Outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction.

OBJECTIVE: To evaluate the early and late outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction (LUTD). MATERIALS AND METHODS: The charts of patients with refractory non-malignant LUTD who underwent continent or incontinent external urinary diversion at University of Cincinnati hospitals in the period between March 2012 and December 2019 were retrospectively reviewed. The demographic and baseline characteristics, surgery indications, operative data, early and late outcomes were collected, analyzed, and compared. RESULTS: A total of 78 patients including 55 patients with neurogenic bladder (NGB) and 23 patients with non-neurogenic bladder (non-NGB) refractory non-malignant LUTD were included. Fifty-three patients underwent incontinent urinary diversions (IUD), while 25 patients underwent continent urinary diversions (CUD). During the first 4 postoperative weeks, 53.85% (n=42) of patients developed complications, and the incidence was nonsignificantly higher in patients with NGB than those with non- NGB (56.36% vs 47.83%, p-value=0.490). Fever was exclusively encountered in patients with NGB earlier, while stomal retraction occurred only in patients with non-NGB later. More non- NGB patients had early wound infection. There was an overall improvement of urological symptoms in 52 patients (66.67%), and the rate was non-significantly higher in non-NGB patients than NGB patients (78.26% vs 61.82%, p-value=0.160). Late complications were reported in 47 patients and were more encountered in those with non-NGB than those with NGB (65.22% vs 58.18%). Stomal leakage and stenosis occurred more with CUD than with IUD (52% vs 0% and 28% vs 3.77%, respectively). CONCLUSIONS: External urinary diversion can achieve a reasonable level of urological symptoms control in patients with refractory non-malignant LUTD, but with associated adverse outcomes. Although non-significantly, these complications tend to be higher in patients with IUD and/or NGB during the early postoperative period and higher with CUD and/or non-NGB on the long-term.

Is Holmium Laser Enucleation of Prostate equally effective in management of benign prostatic hyperplasia patients with either voiding or storage lower urinary tract symptoms? A comparative study.

OBJECTIVE: To evaluate and compare the effectiveness and safety of holmium laser enucleation of prostate (HoLEP) in relieving either voiding or storage lower urinary tract symptoms (LUTS) in benign prostatic hyperplasia (BPH) patients. MATERIALS AND METHODS: The charts of patients with BPH who underwent HoLEP for either predominant voiding or predominant storage LUTS at University of Cincinnati hospitals in the period between February 2015 and December 2020 were retrospectively reviewed and analyzed for changes in voiding symptomatology, storage symptomatology, hematuria, International Prostate Symptom Score (IPSS), peak flow rates (Qmax), presence of detrusor overactivity (DO), and post-voiding residual urine (PVR) from baseline to up to 6 months postoperatively. RESULTS: A total of 132 patients were included in the analysis. Patients were divided into two groups: Group 1 included BPH patients with predominant voiding LUTS (68 Patients) while group 2 involved those with predominant storage LUTS (64 Patients). HoLEP was equally effective in management of both groups with significant improvement in urodynamics study (UDS) parameters, patient voiding and storage symptomatology, and IPSS from preoperatively to up to 6 months postoperatively with relatively low procedure complication rate and postoperative need for medication or procedure. CONCLUSIONS: HoLEP is a safe, effective, and reliable minimally invasive surgical modality that can be relied on for BPH patients with either predominant voiding or predominant storage symptoms with relatively low procedure complicat.

Early Postoperative Complications and Factors Associated with Early vs Late Discharge of Patients Undergoing Colporrhaphy for Pelvic Organ Prolapse: A National Report.

