Patients' Experiences With the Removal of a Ureteral Stent: Insights From In-depth Interviews With Participants in the USDRN STENTS Qualitative Cohort Study.

OBJECTIVE: To describe the experiences of patients undergoing stent removal in the USDRN Study to Enhance Understanding of Stent-Associated Symptoms (STENTS), a prospective, observational cohort study of patients with short-term ureteral stent placement post-ureteroscopy. METHODS: We conducted a qualitative descriptive study using in-depth interviews. Participants reflected on (1) painful or bothersome aspects of stent removal, (2) symptoms immediately after removal, and (3) symptoms in the days following removal. Interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. RESULTS: The 38 participants interviewed were aged 13-77 years, 55% female, and 95% White. Interviews were conducted 7-30 days after stent removal. Almost all participants (n = 31) described that they experienced either pain or discomfort during stent removal, but for most (n = 25) pain was of short duration. Many participants (n = 21) described anticipatory anxiety related to the procedure, and several (n = 11) discussed discomfort arising from lack of privacy or feeling exposed. Interactions with medical providers often helped put participants at ease, but also increased discomfort for some. Following stent removal, several participants described lingering pain and/or urinary symptoms, but these largely resolved within 24 hours. A few participants described symptoms persisting for more than a day post stent removal. CONCLUSION: These findings on patients' experiences during and shortly after ureteral stent removal, particularly the psychological distress they experienced, identify opportunities for improvement in patient care. Clear communication from providers about what to expect with the removal procedure, and the possibility of delayed pain, may help patients adapt to discomfort.

Urethral Stricture Disease Guideline Amendment (2023).

PURPOSE: The symptoms of urethral stricture are non-specific and may overlap with other common conditions that can confound diagnosis. Urologists play a key role in the initial evaluation of urethral stricture, currently provide all accepted treatments, and must be familiar with the evaluation, diagnostic tests, and surgical treatments for urethral stricture. MATERIALS AND METHODS: A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates January 1, 1990 to January 12, 2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture in men. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. The search for the 2023 Amendment was modified to included females and males (search dates December 2015-October 2022 for males; January 1990-October 2022 for females) and a new Key Question on sexual dysfunction was added (search dates: January 1990-10/2022). After inclusion and exclusion criteria were applied, 81 studies were added to the existing evidence base. RESULTS: Once a urethral stricture is diagnosed, clinicians should determine the length and location of the stricture in order to inform treatment. After a period of urethral rest, patients with short (<2cm) bulbar urethral stricture may be treated endoscopically. Urethroplasty may be performed by an experienced surgeon in patients with first time or recurrent anterior and posterior urethral strictures. The best treatment option for urethral stricture in female patients is urethroplasty using oral mucosa grafts or vaginal flaps rather than endoscopic treatment. CONCLUSION: This guideline provides evidence-based guidance to clinicians and patients regarding how to recognize symptoms and signs of a urethral stricture/stenosis, carry out appropriate testing to determine the location and severity of the stricture, and recommend the best options for treatment. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient's history, values, and goals for treatment.

The Patient Voice: Stent Experiences After Ureteroscopy-Insights from In-Depth Interviews with Participants in the USDRN STENTS Nested Qualitative Cohort Study.

Purpose: Ureteral stents are commonly used after ureteroscopy and cause significant discomfort, yet qualitative perspectives on patients' stent experiences remain unknown. We describe psychological, functional, and interpersonal effects of post-ureteroscopy stents and whether additional patient-reported assessments may be needed. Materials and Methods: Using a qualitative descriptive study design, we conducted in-depth interviews with a nested cohort of participants in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS). Participants shared their symptoms with a post-ureteroscopy stent and described symptom bother and impact on daily activities. All interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. During analysis, participants' experiences with interference in daily activities were categorized into three groups based on their impact: minimal, moderate, and substantial. Results: All 39 participants experienced pain, although descriptions varied and differentiated between feelings of pain vs discomfort. Almost all experienced urinary symptoms. Only a few reported other physical symptoms, although several psychological aspects were identified. In the areas of sleep, mood, life enjoyment, work, exercise, activities of daily living, driving, childcare, and leisure/social activities, the stent had little impact on daily living among participants placed in the minimal group (n = 12) and far greater impact for participants in the substantial group (n = 8). For patients in the moderate group (n = 19), some daily activities were moderately or substantially affected, whereas other activities were minimally affected. Conclusions: Counseling to better prepare patients for the impact of stent-associated symptoms may help mitigate symptom burden. While existing instruments adequately cover most symptoms, additional assessments for other domains, particularly psychological factors, may be needed.

