Is There Any Benefit to the Use of Antibiotics with Indwelling Catheters after Urologic Surgery in Adults.

Antibiotic stewardship in urologic reconstruction is critically important, as many patients will require indwelling catheters for days to weeks following surgery and thus are at risk of both developing catheter-associated urinary tract infections (CAUTI) as well as multi-drug resistant (MDR) uropathogens. Accordingly, limiting antibiotic use, when safe, should help reduce antibiotic resistance and the prevalence of MDR organisms. However, there is significant heterogeneity in how antibiotics are prescribed to patients who need indwelling urethral catheters post-operatively. We performed a literature review to determine if there are benefits in the use of antibiotics for various clinical scenarios that require post-operative indwelling catheters for greater than 24 h. In general, for patients undergoing prostatectomy, transurethral resection of the prostate, and/or urethroplasty, antibiotic administration may be limited without increased risk of CAUTI. However, more work is needed to identify optimal antibiotic regimens for these and alternative urologic procedures, whether certain sub-populations benefit from longer courses of antibiotics, and effective non-antibiotic or non-systemic therapies.

Prescribing Trends in Post-operative Pain Management After Urologic Surgery: A Quality Care Investigation for Healthcare Providers.

OBJECTIVE: To assess prescribing and refilling trends of narcotics in postoperative urology patients at our institution. Although the opioid epidemic remains a public health threat, no series has assessed prescribing patterns across urologic surgery disciplines following discharge. METHODS: All urologic surgeries were retrospectively reviewed from May 2017-April 2018. Demographics, comorbidities, and postoperative pain management strategies were analyzed. Narcotics usage following surgery were reported in total morphine equivalents (TME). Opioid refill rate was characterized by medical specialty and stratified by urologic discipline. RESULTS: 817 cases were reviewed. Mean age and TME at discharge was 57±15.6 years and 35.43±19.5 mg, respectively. 13.6% (mean age 55±15.9) received a narcotic refill following discharge (mean TME/refill 37.7±28.9 mg). A higher proportion of patients with a pre-operative opioid prescription received a refill compared to opioid naïve patients (38.2% vs 21.6%, P < .01). Refill rate did not differ between urologic subspecialties (P = .3). Urologists were only responsible for 20.4% of all refills filled, despite all patients continuing follow-up with their surgeon. Procedures with the highest rates of post-operative refills were in oncology, male reconstruction/trauma and endourology. Patients with a history of chronic pain (OR 1.9, CI 1.1-3.3) preoperative narcotic prescription (OR 1.6, CI 1.0-2.6), and higher ASA score (OR 1.8, CI 1.6-2.8) were more likely to obtain a postoperative opioid prescription refill. CONCLUSION: Approximately 1 in 7 postoperative urology patients receive a postoperative narcotics refill; however, nearly two-thirds receive refills exclusively from non-urologic providers. Attempts to avoid overprescribing of postoperative narcotics need to account for both surgeon and nonsurgeon sources of opioid refills.

A Critical Appraisal of the American College of Surgeons Medically Necessary, Time Sensitive Procedures (MeNTS) Scoring System, Urology Consensus Recommendations and Individual Surgeon Case Prioritization for Resumption of Elective Urological Surgery During the COVID-19 Pandemic.

PURPOSE: Resumption of elective urology cases postponed due to the COVID-19 pandemic requires a systematic approach to case prioritization, which may be based on detailed cross-specialty questionnaires, specialty specific published expert opinion or by individual (operating) surgeon review. We evaluated whether each of these systems effectively stratifies cases and for agreement between approaches in order to inform departmental policy. MATERIALS AND METHODS: We evaluated triage of elective cases postponed within our department due to the COVID-19 pandemic (March 9, 2020 to May 22, 2020) using questionnaire based surgical prioritization (American College of Surgeons Medically Necessary, Time Sensitive Procedures [MeNTS] instrument), consensus/expert opinion based surgical prioritization (based on published urological recommendations) and individual surgeon based surgical prioritization scoring (developed and managed within our department). Lower scores represented greater urgency. MeNTS scores were compared across consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores. RESULTS: A total of 204 cases were evaluated. Median MeNTS score was 50 (IQR 44, 55), and mean consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores were 2.6±0.6 and 2.2±0.8, respectively. Median MeNTS scores were 52 (46.5, 57.5), 50 (44.5, 54.5) and 48 (43.5, 54) for individual surgeon based surgical prioritization priority 1, 2 and 3 cases (p=0.129), and 55 (51.5, 57), 47.5 (42, 56) and 49 (44, 54) for consensus/expert opinion based surgical prioritization priority scores 1, 2, and 3 (p=0.002). There was none to slight agreement between consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores (Kappa 0.131, p=0.002). CONCLUSIONS: Questionnaire based, expert opinion based and individual surgeon based approaches to case prioritization result in significantly different case prioritization. Questionnaire based surgical prioritization did not meaningfully stratify urological cases, and consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization frequently disagreed. The strengths and weaknesses of each of these systems should be considered in future disaster planning scenarios.

