Timing Considerations for Artificial Urinary Sphincter Implantation Postpelvic Radiotherapy.

OBJECTIVE: To explore the optimal timing for placing an artificial urinary sphincter (AUS) postradiation therapy (RT). METHODS: A bi-institutional retrospective review of all patients who underwent their first (virgin) AUS placement after pelvic RT between January 1, 2011 and July 1, 2023. To determine the optimal timeline for device implantation 2-5years post-RT, we compared hazard ratios for device revision/explantation (Rev/Exp) using Kaplan-Meier curves for each year (earlier vs later than 2/3/4/5 years post-RT). The Pearson correlation coefficient identified trends in Rev/Exp reasons (erosion/infection vs other). RESULTS: Seventy-two patients met our inclusion criteria with a median age of 65.5years (interquartile range 70-81.25). Fifteen (20.8%) had undergone one or more previous urethral or bladder neck interventions (urethroplasty in 1 [1.4%], internal urethrotomy in 7 [9.7%], and bladder neck incision in 9 [12.5%]). After a median follow-up of 57.5months (interquartile range 13-107), a total of 36 (50%) devices were Rev/Exp, with mechanical failure in 14 (19.4%) and device erosion in 12 (16.7%) being the main reasons. Device survival analysis revealed no significant difference in the risk of device Rev/Exp when implanted earlier vs later than 2, 3, 4, or 5years post-RT, with P-values of .3, .3, .4, and .4, respectively. A constant trend toward higher infection/erosion rates as indication for device Rev/Exp the later the insertion was noticed: R2 = 0.98. CONCLUSION: Despite a small sample size, our study indicates that implanting an AUS within 5 years after RT shows comparable device lifespan. However, later insertions may have higher removal rates due to erosion/infection. CLINICAL TRIAL REGISTRATION: Not applicable.

Comparing the lifespan of virgin artificial urinary sphincters in radiated patients: transcorporal vs. standard placement.

PURPOSE: To compare the lifespan of first transcorporal cuff (TC) placement of an artificial urinary sphincter (AUS) versus standard placement (SP) in patients with prior radiotherapy (RT) for prostate cancer (PCa). METHODS: We reviewed first (virgin) AUS placements from two high-volume care centers between 1/2011 and 1/2021, including PCa patients with RT history. AUS lifespan was assessed via the hazard ratio of device explantation and/or revision within a ten-year timeframe for the TC vs. SP approaches. Chi-square, Fisher's exact, and t-tests compared clinicodemographic variables. Kaplan-Meier curve compared TC and SP lifespan. RESULTS: 85/314 men with AUS met inclusion criteria, with 38.8% (33/85) in the TC group and 61.2% (52/85) in the SP group. Median ages were 69.8 (IQR = 65.2-73.6) and 67.1 (61.6-72.9), respectively, p = 0.17. Over a median follow up of 51.9 (15.8-86.1) and 80.4 (28.1-128.3) months for the TC and SP, overall, 12 (36.4%) TC devices were removed (four [12.1%] due to mechanical failures; eight [24.2%] erosions, and two [6.1%] infections) vs. 29 (55.8%) in the SP group (14 [26.9%] mechanical failures; 11 [21.1%] erosions, and five [9.6%] infections). No statistically significant differences were observed between the two approaches, with HR = 0.717, 95% CI 0.37-1.44, p = 0.35. The calculated device survival probabilities for the TC vs. SP at one, five, and 10 years were 78.8% vs. 76.9%, 69.3% vs. 58.7%, and 62.1% vs. 46.7%, respectively. CONCLUSIONS: TC cuff insertion for the first AUS implantation in pre-radiated patients showed to be comparable to SP when it comes to device survival, with comparable complication rates. Current guidance for approach selection is primarily based on patient selection and surgeon preference.

Pelvic radiation-induced urinary strictures: etiology and management of a challenging disease.

Radiation is a common treatment modality for pelvic malignancies. While it can be effective at cancer control, downstream effects can manifest months to years after treatment, leaving patients with significant morbidity. Within urology, a particularly difficult post-radiation consequence is urinary tract stricture, either of the urethra, bladder neck, or ureter. In this review, we will discuss the mechanism of radiation damage and treatment options for these potentially devastating urinary sequelae.

The Urologist and the Appendix: A Review of Appendiceal Use in Genitourinary Reconstructive Surgery.

Recently, genitourinary reconstruction has experienced a renaissance. Over the past several years, there has been an expansion of the literature regarding the use of buccal mucosa for the repair of complex ureteral strictures and other pathologies. The appendix has been an available graft utilized for the repair of ureteral stricture disease and has been infrequently reported since the early 1900s. This review serves to highlight the use of the appendix for reconstruction in urology, particularly focusing on the anatomy and physiology of the appendix, historical use, and current applications, particularly in robotic upper tract reconstruction.