Risk Factors for Increased Stent-associated Symptoms Following Ureteroscopy for Urinary Stones: Results From STENTS.

PURPOSE: The STudy to Enhance uNderstanding of sTent-associated Symptoms sought to identify risk factors for pain and urinary symptoms, as well as how these symptoms interfere with daily activities after ureteroscopy for stone treatment. MATERIALS AND METHODS: This prospective observational cohort study enrolled patients aged ≥12 years undergoing ureteroscopy with ureteral stent for stone treatment at 4 clinical centers. Participants reported symptoms at baseline; on postoperative days 1, 3, 5; at stent removal; and day 30 post-stent removal. Outcomes of pain intensity, pain interference, urinary symptoms, and bother were captured with multiple instruments. Multivariable analyses using mixed-effects linear regression models were identified characteristics associated with increased stent-associated symptoms. RESULTS: A total of 424 participants were enrolled. Mean age was 49 years (SD 17); 47% were female. Participants experienced a marked increase in stent-associated symptoms on postoperative day 1. While pain intensity decreased ∼50% from postoperative day 1 to postoperative day 5, interference due to pain remained persistently elevated. In multivariable analysis, older age was associated with lower pain intensity (P = .004). Having chronic pain conditions (P < .001), prior severe stent pain (P = .021), and depressive symptoms at baseline (P < .001) were each associated with higher pain intensity. Neither sex, stone location, ureteral access sheath use, nor stent characteristics were drivers of stent-associated symptoms. CONCLUSIONS: In this multicenter cohort, interference persisted even as pain intensity decreased. Patient factors (eg, age, depression) rather than surgical factors were associated with symptom intensity. These findings provide a foundation for patient-centered care and highlight potential targets for efforts to mitigate the burden of stent-associated symptoms.

Complex Penile Surgery: Plication, Grafting, and Implants.

Surgical treatments for Peyronie's disease and erectile dysfunction are generally straightforward and associated with excellent outcomes. However, severe (>60°) and multidirectional curvature, hourglass deformity, severe penile shortening, and ossified plaque may complicate surgery in patients with Peyronie's disease. Similarly, a history of priapism, prior implant infection, and penile injury can pose challenges to successful implant surgery secondary to severe corporal fibrosis. Thus, when these pathophysiological processes cause severe fibrosis and loss of function of the tunica albuginea and deep cavernosal spaces, adjunctive reconstructive techniques are necessary. Herein, we integrate the literature regarding surgical management of complex Peyronie's disease and erectile dysfunction with emphasis on plication, grafting, and implants to achieve satisfactory outcomes across the full range of etiology and degree of surgical complexity.

Quality of life impact and recovery after ureteroscopy and stent insertion: insights from daily surveys in STENTS.

BACKGROUND: Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains. METHODS: In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30. RESULTS: The median age was 44 years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5 mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2 days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability. CONCLUSIONS: This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients' experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS.

Mechanical characterization of fibrotic and mineralized tissue in Peyronie's disease.

Peyronie's disease affects penile mechanics, but published research lacks biomechanical characterization of affected tunica albuginea. This work aims to establish mechanical testing methodology and characterize pathological tissue mechanics of Peyronie's disease. Tunica albuginea was obtained from patients (n = 5) undergoing reconstructive surgery for Peyronie's disease, sectioned into test specimens (n = 12), stored frozen at -20 °C, and imaged with micro-computed tomography (µCT). A tensile testing protocol was developed based on similar soft tissues. Correlation of mechanical summary variables (force, displacement, stiffness, work, Young's modulus, ultimate tensile stress, strain at ultimate tensile stress, and toughness) and µCT features were assessed with linear regression. Specimens empirically grouped into hard or soft stress-strain behavior were compared using a Student's t-test. Surface strain and failure patterns were described qualitatively. Specimens displayed high inter- and intra-subject variability. Mineralization volume was not correlated with mechanical parameters. Empirically hard tissue had higher ultimate tensile stress. Failure mechanisms and strain patterns differed between mineralized and non-mineralized specimens. Size, shape, and quantity of mineralization may be more important in determining Peyronie's disease plaque behavior than presence of mineralization alone, and single summary variables like modulus may not fully describe mechanical behavior.