Persistent Lower Urinary Tract Symptoms After Prostatic Urethral Lift Successfully Treated with Water Jet Ablation of the Prostate: A Case Report and Review of the Literature.

Background: We describe a patient who underwent waterjet ablation of the prostate after an unsuccessful prostatic urethral lift (PUL) procedure. Case Presentation: After PUL, our patient had incomplete bladder emptying with a postvoid residual of 600 mL. Urodynamic study of the bladder suggested detrusor underactivity. Our patient was motivated to undergo a salvage bladder outlet surgery. At 3 months after Aquablation, he reported complete resolution of bothersome lower urinary tract symptoms (LUTS). Conclusion: This case report illustrates return of volitional voiding and significant improvement in LUTS after salvage bladder outlet treatment with waterjet ablation of the prostate.

A Modern Comparison of Urodynamic Findings in Diabetic Versus Nondiabetic Women.

OBJECTIVES: Few contemporary studies exist regarding urodynamic (UDS) findings in patients with diabetes mellitus (DM), and data are conflicting. Our aim was to compare UDS findings in women with and without DM. METHODS: Data from female patients in a prospectively maintained UDS database (2010-2014) were reviewed. Studies were performed according to International Continence Society standards. Clinical data, presenting symptoms, and UDS findings were compared in women with and without DM, controlling for demographic and pertinent variables. RESULTS: There were 384 patients who met the inclusion criteria, of whom 88 (26%) had DM. Symptoms at presentation were not statistically different in women with and without DM. Women with DM had larger bladder capacity (mean, 493 mL vs 409 mL; P = 0.005) and had more detrusor underactivity (30% vs 18%, P = 0.042) when compared with nondiabetic women. Diabetic women were more frequently diagnosed as having impaired sensation, or lack of desire to void, at 75% of capacity (17% vs 5%, P = 0.001). In women with diabetes, a serum hemoglobin A1c level of at least 7.5% was associated with delayed first sensation and first urge. Diagnosis of DM of more than 10 years was associated with greater volume at first urge, and maximal capacity, lower detrusor pressures, and higher postvoid residual. CONCLUSIONS: In this contemporary series, women with DM demonstrated similar presenting complaints to women without DM but had significantly altered UDS findings. Among diabetic female patients, diabetes control and duration of diabetes seem to impact bladder sensation and contractility. Urodynamics may be helpful in diabetic female patients to diagnose underlying concealed bladder dysfunction before initiation of treatment.

Management of Occult Urinary Incontinence with Prolapse Surgery.

PURPOSE OF REVIEW: The purpose of this paper is to review (1) the epidemiology and pathophysiology of pelvic organ prolapse (POP) and occult stress urinary incontinence (SUI), (2) examine the data on combined operative management of POP and occult SUI, (3) discuss the approaches to clinical decision making, and (4) present future therapies. RECENT FINDINGS: Prospective data on many approaches to concomitant treatment of prolapse and occult stress urinary incontinence, such as minimally invasive sacrocolpopexy and midurethral sling, or older approaches that have regained favor among patients and clinicians wishing to avoid synthetic mesh, such as native tissue prolapse repair and pubovaginal sling, are limited. Safe durable treatments with absorbable graft materials that promote a beneficial host response are intriguing but may be far from clinical implementation. Stem cell therapy for the treatment of stress urinary incontinence has demonstrated benefit in phase I/II trials but has not been studied in the setting of concomitant treatment of occult SUI with POP surgery and remains in the preclinical phase for the treatment of POP. A personalized approach to concomitant SUI surgery that incorporates individual risk assessment as well as informed patient preferences likely optimizes the risk/benefit ratio and patient satisfaction. Novel therapies, including graft materials and cellular therapies that stimulate a regenerative response, may improve or maintain continence outcomes while mitigating risk and alter the approach to both POP and SUI surgery.

