares , Humanos , Masculino , Neoplasias Embrionárias de Células Germinativas , Recidiva , Estudos Retrospectivos , Sobreviventes , Neoplasias Testiculares/terapiaRESUMO
BACKGROUND: Recent epidemiologic studies identified credible associations between marijuana smoking and risk of nonseminomatous testicular germ cell tumors (TGCTs), but did not distinguish exposure to cannabinoid compounds from exposure to other constituents of smoke. METHODS: We implemented a systematic review of scholarly literature followed by random effects meta-analysis to quantitatively synthesize published data relating incident TGCT to each of 2 exposure histories: ever using marijuana, and ever smoking tobacco. RESULTS: We identified four epidemiologic studies of marijuana use and 12 of tobacco smoking. Summary data concur with earlier reports of a specific association of marijuana use with nonseminoma, summary odds ratio [sOR]â¯=â¯1.71 (95% confidence interval [CI] 1.12-2.60), and identify a positive association, sORâ¯=â¯1.18 (95% CI 1.05-1.33), between tobacco smoking and all TGCT. CONCLUSIONS: Available data accord with positive associations between incident TGCT and each exposure, implicating both cannabinoid compounds and other constituents of smoke. Etiologic interpretation awaits epidemiologic studies that assess associations between tobacco smoking and nonseminomatous TGCT, investigating not only these exposures but also both co-use of tobacco and marijuana and smoke-free sources of cannabinoids, while adequately evaluating potential confounding among all of these exposures.
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Fumar Maconha/efeitos adversos , Nicotiana/efeitos adversos , Adolescente , Adulto , Estudos Epidemiológicos , Humanos , Incidência , Masculino , Neoplasias Testiculares , Adulto JovemRESUMO
Objective: To evaluate the incidence and natural history of radiologic incisional hernia (IH) in patients who underwent robotic partial or radical nephrectomy. Materials and Methods: We retrospectively reviewed the records of patients who underwent robotic partial or radical nephrectomy for kidney tumor in our institution between January 2011 and April 2017. All pre- and postoperative imagings were re-reviewed for detection of IH per Tonouchi classification. Patients who developed hernia were followed up and classified into stable or progressive group. Clinical findings and radiologic features of these patients are reported. Results: A total of 247 patients (169 partial and 78 radical nephrectomies) were included in the study. The incidence of radiologic IH was 27.53%, graded as early-onset (35.3%), late-onset (51.5%), and bowel/fat containing (13.2%). Median time to radiologic IH was 1.7 years. During the follow-up of 68 patients who developed hernia, 33 (48.5%) had progressive and 8 (11.7%) developed clinical hernia. Median time to progression was 1.5 years. On multivariable analysis, adjuvant therapy was an independent predictor for radiologic hernia development (HR 3.23). Pathologic T stage ≥2 and history of open abdominal surgery were also significantly associated with hernia progression (HR 3.93 and 3.47, respectively). Conclusions: Radiologic IH after robotic partial or radical nephrectomy is common. Progression rate is as high as 50% with median time to progression of 1.5 years. Adjuvant therapy is an independent predictor for IH development, whereas higher stage and history of open abdominal surgery are associated with IH progression.
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Hérnia Incisional , Procedimentos Cirúrgicos Robóticos , Humanos , Hérnia Incisional/diagnóstico por imagem , Hérnia Incisional/epidemiologia , Hérnia Incisional/etiologia , Nefrectomia/efeitos adversos , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Procedimentos Cirúrgicos Robóticos/efeitos adversosRESUMO
OBJECTIVE: To determine if the timing of radical cystectomy for variant histology of urothelial carcinoma has an impact on survival. Variant histology has been associated with aberrant behavior compared to pure urothelial carcinoma, however the timing of surgery for these patients has not been studied. MATERIALS AND METHODS: We identified 363 patients with cT2-T4N0M0 urothelial carcinoma who underwent radical cystectomy without perioperative intravesical and/or systemic therapy from 2003 to 2014. Clinicopathologic data were compared between pure urothelial carcinoma and variant histology. The time from diagnosis to radical cystectomy was analyzed as a continuous variable and dichotomized at 4-, 8-, and 12-weeks to determine impact on oncologic outcomes. RESULTS: Patients with variant histology, when compared to those with pure urothelial carcinoma, were more likely to present with extravesical disease (P <.01), be upstaged (P <.01), have lymphovascular invasion (P <.01) and have lymph node metastasis at radical cystectomy (Pâ¯=â¯.02). The median days to radical cystectomy did not differ between pure urothelial and variant histology. On multivariable analysis controlling for age, comorbidities, tumor stage, lymph node status, lymphovascular invasion, and surgical margins, every month in delay was associated with a worse overall survival for variants (HRâ¯=â¯1.36, Pâ¯=â¯.003). At an 8-week delay or longer, those with variant histology had a statistically worse survival (Pâ¯=â¯.03). CONCLUSION: For patients with variant histology, delays in surgery were associated with an increased risk of death.