Geometrical Model of Free Skin Graft for the Optimization of Glans Reconstruction after Partial Penectomy / Modelo geométrico de injerto de piel libre para la optimización de reconstrucción de glande tras penectomía parcial

Introduction and Objective The management of penile carcinoma is very disabling and mutilating, bur early treatment can be curative. Our group systematically performs oncological management with immediate penile reconstruction and preservation of the organ (partial penectomy, resurfacing, or glansectomy) when feasible. Due to the low incidence of penile carcinoma, it is difficult to achieve experience in penile reconstruction using free grafts in a standardized and reproducible way. Therefore, we herein present the results of the use of an inanimate model to identify the most efficient geometric way to procure and apply a free skin graft to reconstruct the penis. Methods A preclinical inanimate model of the penis was developed to simulate the surgical reconstruction using a free skin graft. Six different geometric skin-graft models were created and tested. For each of them, we measured graft's surface area as well as the discarded surface after placing the graft on the penis for reconstruction. We also measured the amount of suture lines required for reconstruction. All of these measurements in the six different models were compared. Results Based on the six models, we identified that the longitude of the graft must measure the same as the maximum perimeter of the glans in order to have a square that enables the complete coverage of the penile defect. The total graft area for the first 4 models was of 40 cm2; for models 5 and 6, it was of 60 cm2. The average discarded area of the graft was of 18.135 cm2 (range: 12 cm2 to 30 cm2). Models 4 years 6 were the ones with the least discarded tissue: 12 cm2. The average amount of suture lines to secure the different model grafts was 7.3 (range: 5 to 12). The models that required the least amount of suture lines were number 1 and 4, with a total of 5 suture lines. Conclusions The double trapezoid is the most efficient model to reconstruct the glans after organ-sparing oncological management. Our results contribute to establish a more standardized and predictable technique to reconstruct the penis.

Introducción y Objetivo El manejo del cáncer de pene es muy mutilante y discapacitante. Pero el manejo quirúrgico oportuno puede ser curativo. Nuestro grupo realiza de manera sistemática el manejo oncológico con reconstrucción inmediata del pene y preservación del órgano (penectomía parcial, desepitelización, o gladectomía) cuando sea viable. Como la incidencia de cancer de pene es baja, lograr obtener la experiencia en reconstrucción de pene con el uso de injertos libres de manera estandarizada y reproducible resulta difícil. Por lo tanto, presentamos en este artículo los resultados de un modelo inanimado para identificar la forma geométrica mas eficiente de obtener y aplicar un injerto de piel libre para reconstruir el pene. Materiales y Métodos Se desarrolló un modelo preclínico y inanimado del pene para que se simulara su reconstrucción quirúrgica con el uso de un ijerto de piel libre. Desarrollamos y evaluamos seis modelos geométricos de injerto de piel distintos. Para cada uno, medimos el area total del injerto y la del tejido desechado tras ponerlo en el pene para la recosntrucción. También medimos la cantidad de líneas de sutura necesarias para la recosntrucción. Comparamos todas las medidas entre los seis modelos distintos. Resultados De los 6 modelos diferentes, encontramos que la longitud del injerto debe tener la misma medida que el perímetro máximo del glande para que se tenga un cuadrado que nos permita cubrir todo el defecto del pene. El area total de los 4 modelos iniciales fue de 40 cm2, y el area de los modelos 5 y 6 fue de 60 cm2. El area promedio del tejido desechado en los injertos fue de 18,135 cm2 (rango: 12 cm2 a 30 cm2). Los modelos 4 y 6 fueron los que tuvieron la menor cantidad de tejido desechado: 12 cm2. El promedio de la cantidad de líneas de sutura para atar los distintos modelos de injerto fue de 7,3 (rango: 5 a 12). Los modelos con la menor cantidad de líneas de sutura fueron el 1 y el 4, con un total de 5 líneas. Conclusiones El modelo de doble trapezoide es el más eficiente para reconstruir el glande tras el majejo oncológico en que se preserva el órgano. Nuestros resultados contribuyen para establecer una técnica de reconstrucción del pene más estandarizada y previsible.