INTRODUCTION: Pelvic organ prolapse is a highly prevalent condition that is commonly managed with surgical intervention. Our purpose was to determine associated factors and postoperative morbidity rates of early (≤1 day) vs late (>1 day) hospital discharge after outpatient colporrhaphy. METHODS: From the National Surgical Quality Improvement Program® database, 11,652 female patients who received colporrhaphy between 2005 and 2016 were identified; 3,728 were stratified into the early discharge group and 7,924 into the late discharge group. Patient characteristics, surgical data and 30-day postoperative complications were recorded, and variables were compared between groups. RESULTS: In comparison to the late discharge group, the early discharge group had a shorter mean operating time (p <0.001) and overall was less likely to suffer from 30-day morbidity (OR 0.67 [95% CI 0.55-0.82]), reoperation (OR 0.59 [95% CI 0.39-0.90]) or readmission (OR 0.40 [95% CI 0.26-0.90]). Factors independently associated with a lower likelihood of early discharge included age ≥55 years, higher body mass index, White race, current smoker, American Society of Anesthesiologists® classification IV/V and longer operating time. Increased likelihood of early discharge was associated with receiving colporrhaphy after 2012 and posterior colporrhaphy. CONCLUSIONS: Patients discharged from the hospital early had lower rates of postoperative morbidity than those discharged later. Early discharge was associated with procedures performed after 2012 and with isolated posterior colporrhaphy. Longer hospital stays were associated with longer operating times and older age, White race, obesity, comorbidities and history of smoking.

Postoperative Urinary Retention in Patients Who Undergo Joint Arthroplasty or Spine Surgery.

Postoperative urinary retention (POUR) may result from orthopaedic procedures and potentially lead to bacteremia and chronic voiding difficulties. Risk factors for POUR include age, undergoing joint arthroplasty, male sex, intraoperative intravenous fluid administration, operative time, and history of benign prostatic hyperplasia. Indwelling catheterization is the preferred management strategy for patients at risk for developing POUR. A consistent definition of POUR is needed in order to draw conclusions from future studies.

Biochemical Recurrence in Prostate Cancer and Temporal Association to Bone Metastasis.

BACKGROUND Prostate cancer is a common cancer in men. Radical prostatectomy, i.e., the surgical removal of the entire prostate, is a frequently used option. Biochemical recurrence (BCR), i.e., detectable prostate specific antigen (PSA), is common in some men following such treatment. The timing of BCR to metastatic spread of disease in bones is usually a few years. If the biochemical failure occurs after a longer duration from the time of curative intent, it is generally believed to lead to local recurrence. CASE REPORT We report on two cases. A 78-year-old male was diagnosed with Gleason 7, prostate cancer in 2001. He subsequently underwent an open radical prostatectomy. Serial post-operative PSA's were undetectable (<0.01 ng/mL) up to 2016. He was diagnosed with a detectable PSA for the first time with a value of 0.3 ng/mL, that year. The PSA continued to rise to a level of 1.1 ng/mL. This rise in the PSA was within a 12-month interval. Subsequent bone scan and bone biopsy detected prostate cancer metastasis in multiple bones. Our second case was a 65-year-old male who underwent a laparoscopic radical prostatectomy in the year 2006 for a biopsy proven prostate cancer with Gleason 3+4=7. Serial post-operative PSA's were undetectable up to 2017. Within a span of 8 months, the PSA rose from 0.3 ng/mL to 1.52 ng/mL. A positron emission tomography scan demonstrated pubic bone lesion indicative of prostate cancer metastasis. CONCLUSIONS BCR can occur a decade after curative intent treatment of prostate cancer. The duration from BCR to detectable metastasis can be shorter. We demonstrated here that the site of recurrence, in such scenarios, can be distant metastasis and not local recurrence alone. Better imaging modalities are needed to identify the spread of prostate cancer at low levels of PSA.

Vaginal Approach to Excise a Rare Paraurethral Leiomyoma.

Leiomyomas are benign tumors of smooth muscle origin occurring throughout the genitourinary system. While leiomyomas in the uterus are frequently seen, urethral and paraurethral leiomyomas are extremely rare with a hand full of cases in the literature. Typically, periurethral leiomyomas can present with a mass protruding from the urethra originating from the proximal and posterior portion of the urethra. Herein, we present a new case of a paraurethral leiomyoma causing mass effect on the bladder leading to lower urinary tract symptoms (LUTS) with no gross involvement of the urethra.