Assessment of practices in screening and treating women with bacteriuria.

INTRODUCTION: Evidence-based screening and treatment for bacteriuria is crucial to prevent increasing antibiotic resistance. The Infectious Disease Society of America (IDSA) previously released guidelines on the management of asymptomatic bacteriuria (ASB) and uncomplicated urinary tract infections (UTIs) in women. The study's objective was to assess physicians' practices in managing women with bacteriuria relative to these guideline recommendations. MATERIALS AND METHODS: Cross-sectional data from physicians were collected using an anonymous questionnaire. Multivariable logistic regression analyses identified independent predictors of adherence to guidelines. RESULTS: Data were collected from 260 physicians. Over half of physicians surveyed were unfamiliar with IDSA guidelines and overtreat ASB. Variables independently associated with overtreatment of ASB included a non-academic practice and practicing as an OBGYN. Nearly one third (30.1%) of physicians reported prescribing an antibiotic other than a recommended first-line agent for uncomplicated cystitis. Relative to internists, OBGYNs and urologists were more likely to prescribe a recommended first-line agent to women with uncomplicated cystitis. Of those who correctly selected a first-line agent, 29.8% prescribed a longer than recommended duration of therapy. IDSA guideline awareness was not associated with physicians' practices in managing women with bacteriuria. CONCLUSIONS: Most physicians surveyed were unfamiliar with guidelines related to managing ASB and uncomplicated UTIs in women, likely contributing to overscreening and overtreatment of ASB and the use of inappropriate antibiotic regimens in treating uncomplicated cystitis. However, optimal antibiotic prescribing was not associated with knowledge of IDSA guidelines, suggesting that guideline dissemination alone may not alter practice patterns among physicians managing women with bacteriuria.

Painful Bladder Symptoms Related to Somatic Syndromes in a Convenience Sample of Community Women with Overactive Bladder Symptoms.

PURPOSE: We investigated the relationship of painful bladder filling and urinary urgency to somatic and chronic pain symptoms in women with overactive bladder without an interstitial cystitis/bladder pain syndrome diagnosis. MATERIALS AND METHODS: Women who met overactive bladder criteria based on symptoms were recruited, including 183 (83.9%) from the community and 35 (16.1%) from the urology clinic to complete validated questionnaires assessing urinary symptoms, somatic symptoms and pain syndromes. Participants were categorized into 1 of 3 groups, including 1) neither symptom, 2) either symptom or 3) both symptoms, based on their reports of painful urinary urgency and/or painful bladder filling. Multivariable regression analyses were performed to determine factors predictive of having painful urgency and/or painful filling. RESULTS: Of 218 women with overactive bladder 101 (46%) had neither painful bladder filling nor urinary urgency, 94 (43%) had either symptom and 23 (11%) had both symptoms. When controlling for age, women with either or both urological pain symptoms were more likely to have irritable bowel syndrome, chronic pelvic pain and temporomandibular disorder than women in the neither group. Additionally, these women had higher pain intensity and somatic symptoms scores than women with neither symptom. CONCLUSIONS: The majority of women with overactive bladder who had not been diagnosed with interstitial cystitis/bladder pain syndrome reported painful urgency and/or painful filling. Experiencing painful urgency and/or filling was associated with an increased somatic symptom burden and greater pain intensity. These findings support the hypothesis that overactive bladder and interstitial cystitis/bladder pain syndrome diagnoses may represent a continuum of bladder hypersensitivity.

Road to recovery after transvaginal surgery for urethral mesh perforation: evaluation of outcomes and subsequent procedures.

INTRODUCTION AND HYPOTHESIS: Urethral injury resulting from transvaginal mesh slings is a rare complication with an estimated incidence of <1%. Our objective was to review the surgical management and functional outcomes of women presenting with urethral mesh perforation following midurethral sling (MUS) placement. METHODS: This was a retrospective multicenter review of women who from January 2011 to March 2016 at two institutions underwent mesh sling excision for urethral perforation with Female Pelvic Medicine and Reconstructive Surgery fellowship-trained surgeons. Data comprising preoperative symptoms, operative details, and postoperative outcomes were collected by telephone (n 13) or based on their last follow-up appointment. RESULTS OBTAINED: Nineteen women underwent transvaginal sling excision for urethral mesh perforation. Eight (42%) patients had undergone previous sling revision surgery. Sixty percent of women had resolution of their pelvic pain postoperatively. At follow-up, 92% reported urinary incontinence (UI), and three had undergone five additional procedures for vaginal prolapse mesh exposure (n 1), incontinence (onabotulinum toxin injection n 1, rectus fascia autologous sling n 1), prolapse (colpopexy n 1), and pain (trigger-point injection n 1). Patient global impression of improvement data was available for 13 patients, of whom seven (54%) rated their postoperative condition as Very much better or Much better. CONCLUSIONS: The management of urethral mesh perforation is complex. Most women reported resolution of their pelvic pain and a high rate of satisfaction with their postoperative condition despite high rates of incontinence.