Study to Enhance Understanding of Stent-Associated Symptoms: Rationale and Study Design.

Background: Ureteral stents are commonly employed after ureteroscopy to treat urinary stone disease, but the devices impose a substantial burden of stent-associated symptoms (SAS), including pain and urinary side effects. The NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) Urinary Stone Disease Research Network sought to develop greater understanding of SAS causes and severity among individuals treated ureteroscopically for ureteral or renal stones. Materials and Methods: We designed a prospective, observational cohort study comprising adolescents and adults undergoing ureteroscopic intervention for ureteral or renal stones. Participants will undergo detailed symptom assessment using validated questionnaires, a psychosocial assessment, and detailed collection of clinical and operative data. Quantitative sensory testing will be utilized to assess pain sensitization. In addition, a small cohort (∼40 individuals) will participate in semi-structured interviews to develop more granular information regarding their stent symptoms and experience. Biospecimens (blood and urine) will be collected for future research. Results: The Study to Enhance Understanding of sTent-associated Symptoms (STENTS) enrolled its first participant in March 2019 and completed nested qualitative cohort follow-up in August 2019. After a planned pause, enrollment for the main study cohort resumed in September 2019 and is expected to be completed in 2021. Conclusion: STENTS is expected to provide important insights into the mechanisms and risk factors for severe ureteral SAS after ureteroscopy. These insights will generate future investigations to mitigate the burden of SAS among individuals with urinary stone disease.

Risk factors for orgasmic and concomitant erectile dysfunction in men with type 1 diabetes: a cross-sectional study.

In this study, we sought to determine the burden and characteristics of orgasmic dysfunction (OD) and concomitant erectile dysfunction (ED) in men with type 1 diabetes (T1D) enrolled in the Epidemiology of Diabetes Interventions and Complications (EDIC) study. In 2010, we assessed orgasmic and erectile function using the International Index of Erectile Function (IIEF). Sociodemographic, clinical, and diabetes characteristics were compared by OD status (OD only, OD and ED, no ED or OD). Age-adjusted associations between risk factors and OD status were examined. OD and ED information was available from 563 men. Eighty-three men (14.7%) reported OD of whom 21 reported OD only and 62 reported OD and ED. Age-adjusted odds ratios demonstrated that men who reported OD only had higher odds of depression, low sexual desire, and decreased alcohol use compared with men reporting no dysfunction. Men with OD concomitant with ED had greater odds of elevated hemoglobin A1C, peripheral and autonomic neuropathy, and nephropathy. Men reporting both dysfunctions were also more likely to report smoking, lower urinary tract symptoms, and had greater odds of androgen deficiency than men with no sexual dysfunction. Men with longstanding T1D suffer from an increased burden of OD. Psychogenic factors predominate in men reporting OD only while men who present with concomitant ED report increased burden of diabetes severity, characteristics previously observed with incident ED. ED may be the central impediment to sexual function in men with OD and ED. Longitudinal studies to characterize OD and ED experience over time are warranted.

Comparison of clinician and patient users of a mobile phone application to assess penile curvature in Peyronie's disease.

Assessment of Peyronie's disease with penile injection is invasive and uncomfortable. We developed a smartphone application (UWPEN) to assess penile angulation in the home environment. The purpose of this study was to compare clinician and patient measurements and assess the patient experience with UWPEN in a clinical setting. We prospectively enrolled patients with Peyronie's disease undergoing intracavernosal injection of alprostadil. Penile angulation and narrowing were then assessed by patients and clinicians using UWPEN and compared to values obtained via a goniometer and a ruler (gold standard). Measurements were compared using the Pearson correlation test. Upon completion of measurements, patients were surveyed regarding the ease of use, confidence with use, and measurement preferences. Twenty patients were enrolled in the study; two patients were excluded for poor penile turgidity after a maximum dosage of intracavernosal alprostadil. Correlation between UWPEN and gold standard measurements by patients and clinicians was R = 0.55 (p = 0.01) and R = 0.87 (p < 0.01) for dorsal measurements, R = 0.62 (p = 0.01) and R = 0.77 (p < 0.01) for lateral measurements, and R = 0.73 (p < 0.01) and R = 0.64 (p < 0.01) for girth measurements, respectively. Prior evaluation of correlation suggests a strong correlation at R = 0.8, and good correlation at R = 0.5. Overall, patients preferred using UWPEN to traditional measurements, and 75% reported UWPEN as their first preference for measurements. UWPEN enables patients to assess their disease severity with good correlation to gold standard measurements. Patients prefer mobile platforms for disease monitoring, and development of technology for disease monitoring should be a priority within the Peyronie's disease research community.