Operative Management of Crossover Femoral-femoral Graft Erosion into Bladder: A Case Report.

Erosion of vascular grafts is not uncommon as seen in the recent literature. There have been many case reports documenting the work up and management of erosion of these grafts into bowel. We report a case of a crossover femoral-femoral graft that eroded into the anterior bladder wall and was incidentally found as an adherent bladder stone during cystoscopy. We demonstrate the importance of having a high level of clinical suspicion for eroding vascular grafts when preoperative imaging shows close proximity of graft to bladder.

The outcome of transobturator anterior vaginal wall prolapse repair using porcine dermis graft: intermediate term follow-up.

INTRODUCTION AND HYPOTHESIS: We evaluated the anatomical success and complications of Perigee® with porcine dermis Graft in the repair of anterior vaginal wall prolapse (AVWP) MATERIALS AND METHODS: After Institutional Review Board (IRB) approval, the charts of all patients who underwent AVWP repair using the Perigee/InteXen® kit from July 2005 to July 2009 were reviewed. Patients who had less than 6-month follow-up were excluded. Preoperative data including patient age, previous AVWP repairs, hysterectomy status, preoperative dyspareunia and pertinent physical findings were collected and recorded. Postoperative success was defined as anatomical stage 0 or I using the Pelvic Organ Prolapse Quantification (POP-Q) scoring system. Graft related complications were also recorded. RESULTS: Out of 89 patients, 69 completed at least 6-month follow-up. Median follow-up was 13 (6-48) months. Seventeen patients (25%) had previous AVWP repair and 32 (46%) had previous hysterectomy. Preoperatively, AVWP stage II was found in 9 (13%), stage III in 27 (39%) and stage IV in 33 (48%) patients. Anatomic success was found in 48 (69%) patients, with 23 (33%) having stage 0 and 25 (36%) stage I AVWP. Intraoperative complications included incidental cystotomy in one patient and bladder perforation in one. Postoperative complications included vaginal exposure and dyspareunia in one case, wound dehiscence in one and tenderness over the graft arm with dyspareunia in one. CONCLUSIONS: The use of porcine dermis in AVWP repair is safe with minimal graft related complications; however, anatomical success is lower than that reported with the use of synthetic grafts.

The outcome of transobturator anterior vaginal wall prolapse repair using porcine dermis graft: intermediate term follow-up

Introduction and Hypothesis We evaluated the anatomical success and complications of Perigee® with porcine dermis Graft in the repair of anterior vaginal wall prolapse (AVWP) Materials and Methods After Institutional Review Board (IRB) approval, the charts of all patients who underwent AVWP repair using the Perigee/InteXen® kit from July 2005 to July 2009 were reviewed. Patients who had less than 6-month follow-up were excluded. Preoperative data including patient age, previous AVWP repairs, hysterectomy status, preoperative dyspareunia and pertinent physical findings were collected and recorded. Postoperative success was defined as anatomical stage 0 or I using the Pelvic Organ Prolapse Quantification (POP-Q) scoring system. Graft related complications were also recorded. Results Out of 89 patients, 69 completed at least 6-month follow-up. Median follow-up was 13 (6-48) months. Seventeen patients (25%) had previous AVWP repair and 32 (46%) had previous hysterectomy. Preoperatively, AVWP stage II was found in 9 (13%), stage III in 27 (39%) and stage IV in 33 (48%) patients. Anatomic success was found in 48 (69%) patients, with 23 (33%) having stage 0 and 25 (36%) stage I AVWP. Intraoperative complications included incidental cystotomy in one patient and bladder perforation in one. Postoperative complications included vaginal exposure and dyspareunia in one case, wound dehiscence in one and tenderness over the graft arm with dyspareunia in one. conclusions The use of porcine dermis in AVWP repair is safe with minimal graft related complications; however, anatomical success is lower than that reported with the use of synthetic grafts. .

Urinary tract injury at the time of laparoscopic and robotic surgery: presentation and management.