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Carcinoma de Células de Transição/patologia , Carcinoma de Células de Transição/cirurgia , Cistectomia/métodos , Tempo para o Tratamento , Neoplasias da Bexiga Urinária/patologia , Neoplasias da Bexiga Urinária/cirurgia , Idoso , Carcinoma de Células de Transição/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Tempo para o Tratamento/estatística & dados numéricos , Neoplasias da Bexiga Urinária/mortalidadeRESUMO
PURPOSE OF REVIEW: The current review covers recent research examining the utility of preoperative frailty assessments to predict worse postoperative outcomes after radical cystectomy. It also discusses how to implement frailty assessments into routine clinical practice. RECENT FINDINGS: Frailty is associated with worse postoperative outcomes after radical cystectomy, including increased complications and nonhome discharge. Although the majority of these studies have been retrospective using a frailty index, prospective studies using a preoperative frailty assessment have also shown frailty to be associated with worse outcomes. Preoperative frailty assessments based on patients' physiologic fitness, such as the Fried Frailty Criteria or psoas muscle volume, have been the best predictors of worse outcomes on prospective cohorts. However, no study to date has directly compared a prospective frailty assessment and frailty index to determine the most effective tool for routine clinical care. National guidelines are lacking on how to assess frailty preoperatively before radical cystectomy. SUMMARY: Frailty has been consistently shown to correlate with worse postoperative outcomes after radical cystectomy. Although the most effective and efficient method for preoperative assessment has yet to be determined, assessments based on physiologic fitness are likely to be most useful. Improved guidelines will likely increase implementation of frailty assessments into routine management.
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Cistectomia/efeitos adversos , Fragilidade/complicações , Neoplasias da Bexiga Urinária/cirurgia , Humanos , Cuidados Pré-Operatórios , Prognóstico , Medição de Risco , Neoplasias da Bexiga Urinária/complicaçõesRESUMO
PURPOSE: Frailty has been correlated with worse postoperative outcomes. Prospective studies examining frailty and bladder cancer are lacking. We aimed to determine whether a prospective frailty assessment or traditional risk indices can identify patients undergoing radical cystectomy (RC) at risk for complications. MATERIALS AND METHODS: Patients ≥65 years undergoing RC were preoperatively assessed using Fried Frailty Criteria (FFC; grip strength, gait speed, exhaustion, physical activity, shrinking), Charlson Comorbidity Index, American Society of Anesthesiologists score, Katz Index of Independence in Activities of Daily Living, Karnofsky Performance Scale, Eastern Cooperative Oncology Group performance status, and Center for Epidemiological Studies Depression scale. Thirty-day and 90-day postoperative complications were recorded. Univariate and multivariate analyses were performed. RESULTS: One hundred and twenty three patients were assessed with median age of 74 years. Fifty-nine patients (48.0%) had ≥1 complication within 30 days and 72 (58.5%) within 90 days. Center for Epidemiological Studies Depression scale (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.17, Pâ¯=â¯0.027) and shrinking (OR 3.79, 95% CI 1.64-9.26, P = 0.0024) were significant for any 30-day complication, while physical activity was protective (OR 0.84, 95% CI 0.69-1.00, Pâ¯=â¯0.072) for any 90-day complication. Being intermediately frail or frail was associated with high-grade 30-day (OR 4.87, 95% CI 1.39-22.77, P = 0.022) and 90-day complications (OR 3.01, 95% CI 1.05-9.37, P = 0.045), along with Eastern Cooperative Oncology Group score ≥3 (OR 45.00, 95% CI 6.92-437.69, P = 0.0010 and OR 17.85, 95% CI 3.21-143.26, P = 0.0079, respectively). CONCLUSIONS: Fried Frailty Criteria were predictive of high-grade complications, while individual components were predictive of having any complication. Elderly patients should be routinely assessed prior to RC to guide postoperative care.