The role of international partnerships in improving urethral reconstruction in low- and middle-income countries.

PURPOSE: To explore the impact of education and training in international surgical partnerships on outcomes of urethral stricture disease in low- and middle-income countries. To encourage data collection and outcomes assessments to promote evidence-based and safe surgical care. METHODS: Qualitative data were collected through observation of a reconstructive surgical workshop held by IVUmed at a host site in Dakar, Senegal. Quantitative data were collected through a retrospective review of 11 years of hospital data to assess surgical outcomes of urethral stricture disease before and after IVUmed started reconstructive workshops at the site. RESULTS: In the 11-year study period, 569 patients underwent 774 surgical procedures for urethral strictures. The numbers and types of urethroplasty techniques increased after IVUmed started its workshops. The average number of urethroplasties increased from 10 to 18.75/year. There was a statistically significant improvement in the mean success rate of urethroplasties from 12.7% before to 29% after the workshops. Anastomotic urethroplasty success rates doubled from 16.7 to 35.1%, but this was not statistically significant (p = 0.07). The improved success rate was sustained in cases performed without an IVUmed provider. CONCLUSIONS: Urethral stricture disease treatment in low- and middle-income countries is fraught with challenges due to complex presentations and limited subspecialty training. Improper preoperative management, lack of specialty instruments, and suboptimal wound care all contribute to poor outcomes. International surgical groups like IVUmed who employ the "teach-the-teacher" model enhance local practitioner expertise and independence leading to long-term improvements in patient outcomes. Tailoring practice guidelines to the local resource framework and encouraging data collection and outcomes assessment are vital components of providing responsible care and should be encouraged.

Factors Associated with Secondary Overtriage in Renal Trauma.

OBJECTIVE: To examine secondary overtriage for isolated renal trauma patients and to use secondary overtriage criteria to determine factors associated with unnecessary interhospital transfers in patients with isolated renal trauma. METHODS: The National Trauma Data Bank was used to identify isolated renal trauma patients of any age who were transferred to a level I or II trauma center from 2007 to 2014. Secondary overtriage criteria were defined as hospital length of stay <72 hours, no ICU admission, no emergent transfer from the ED to the OR, no operating room procedure, and no renal IR/OR procedure. Adjusted risk ratios (RR) and 95% confidence intervals were estimated using Poisson regression. RESULTS: A total of 8156 isolated renal injury patients who were transferred to either a level I or II trauma center were identified. More than half (53%) of the transferred patients had low-grade renal injuries (American Association for the Surgery of Trauma (AAST) Grade I/II). Our definition of secondary overtriage was met in 3005 patients (37%). In this group, 59% had low-grade renal injuries. The risk of being overtriaged was significantly reduced with increasing renal injury grade, hypotension in the emergency department, firearm injuries, older age (>65 years), medicare payer status, and any substance abuse. CONCLUSION: Secondary overtriage is common in isolated renal trauma. Factors associated with secondary overtriage are age ≤65 years, falls, and low renal injury grade. The high rate of unnecessary transfers shows that there is a need for disease-specific transfer guidelines to assure safe, cost-effective, and efficient health care in isolated renal trauma.

Blood pressure, antihypertensive medication use, and risk of erectile dysfunction in men with type I diabetes.