OBJECTIVE: To report a series of urinary tract injuries resultant of laparoscopic or robotic procedures performed for a gynecologic indication. METHODS: We identified 16 patients with urinary tract fistulas after laparoscopic or robotic gynecologic procedures between 2009 and 2012. We extracted demographic data and prior surgical data as well as reviewed our management of each case. RESULTS: Thirteen subjects had undergone robotic procedures, 2 traditional laparoscopies, and a single-port laparoscopy with time to presentation from 2 days to 9 months postoperatively. Seven patients presented with vesicovaginal fistulas (43%), of which one healed spontaneously. Eight patients had ureterovaginal fistulas. Two patients (25%) were managed with ureteroneocystotomy, 2 patients (25%) were managed with Boari flap, and 4 patients (50%) were managed with double-J stent placement. One patient had a vesicocervical fistula managed via trachelectomy and partial cystectomy. CONCLUSION: The authors have seen an increase in referrals for urinary tract fistulas in minimally invasive surgery. It is imperative to investigate the effect of a steep learning curve, unfamiliarity with new energy sources, or poor patient selection as contributing factors.

Vaginal repair of ureterovaginal fistula may be suitable for selected cases.

Ureterovaginal fistula (UVF) is an uncommon but devastating complication of gynecologic surgery. Management includes ureteral stenting for 6-8 weeks. For stent failure, ureteroneocystostomy (UNC) through an open, laparoscopic, or robotic abdominal approach is the classic alternative. Originally pioneered for repair of vesicovaginal fistulas (VVF), the use of the vaginal approach in UVF is scarcely reported in the literature. We report the successful repair of UVF performed exclusively through the vaginal approach in two women after robotic hysterectomy. In select clinical scenarios, this approach may be applied, as it provides a minimally invasive option for managing UVF after failure of ureteral stenting.

Nephrogenic adenoma in a urethral diverticulum.

Nephrogenic adenoma (NA) is a rare benign metaplastic lesion of the urothelial tract that arises as a response to injury and chronic inflammation. Although the most common site for NA is the bladder, it can occur in any part of urinary tract lined by urothelium. NA can mimic minor variants of urothelial cancer, clear cell adenocarcinoma, and prostate adenocarcinoma, making a combination of histologic examination and immunohistochemistry essential for diagnosis. We hereby report a rare case of nephrogenic adenoma arising in a urethral diverticulum.

Successful treatment of stent knot in the proximal ureter using ureteroscopy and holmium laser.

Knotted ureteral stent is rare yet tedious complication that might represent a treatment challenge to the endourologist. Only twelve cases of knotted stent have been reported. Different management options have been reported, including simple traction, ureteroscopy, percutaneous removal, and open surgery. In this paper, we present the successful untying of the knot using ureteroscopy with holmium laser.

Treatment of female stress urinary incontinence: what women find acceptable and the impact of clinical and urodynamic evaluation on their final choice.

OBJECTIVES: The aim of this study was determine what women find acceptable regarding treatment modality for Stress urinary incontinence (SUI) and to assess the impact of clinical and urodynamic evaluation on their final decision. MATERIAL AND METHODS: This prospective, institutional review board-approved study included 100 consecutive women with primary SUI. All women were given a questionnaire that included the Urinary Distress Inventory (UDI-6) and the American Urologic Association Quality of Life questionnaire (AUA-QoL6). The patients were also asked to choose one of the four available treatment options, which included major surgeries, minor surgeries, office procedures and medication. Factors affecting the initial choice of treatment were studied. A Q-tip test and multichannel urodynamics were then carried out and the patients were recounseled by the urologist. The patients' final decision was compared with their initial choice and statistical analysis was performed. RESULTS: Initially, 22% patients chose major surgery, 39% minor surgery, 27% an office procedure and 12% medication. This was affected by age, symptom severity and quality of life bother. After clinical and urodynamic evaluation, 34% shifted to a different treatment modality; this correlated significantly with young age, severe symptoms, limited urethral mobility and low Valsalva leak point pressure. CONCLUSIONS: Patients' initial choice for treatment of SUI was affected by age, symptom severity and quality of life; however, the final decision was more influenced by the clinical and urodynamic evaluation. It is important to counsel the patients before definitive treatment, to achieve a better outcome.