The Expanding Use of Buccal Mucosal Grafts in Urologic Surgery.

The advent and success of buccal mucosal grafts as a substitution material in the urinary tract has changed the landscape of reconstructive urology. Due to its ease to harvest, low morbidity, and advantageous properties, there has been a growing number of applications for buccal mucosal grafts in upper and lower urinary tract reconstruction as well as genital reconstruction. In this article, we review the historical application and the evolution of buccal mucosal grafts and provide an up-to-date review on its utilization in urologic procedures.

Salvage Pelvic Lymph Node Dissection After Fluciclovine Positron Emission Tomography/Computed Tomography Detected Prostate Cancer Recurrence.

Background: Multiple new systemic agents have been targeted to metastatic prostate cancer, with decreased progression of disease but no cure. Surgical management of metastatic disease has been gaining interest, primarily in the setting of high-risk prostatectomies. However, metastasis-directed surgical intervention has been employed in rare scenarios, especially in oligometastatic disease. We report here on a salvage robot-assisted pelvic lymph node dissection for a solitary metastatic site. Case Presentation: A 63-year-old Hispanic man who was initially treated with prostatectomy for intermediate risk cancer developed rapid biochemical recurrence. After salvage radiation, fluciclovine positron emission tomography (PET)/computed tomography (CT) scan showed a solitary pelvic lymph node metastasis. A robot-assisted laparoscopic pelvic lymph node dissection was carried out, with subsequent nadir of his prostate-specific antigen at 0.026. Conclusion: To our knowledge, this is the first report of salvage pelvic lymph node dissection after metastatic detection by fluciclovine PET/CT scan. Our patient experienced a complete biochemical response; however, it remains to be seen whether this will be a lasting response. Surgical resection of metastatic sites in prostate cancer offers a safe alternative to systemic therapy and avoids systemic side effects.

Nonmetastatic Castration-resistant Prostate Cancer: A Modern Perspective.

Nonmetastatic castration-resistant prostate cancer (nmCRPC) presents a challenge to urologists as currently there are no Food and Drug Administration-approved therapies. However, there are new imaging modalities, including fluciclovine positron emission tomography-computed tomography and Ga-PSMA (prostate specific membrane antigent) positron emission tomography-computed tomography, which are improving accuracy of diagnosis. With improved imaging, we are better able to target therapy. Today there are 3 ongoing clinical trials studying second-generation antiandrogens in nmCRPC, which hold the promise of a new treatment paradigm. In this article, we will review the new imaging techniques and the rationale behind novel treatment modalities in nmCRPC.

The Representation of Women in Urological Leadership.

INTRODUCTION: While urology has historically been a male dominated field, the number of female urologists is increasing. In 2015 women made up 7.7% of practicing urologists and 17.1% of urologists younger than age 45 years. In the medical field overall females have been markedly underrepresented in leadership positions. We assess the current prevalence of women in urological leadership roles. METHODS: Using data from the Accreditation Council for Graduate Medical Education, and society and journal leadership boards, we compiled a list of editorial staff, boards of directors, department chairs and program directors in July 2016. Queried societies included the American Board of Urology, American Urological Association, Society of Genitourinary Reconstructive Surgeons, Societies for Pediatric Urology, Society of Urologic Oncology, Society of Academic Urologists, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, and the Large Urology Group Practice Association. Editorial boards examined were from The Journal of Urology® and Urology. We also included committee members who wrote American Urological Association guidelines between 2011 and 2016. RESULTS: Women represent 10% of leadership positions in the queried organizations and are underrepresented in advanced leadership positions. There were no women on the American Urological Association board of directors and women made up 1.6% of department chairs. Of the committees 76% included at least 1 woman. Overall, 75% of women on committees were urologists. By comparison, 95% of men on committees were urologists. CONCLUSIONS: Overall, women are fairly represented in a broad cross-section of leadership roles. Women are less well represented in the upper echelon of urological leadership, especially department chairs.

Subcutaneous emphysema following cystoscopic clot evacuation.

Gross hematuria is a common urologic problem which often requires surgical intervention. While generally a safe procedure, clot evacuation can have serious complications. Here we describe the case of an 85-year-old male who developed extensive subcutaneous emphysema following a small extraperitoneal bladder perforation during a clot evacuation. While our patient did well with expectant management, subcutaneous emphysema can lead to serious complications and any endourologic procedure should be stopped once crepitus is noted.