Postoperative Complications of Patients With Spina Bifida Undergoing Urologic Laparotomy: A Multi-institutional Analysis.

OBJECTIVE: To characterize perioperative morbidity and mortality in adult patients with spina bifida undergoing laparotomy. PATIENTS AND METHODS: We retrospectively studied the postoperative complications of 59 operations of patients with spina bifida undergoing abdominal laparotomies for urologic indications at 3 institutions. We evaluated postoperative complications using the Clavien-Dindo classification scale. RESULTS: The overall complication rate was 91.5%. The most common complications were ileus, pressure ulcers, urinary tract infection, and wound infection. Over 40% of the patients developed a class 3 or 4 complication requiring subsequent surgery or intensive care unit admission. The hospital readmission rate was 42% and was correlated with higher-grade complications. On multivariable analysis, only older age was significantly associated with grade of complication. CONCLUSION: These data demonstrate that adult patients with spina bifida comprise a unique population that faces an extremely high surgical risk even in centers of excellence. As patients with spina bifida live longer lives, thanks to modern medicine, there is a timely opportunity for research on perioperative management in these patients to improve postsurgical outcomes.

Management of Voiding Dysfunction After Female Neobladder Creation.

PURPOSE OF REVIEW: Functional complications after orthotopic neobladder urinary diversion (ONB), including urinary incontinence and urinary retention, present unique challenges. The purpose of this review is to outline contemporary treatment options for voiding dysfunction after ONB in females. RECENT FINDINGS: Meticulous surgical technique in the form of urethral nerve-sparing has been shown to play an important role in maintaining continence, as has sparing the uterus when possible. Data supporting the effectiveness of lifestyle measures, urethral bulking, pubovaginal slings, and transobturator slings in the treatment of urinary incontinence are widely variable and limited to case reports. Urinary retention is still most effectively managed with self-catheterization. Voiding dysfunction after ONB can be devastating. Recent advances focus on improving surgical techniques to decrease the risk of incontinence and retention, as post-operative management options are limited.

Treatment of Pelvic Floor Disorders Following Neobladder.

Radical cystectomy remains the gold standard treatment for organ-confined high-grade recurrent or muscle-invasive bladder cancer. Orthotopic neobladder urinary diversion following cystectomy represents an option for patients wishing for continent urinary diversion. Female patients who undergo radical cystectomy with orthotopic bladder substitution are at risk for developing both common and neobladder-specific disorders of the pelvic floor, including urinary incontinence, hypercontinence, vaginal prolapse, and neobladder-vaginal fistula. Each of these sequelae can have significant impact on the patient's quality of life. Due to the increased frequency of orthotopic neobladder creation in women, subspecialty urologists are more likely to confront such pelvic floor disorders in bladder cancer survivors. This review presents the most current information on the treatment of pelvic floor disorders after orthotopic bladder substitution.

Phenotyping women with detrusor underactivity by presumed etiology: Is it plausible?

AIMS: Underactive bladder (UAB) is a symptom complex with poorly characterized causation. The aim of this study was to determine if clinical and UDS parameters differed between categories of presumed detrusor underactivity (DU) etiologies. METHODS: A retrospective review was performed at a single institution from 2011 to 2015 to identify patients with symptoms of UAB. Patients were excluded if they were male, had anti-incontinence, or pelvic organ prolapse (POP) surgery within 1 year, or the UDS did not demonstrate DU as defined within. Subjects were stratified by etiology into four cohorts: cardiovascular disease manifestations (CV), cardiac risk factors (CVR), neurologic (N), or idiopathic (I). Patient demographics, comorbidities, symptomatology, physical exam, and UDS parameters were compared. RESULTS: A total of 200 patients met inclusion criteria (CV: n = 53 [26.5%], CVR: n = 44 [22%] N: n = 81 [40.5%], I: n = 22 [11%]). Women in the CV cohort were significantly older and more likely to be post-menopausal (P < 0.001). There were no differences between cohorts for BMI (P = 0.48), recurrent UTI (P = 0.63), history of urinary retention (AUR) (P = 0.65), POP (0.49), American Urological Association Symptom Score (AUA-SS) (P = 0.06), presenting symptomatology [urgency, frequency, urgency urinary incontinence, AUR, incomplete emptying, hesitancy, UTI (P = 0.97)], or UDS parameters (first sensation [P = 0.25], normal desire [P = 0.80], strong desire [P = 0.58], capacity [P = 0.11], Qmax [P = 0.50], Pdet at Qmax [P = 0.22], post-void residual [P = 0.82]). CONCLUSIONS: Though differences were observed between cohorts for age and menopausal status, clinical or urodynamic parameters did not demonstrate distinct differences across presumed categories of etiology, suggesting that the etiology of DU may be multifactorial. Neurourol. Urodynam. 36:1151-1154, 2017. © 2016 Wiley Periodicals, Inc.