Biologic grafts for cystocele repair: does concomitant midline fascial plication improve surgical outcomes?

INTRODUCTION AND HYPOTHESIS: This study aims to compare the efficacy of porcine graft-augmented anterior prolapse repair with and without underlying pubocervical fascia plication. METHODS: Women with symptomatic anterior prolapse who underwent transvaginal repair, using biologic graft via transobturator approach, were retrospectively studied. An initial cohort had the graft placed without fascial plication. A second cohort had graft placement as an overlay to fascial plication. RESULTS: Between March 2005 and September 2008, 65 subjects underwent anterior repair with biologic graft; 35 without fascial plication and 30 as an overlay to plication. At 6 months follow-up, anatomic recurrence (Ba>/= -1) was significantly higher in the non-plicated group (18/35, 51%) compared with the plicated group (2/30, 7%) p < 0.01. Five (5/35, 14%) in the non-plicated group compared with none (0/30) in the plicated group underwent further treatment (p = 0.06). CONCLUSIONS: When using a non-crosslinked biologic graft for repair of anterior vaginal prolapse, we recommend the addition of concomitant midline fascial plication to enhance anatomic outcome.

Differential profile analysis of urinary cytokines in patients with overactive bladder.

INTRODUCTION AND HYPOTHESIS: We hypothesize that overactive bladder (OAB) can produce inflammatory cytokines due to afferent neural plasticity or urothelial dysfunction. This study aimed to detect abnormal cytokine levels in urine of patients with OAB compared to urinary tract infections (UTI) and controls. METHODS: This was a prospective, single blind study including 20 premenopausal women (control), 20 with OAB and 16 with UTI. Urine samples were collected, centrifuged, and stored (-80°C). Urinary total proteins were quantified and detected by antibody-based array chip for release of 120 human cytokines in the two groups relative to the controls. RESULTS: Majority of cytokines showed the same expression in the OAB compared with the controls. Cytokines exclusively expressed in OAB were: monocyte chemoattractant protein (MCP) 1, TARC, PARC, and Fas/TNFRSF6. MCP-2, MCP-3, tumor necrosis factor-ß, GCSF and eotaxin-3 showed a shared expression in UTI and OAB. Conversely, few of the cytokines were downregulated in OAB (IL-5, IL-6, IL-7, and GM-CSF). CONCLUSIONS: Taken together, the results suggest that a subset of inflammatory cytokines and chemokines provides a framework for development of highly optimized urinary biomarker assay for differential diagnosis and treatment of OAB.

Objective cure of urinary retention following laparoscopic hysterectomy for a large uterine fibroid.

Acute urinary retention (AUR) in women is not uncommon. Many reports have been published discussing the possible theories and pathogeneses of this condition. AUR induced by uterine fibroid is a rare entity that has been mentioned only in case reports. All the reported cases focused mainly on the different approaches for fibroid management. In this study, we present a 52-year-old female with recurrent episodes of urinary retention that was related to periods of menstruation. Pelvic magnetic resonance imaging revealed a markedly enlarged uterus with multiple fibroids. The patient had laparoscopic hysterectomy with postoperative resolution of patient's symptoms and improved uroflow studies. This is the first article that proves the cure of AUR following hysterectomy using an objective tool.

Rectourethral fistula stenting: a technique for better fistula visualization and efficient repair.

In this study, the authors present a technical tip for better and easier visualization of rectourethral fistula both during dissection and fistula closure. In this technique, a small-caliber ureteral catheter is used for catheterization of the fistulous tract under direct urethroscopic guidance. Five cases were treated using this technique. All cases had either brachytherapy as a monotherapy or combined brachytherapy and external beam radiotherapy. All cases had the fistula completely healed except for one failed case that had a 2-cm fistula.