Histopathology in Ureteropelvic Junction Obstruction With and Without Crossing Vessels.

OBJECTIVE: To determine if the histopathology of the ureteropelvic junction differs between those with and without crossing vessels who present with a ureteropelvic junction obstruction (UPJO). MATERIALS AND METHODS: Our database was queried for patients undergoing pyeloplasty (Current procedural terminology 50400, 50405, and 50544) between June 1, 2002, and March 10, 2016. We excluded patients with other renal anatomic abnormalities and patients undergoing surgery for upper tract tumor. One genitourinary pathologist reviewed all slides for muscle hypertrophy, fibrosis, edema, and inflammation. Statistics were modeled in SAS 9.4 (SAS, Cary, NC) using logistic regression with maximum likelihood. RESULTS: A total of 178 patients met the inclusion criteria, and pathology slides were available for 136 patients. Thirty-three patients had crossing vessels in association with a UPJO. The degrees of muscle hypertrophy (P = .89) and fibrosis (P = .17) were not predictive of etiology. The odds of a crossing vessel increased by 4.3 times (95% confidence interval 1.8-9.9) when edema was present (P = .009) and by 4.4 (95% confidence interval 1.4-13.7) times when inflammation was present (P = .0103). CONCLUSION: In the largest pathology series to date, histopathology showed increased inflammation in the presence of a crossing vessel but a similar composition of muscle and fibrosis. These data suggest that UPJO with an associated lower-pole vessel may represent a chronic process, which would explain why patients with a crossing vessel present later in life.

Contralateral metachronous undescended testis: Is it predictable?

INTRODUCTION: Metachronous undescended testis (mcUDT), an acquired UDT after contralateral orchiopexy, can occur in some boys. If one were able to predict its occurrence, one might consider a proactive approach or at least one would be able to counsel the parents accordingly. Our hypothesis was there may be characteristics evident at the time of initial orchiopexy which could predict the development of contralateral mcUDT. OBJECTIVE: The aim was to Identify factors present at initial orchiopexy that predict development of subsequent mcUDT. STUDY DESIGN: Subjects were identified using the Current Procedural Terminology code for inguinal orchiopexy (54640). We included patients from January 1997 to October 2015. We included patients who underwent orchiopexy for unilateral UDT (uUDT). The study population consisted of patients who had undergone metachronous orchiopexies; controls were patients who were 17 years at time of data collection with a single orchiopexy. Cox proportional hazard regression was used to model the relationship between possible predictors of subsequent UDT using PROC PHREG with SAS Software 9.4. RESULTS: From 1035 eligible patients we identified 38 with mcUDT and 207 controls (uUDT). Median age at the first orchiopexy of mcUDT patients was 2.5 years (min/max, 0.50/10.4 years) and 8.2 years (min/max 0.70/12.8 years) for uUDT, p < 0.0001. Subjects with a contralateral retractile testis on preoperative exam had a 4.2 times higher rate of subsequent UDT than patients with a contralateral descended testis (95% CI 2.077-8.353). The rate of mcUDT was 6.7 times higher if the testis was a retractile testis under anesthesia (95% CI 2.7-16.5) (Table). DISCUSSION: Contralateral retractile UDT was a significant predictor of mcUDT. We believe patients with a contralateral retractile testis at time of orchiopexy should be counseled on bilateral orchiopexy. The risks of complications with orchiopexy should be weighed against risks of a subsequent surgery and anesthesia event. CONCLUSION: A discussion of risks and benefits regarding bilateral orchiopexies should be undertaken with the parents prior to surgery in the setting of an UDT with contralateral retractile testis.

Endourologic and Open Ureterolithotomy and Common Sheath Reimplant for Large Bladder and Distal Ureteral Calculi.

A twenty-eight-year-old female with a history of suprapubic pain and recurrent urinary tract infections presents for urology referral with a kidney, ureter, and bladder radiograph showing a 4.4 cm bladder calculus and 6.5 cm distal left ureteral stone. She underwent effective cystolitholapaxy of the bladder stone. Endourologic attempt (left ureteroscopy) was unsuccessful because of ureteral stone burden. Findings at ureteroscopy revealed a duplicated system on the left with the lower pole moiety joining just proximal to the ureteral orifice. The stone was found to be in the upper pole moiety ureter. An open ureterolithotomy was performed with intraoperative ureteroscopic laser lithotripsy and common sheath ureteral reimplant. Furthermore, a previously placed stent was found to be encrusted at the time of the ureterolithotomy. Effective ureteroscopy and lasering were performed through the ureterotomy up to the renal pelvis of the upper pole ureter.