OBJECTIVE: To gain insight into the effect of blood pressure on the pathophysiology of diabetic erectile dysfunction, we determined the onset, severity and treatment of hypertension and risk of incident erectile dysfunction in men with type I diabetes. METHODS: This prospective cohort study included 692 men without prevalent erectile dysfunction in the Epidemiology of Diabetes Interventions and Complications study. Erectile dysfunction was assessed yearly for 16 years with a single question querying presence of impotence. Multivariable cox proportional hazards models examined associations of hypertension variables with risk for incident erectile dysfunction. RESULTS: Over 7762 person-years of follow-up, 337 of 692 men reported incident erectile dysfunction representing an unadjusted rate of 43.4 cases per 1000 person-years. Risk of erectile dysfunction significantly increased with each 10 mmHg of SBP elevation for those not taking antihypertensive medications, after adjustment for age, cigarette smoking and HbA1c levels [relative risk (RR) = 1.21, 95% CI = 1.04-1.41]. This relationship disappeared among those reporting antihypertensive medication use (RR = 0.96, 95% CI = 0.84-1.10) and the interaction between SBP and medication use was statistically significant (P = 0.02). Antihypertensive medication did not confer any reduction of erectile dysfunction risk, with similar rates across all measures of blood pressure and hypertension. CONCLUSION: Among men with type 1 diabetes not using antihypertensive medications, higher SBP is associated with increased risk of developing erectile dysfunction. These findings provide evidence to support further investigation into the potential benefit of early blood pressure control on risk of erectile dysfunction in men with diabetes regardless of age, blood pressure level, or glycemic control.

The Urology Applicant: An Analysis of Contemporary Urology Residency Candidates.

OBJECTIVE: To better understand today's urology applicant. METHODS: All 2016 Urology Residency Match applicants to the study-participating institutions were provided a survey via email inquiring about their paths to urology, their career aspirations, how they evaluate a training program, and how they perceive residency programs evaluate them. RESULTS: Of a possible 468 applicants registered for the match, 346 applicants completed the survey. Only 8.7% had a mandatory urology rotation, yet 58.4% believed that a mandatory urology rotation would influence their career decision. Most applicants (62.1%) spent more than 8 weeks on urology rotations, and 79.2% completed 2 or more away rotations. Applicants were attracted to urology by the diversity of procedures, prior exposure to the field, and the mix of medicine and surgery, with mean importance scores of 4.70, 4.52, and 4.45 of 5, respectively. Female applicants were more likely to be interested in pediatric urology, trauma or reconstructive urology, and female pelvic medicine and reconstructive surgery. Significant differences in survey results were noted when applicants were separated by gender. Three-fourths of respondents (75.7%) applied to more than 50 residency programs. Applicants ranked operative experience, interactions with current residents, and relationships between faculty and residents as the most important criteria when evaluating training programs. Of the subspecialties, 62.1% of applicants expressed most interest in urologic oncology. At this stage in their career, a significant majority (83.5%) expressed interest in becoming academic faculty. CONCLUSION: This study provides new information that facilitates a more comprehensive understanding of today's urology applicants.

Incidence of Stress Urinary Incontinence After Posterior Urethroplasty for Radiation-induced Urethral Strictures.

OBJECTIVE: To identify the frequency of de novo stress urinary incontinence (SUI) after posterior excision and primary anastomotic (EPA) urethroplasty in patients with radiation-induced urethral strictures (RIUS) and compare with patients with pelvic fracture urethral injuries (PFUIs). MATERIALS AND METHODS: A retrospective review was conducted among patients who underwent successful posterior EPA urethroplasty between 2008 and 2016 for RIUS from prostate cancer or PFUI from blunt trauma. Only patients with an intact bladder neck on imaging were included. SUI was defined by patient-reported outcomes and daily pad use. RESULTS: Inclusion criteria were met by 36 patients with RIUS and 33 patients with PFUI. Among the RIUS cohort, mean follow-up was 18 months, mean stricture length was 2.5 cm, and surgical dissection extended to the prostatic urethra in 67% (n = 24). The overall frequency of de novo SUI among patients with RIUS was 33% (n = 12), of which 75% (9 of 12) had prostatic urethral involvement. Two patients with RIUS (17%, n = 12) proceeded with artificial urinary sphincter (AUS) placement, whereas the remaining 10 patients required pads. SUI after urethroplasty in patients with PFUI was less common (12%, n = 4) and the prostatic urethra was involved in only 3% (n = 1) of all patients with PFUI. One patient with PFUI underwent AUS placement, whereas the remaining 3 patients did not require pads. CONCLUSION: Among RIUS patients with an intact bladder neck, SUI impacts one-third of patients. Subsequent AUS placement is uncommon. Prostatic urethral involvement increases risk of SUI. SUI is less common among patients with PFUI, likely related to a more limited involvement of the proximal bulbomembranous urethra and lack of radiation.