Assessing variability of the 24-hour pad weight test in men with post-prostatectomy incontinence.

PURPOSE: Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity. MATERIALS AND METHODS: 25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used. RESULTS: Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74-0.93), p<0.001). The mean difference between the minimum pad weight leakage and maximum leakage per patient was 133.4g (95% CI 80.4-186.5). The mean increase in 24-hour leakage for a one-point increase in self-reported activity level was 118.0g (95% CI 74.3-161.7, p<0.001). Pad weights also varied significantly when self-reported activity levels did not differ (mean difference 51.2g (95% CI 30.3-72.1), p<0.001). CONCLUSIONS: 24-hour pad weight leakage may vary significantly on different days of collection. This variation is more pronounced with changes in activity level. Taking into account patient activity level may enhance the predictive value of pad weight testing.

Assessing variability of the 24-hour pad weight test in men with post-prostatectomy incontinence

ABSTRACT Purpose: Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity. Materials and Methods: 25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used. Results: Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74–0.93), p<0.001). The mean difference between the minimum pad weight leakage and maximum leakage per patient was 133.4g (95% CI 80.4–186.5). The mean increase in 24-hour leakage for a one-point increase in self-reported activity level was 118.0g (95% CI 74.3–161.7, p<0.001). Pad weights also varied significantly when self-reported activity levels did not differ (mean difference 51.2g (95% CI 30.3–72.1), p<0.001). Conclusions: 24-hour pad weight leakage may vary significantly on different days of collection. This variation is more pronounced with changes in activity level. Taking into account patient activity level may enhance the predictive value of pad weight testing.

Use of Botulinum Toxin A in the Treatment of Lower Urinary Tract Disorders: A Review of the Literature.

Botulinum neurotoxin (BoNT) is used to treat a variety of ailments, and its therapeutic application in lower urinary tract disorders (LUTDs) is well studied. Robust evidence supporting the efficacy and tolerability of BoNT in the treatment of neurogenic detrusor overactivity (NDO) and non-neurogenic overactive bladder (OAB) has led to regulatory approval for these conditions. Use of BoNT in the treatment of interstitial cystitis/bladder pain syndrome, chronic pelvic pain, and detrusor sphincter dyssynergia has demonstrated some promise, but is still evolving and off-label for these indications. Trials to date do not support the use of BoNT for benign prostatic hyperplasia. This comprehensive review outlines the mechanisms of BoNT in the treatment of LUTDs in adults and presents background and updated data examining the efficacy and adverse events associated with the use of BoNT in common urologic applications.

Urinary tract infection-like symptom is associated with worse bladder cancer outcomes in the Medicare population: Implications for sex disparities.

OBJECTIVES: To determine the time to bladder cancer diagnosis from initial infection-like symptoms and its impact on cancer outcomes. METHODS: Using Surveillance, Epidemiology and End Results-Medicare, we designed a retrospective cohort study identifying beneficiaries aged ≥ 66 years diagnosed with bladder cancer from 2007 to 2009. Patients were required to have a hematuria or urinary tract infection claim within 1 year of bladder cancer diagnosis (n = 21 216), and have 2 years of prior Medicare data (n = 18 956) without any precedent hematuria, bladder cancer or urinary tract infection claims (n = 12 195). The number of days to bladder cancer diagnosis was measured, as well as the impact of sex and presenting symptom on time to diagnosis, pathology, and oncological outcomes. RESULTS: The mean time to bladder cancer diagnosis was 72.2 days in women versus 58.9 days in men (P < 0.001). A logistic regression model identified the greatest predictors of ≥ pT2 pathology were both women (odds ratio 2.08, 95% confidence interval 1.70-2.55) and men (odds ratio 1.71, 95% confidence interval 1.49-1.97) presenting with urinary tract infection. Cox proportional hazards analysis identified an increased risk of mortality from bladder cancer and all causes in women presenting with urinary tract infection (hazard ratio 1.37, 95% confidence interval 1.10-1.71, and hazard ratio 1.47, 95% confidence interval 1.28-1.69) compared with women with hematuria. CONCLUSIONS: Women have a longer interval from urinary tract infection to diagnosis of bladder cancer. Urinary tract infection presentation can adversely affect time to diagnosis, pathology and survival. Time to diagnosis seems not to be an independent predictor of bladder cancer outcomes.