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Cistectomia/efeitos adversos , Idoso , Cistectomia/métodos , Feminino , Idoso Fragilizado , Fragilidade , Humanos , Masculino , Complicações Pós-Operatórias , Estudos Prospectivos , Fatores de RiscoRESUMO
OBJECTIVES: To determine patient satisfaction with testicular prostheses (TP) for testicular cancer. Reconstruction represents an important part of surgical oncology, yet placement of TP following orchiectomy is infrequently performed. Improved data on patient satisfaction with TP would help in counseling patients with testicular cancer. MATERIALS AND METHODS: Forty patients who underwent orchiectomy and TP placement for testicular cancer participated in a survey that was blinded to the providers in an outpatient clinic (2012-2014) to evaluate TP satisfaction. Categorical variables associated with satisfaction were compared using the Fisher's exact test. RESULTS: Median age at TP placement was 31 years (17-59). Most patients had their prosthesis in place for >1 year (81%) at the time of the survey. No patient reported complications from the TP and none underwent explantation. All patients felt that being offered an implant before orchiectomy was important. Overall, 33 patients (82.5%) rated the TP as good or excellent, and 35 men (87.5%) would have the prosthesis implanted again. Thirty-seven patients (92.5%) found the TP to be comfortable or very comfortable. However, 44% considered the TP too firm and 20% felt the position was not appropriate. Appropriate size, appropriate position, and TP comfort were significantly associated with good or excellent overall TP satisfaction (P < .05). CONCLUSION: Overall satisfaction with testicular implants after orchiectomy for testicular cancer is high. Patients should be offered a testicular prosthesis, especially at the time of orchiectomy. Efforts should be made to optimize implant firmness, and care should be given to proper size selection and positioning.
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Satisfação do Paciente , Próteses e Implantes , Neoplasias Testiculares/cirurgia , Testículo , Adolescente , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Orquiectomia , Desenho de Prótese , Adulto JovemRESUMO
While several studies have investigated maternal exposures as risk factors for oral clefts, few have examined paternal factors. We conducted an international multi-centered case-control study to better understand paternal risk exposures for oral clefts (cases = 392 and controls = 234). Participants were recruited from local hospitals and oral cleft repair surgical missions in Vietnam, the Philippines, Honduras, and Morocco. Questionnaires were administered to fathers and mothers separately to elicit risk factor and family history data. Associations between paternal exposures and risk of clefts were assessed using logistic regression adjusting for potential confounders. A father's personal/family history of clefts was associated with significantly increased risk (adjusted OR: 4.77; 95% CI: 2.41-9.45). No other significant associations were identified for other suspected risk factors, including education (none/primary school v. university adjusted OR: 1.29; 95% CI: 0.74-2.24), advanced paternal age (5-year adjusted OR: 0.98; 95% CI: 0.84-1.16), or pre-pregnancy tobacco use (adjusted OR: 0.96; 95% CI: 0.67-1.37). Although sample size was limited, significantly decreased risks were observed for fathers with selected occupations. Further research is needed to investigate paternal environmental exposures as cleft risk factors.
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Fenda Labial/epidemiologia , Fissura Palatina/epidemiologia , Exposição Paterna/efeitos adversos , Estudos de Casos e Controles , Pré-Escolar , Fenda Labial/etiologia , Fissura Palatina/etiologia , Honduras/epidemiologia , Humanos , Lactente , Recém-Nascido , Masculino , Marrocos/epidemiologia , Filipinas/epidemiologia , Fatores de Risco , Fatores Socioeconômicos , Vietnã/epidemiologiaRESUMO
Isolated cleft palate (CPO) is the rarest form of oral clefting. The incidence of CPO varies substantially by geography from 1.3 to 25.3 per 10,000 live births, with the highest rates in British Columbia, Canada and the lowest rates in Nigeria, Africa. Stratified by ethnicity/race, the highest rates of CPO are observed in non-Hispanic Whites and the lowest in Africans; nevertheless, rates of CPO are consistently higher in females compared to males. Approximately fifty percent of cases born with cleft palate occur as part of a known genetic syndrome or with another malformation (e.g., congenital heart defects) and the other half occur as solitary defects, referred to often as non-syndromic clefts. The etiology of CPO is multifactorial involving genetic and environmental risk factors. Several animal models have yielded insight into the molecular pathways responsible for proper closure of the palate, including the BMP, TGF-ß, and SHH signaling pathways. In terms of environmental exposures, only maternal tobacco smoke has been found to be strongly associated with CPO. Some studies have suggested that maternal glucocorticoid exposure may also be important. Clearly, there is a need for larger epidemiologic studies to further investigate both genetic and environmental risk factors and gene-environment interactions. In terms of treatment, there is a need for long-term comprehensive care including surgical, dental and speech pathology. Overall, five main themes emerge as critical in advancing research: (1) monitoring of the occurrence of CPO (capacity building); (2) detailed phenotyping of the severity (biology); (3) understanding of the genetic and environmental risk factors (primary prevention); (4) access to early detection and multidisciplinary treatment (clinical services); and (5) understanding predictors of recurrence and possible interventions among families with a child with CPO (secondary prevention).