Updated Outcomes of Early Endoscopic Realignment for Pelvic Fracture Urethral Injuries at a Level 1 Trauma Center.

OBJECTIVE: To present our updated experience and discuss potential benefits of early endoscopic realignment (EER) for patients with pelvic fracture urethral injuries (PFUIs). METHODS: A retrospective review of patients treated with EER after blunt PFUIs was performed. EER was performed with a retrograde or a combined antegrade or retrograde approach with a cystoscope. Treatment success was defined as no secondary procedure or the ability to pass a cystoscope across the area of injury or surgical anastomosis. RESULTS: Thirty-two patients (mean age 38 years, range 17-73) underwent EER between 2004 and 2016 with a mean follow-up of 26 months (range 1-102). Median time to realignment was 2 days (range 0-6) and was performed concomitantly with another surgical service in 72% of cases. Median operative time for EER was 38 minutes (range 8-100). Using an intent-to-treat analysis, 29 patients (91%) failed EER. Nine patients underwent a subsequent endoscopic procedure with 22% success rate. Excision and primary anastomotic urethroplasty was performed in 24 patients as a primary or secondary treatment with 96% success rate. CONCLUSION: Our overall success rate for EER was 9%, but did not hinder subsequent urethroplasty success. The decision for performing EER should not be based on success alone. Secondary benefits of EER exist and may assist with the multidisciplinary care of a patient with complex trauma. The management of PFUI is challenging and these patients should be referred to tertiary centers.

Surgical and Functional Outcomes Following Buried Penis Repair With Limited Panniculectomy and Split-thickness Skin Graft.

OBJECTIVE: To report surgical and functional outcomes of buried penis surgery. METHODS: Outcomes following buried penis surgery at the University of Washington were assessed from June 1, 2005 to June 1, 2016. Patient demographic and surgical data were abstracted from a retrospective chart review. All patients were attempted to be contacted by phone for long-term follow-up. Uni- and multivariate analysis was performed to evaluate for association with any complication. RESULTS: A total of 42 men underwent buried penis repair surgery (mean short-term follow-up 8.1 months). There was an overall 33% 90-day complication rate (21 events). In univariate analysis, body mass index (BMI; P = .02) and no history of gastric bypass (P = .03) were significant predictors of any complication. In multivariate analysis, only BMI remained significant (odds ratio 1.1 for each increase in unit of BMI, 95% confidence interval 1.01-1.27). Twenty-seven patients were reached for long-term follow-up (mean 39 months). Patients reported improvements in every functional domain that was assessed. Of the patients, 85% reported they would undergo buried penis surgery again, 74% that surgery led to a positive change in their lives, and 85% that the surgery had remained a long-term success. CONCLUSION: Surgical correction of buried penis with penile split-thickness skin graft and limited panniculectomy is well tolerated and results in functional, long-term improvements. BMI is associated with an increased likelihood of a complication following surgery.

Male Urethral Stricture: American Urological Association Guideline.

PURPOSE: The purpose of this Guideline is to provide a clinical framework for the diagnosis and treatment of male urethral stricture. MATERIALS AND METHODS: A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional guidance is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. RESULTS: The Panel identified the most common scenarios seen in clinical practice related to the treatment of urethral strictures. Guideline statements were developed to aid the clinician in optimal evaluation, treatment, and follow-up of patients presenting with urethral strictures. CONCLUSIONS: Successful treatment of male urethral stricture requires selection of the appropriate endoscopic or surgical procedure based on anatomic location, length of stricture, and prior interventions. Routine use of imaging to assess stricture characteristics will be required to apply evidence based recommendations, which must be applied with consideration of patient preferences and personal goals. As scientific knowledge relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.