Robot-assisted Laparoscopic Augmentation Ileocystoplasty and Mitrofanoff Appendicovesicostomy in Children: Updated Interim Results.

BACKGROUND: Robot-assisted laparoscopic augmentation ileocystoplasty with Mitrofanoff appendicovesicostomy (RALIMA) may protect the upper urinary tract and reestablish continence in patients with refractory neurogenic bladder. Robotic assistance can provide the benefits of minimally invasive surgery without the steep learning curve of pure laparoscopy. OBJECTIVE: To highlight the interim outcomes of RALIMA with salient tips and technical modifications through comparison with patients undergoing open augmentation ileocystoplasty (OAI). DESIGN, SETTINGS, AND PARTICIPANTS: A retrospective chart review of 17 patients undergoing robot-assisted laparoscopic augmentation ileocystoplasty (RALI) and 13 patients undergoing OAI by a single surgeon at an academic center from 2008 to 2012 (OAI) or 2014 (RALI). SURGICAL PROCEDURE: RALI and all concomitant procedures were performed completely intracorporeally using the da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Outcomes of interest included change in bladder capacity, operative time, pain medication use, hospitalization time, and perioperative complication rates. RESULTS AND LIMITATIONS: Of 17 patients selected, 15 successfully underwent RALI. Overall, 11, 6, and 4 patients had a concomitant Mitrofanoff appendicovesicostomy, antegrade colonic enema channel, and bladder neck closure, respectively. The median operative time was significantly longer in RALI (623 vs 287 min; p<0.01). Median length of stay (LOS) was shorter in RALI (6 vs 8 d; p=0.01). The postoperative percentage increase in bladder capacity, narcotic use, and complication rates did not differ between RALI and OAI. Limitations include the retrospective study design and the small cohort of patients. CONCLUSIONS: RALI appears to offer functional outcomes similar to OAI. Although it is a significantly longer procedure, it may decrease LOS and avoid epidural use. Further refinements may reduce operative time. PATIENT SUMMARY: In this report, we examined outcomes after robotic bladder augmentation surgery in children. We found that the robotic approach may eliminate epidural analgesia use and decrease hospitalization time after surgery.

Buccal mucosal graft urethroplasty for the treatment of urethral stricture in the neophallus.

OBJECTIVE: To present our operative approach and outcomes with buccal mucosal graft urethroplasty for anastomic stricture in the neophallus. METHODS: All patients who underwent buccal mucosal graft urethroplasty by a single surgeon for urethral stricture in a neophallus between March 1998 and June 2013 were identified. Urethroplasties were performed using 1-stage ventral onlay buccal mucosal graft after incision of the stricture. RESULTS: Ten patients were included in analysis. One patient underwent creation of neophallus after trauma, whereas all others were performed as gender reassignment. In all patients, strictures were located at the anastomosis between the native and the neourethra. Mean age was 39 years (range, 26-56 years). Mean stricture length was 3.6 cm (range, 2-6 cm). Median follow-up was 9.5 months (range, 2.7-84 months). At last follow-up, all the first 3 patients had stricture recurrence, whereas 5 of the next 7 patients remained free of stricture (overall success rate, 50%). A total of 11 follow-up procedures were performed for recurrent strictures in these patients, including 8 internal urethrotomies, 1 suprapubic tube placement, and 2 repeat urethroplasties. The only perioperative complication was a patient who experienced mild rhabdomyolysis, which resolved with supportive measures. CONCLUSION: Experience with urethral strictures in the neophallus is limited, and management is complex. Buccal mucosal graft urethroplasty may be more effective than endoscopic management, but failure remains common. Modifications in surgical approach and experience may improve outcomes.