Urinalysis is predictive for absence of urinary tract infection in men with and without catheters.

OBJECTIVES: To determine accuracy of negative urinalysis (UA) for predicting negative urine culture and the absence of urinary tract infection (UTI), and optimal urine culture growth cutoff for UTI diagnosis in men with and without urinary catheters. SUBJECTS AND METHODS: UAs with urine cultures within 1 week from adult men were identified and evaluated. Predictive values for the absence of UTI (absence of ≥1 of the following criteria: documentation of UTI diagnosis, antibiotic prescription, uropathogen presence on culture) were calculated. RESULTS: In total, 22 883 UAs were included. Negative UA had a high predictive value for negative urine culture (0.95, 95% confidence interval [CI]: 0.94-0.95) and absence of UTI (0.99, CI: 0.99-0.995) in the overall cohort. Negative UA also had a high predictive value for negative urine culture (0.93, CI: 0.90-0.95) and absence of UTI (0.99, CI: 0.98-0.999) in those with indwelling urinary catheters. The traditional threshold of culture growth of 100 000 colony-forming units (CFU)/mL did not capture 22% of UTIs. CONCLUSION: UA exhibits high predictive value for negative urine culture and absence of UTI in men, supporting a protocol wherein culture is only performed in the context of abnormal UA. The traditional 100 000 CFU/mL cut-off may have not captured a subset of UTI in the male population, and warrants further investigation.

Decisional regret and impacts on quality of life following genitourinary reconstruction for neurogenic bladder: A comparison between acquired and congenital spinal cord injury.

INTRODUCTION: Patient expectations and baseline health are important drivers of outcomes following major genitourinary reconstructive surgery for neurogenic bladder (NGB). Differences in expectations and quality of life (QoL) improvements among different populations with NGB remain insufficiently explored in the literature. OBJECTIVE: To compare decisional regret (DR) and urinary-related QoL (UrQoL) in patients undergoing urinary diversion for NGB arising from spinal cord injury of acquired (A-SCI) and congenital (C-SCI) etiologies. We hypothesize that patients with A-SCI have higher expectations of improvement in QoL following surgery when compared with C-SCI, which may lead to higher DR and decreased UrQoL, postoperatively. DESIGN: In this cross-sectional survey study, we compared A-SCI to C-SCI in terms of DR, UrQoL, and postoperative changes in self-reported physical health, mental health, and pain using validated patient-reported outcome measures. SETTING: Participants were enrolled from a quaternary care institution via mail and MyChart. PARTICIPANTS: The A-SCI group consistied of 17 patients with traumatic spinal cord injury the C-SCI group was composed of 20 patients with spina bifida. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Decisional Regret Scale, Short form- Qualiveen (SF-Qualiveen), and Patient-reported outcomes measurement Information system-10 (PROMIS-10) Global Health surveys. RESULTS: The A-SCI group displayed poorer preoperative physical health than the C-SCI cohort, but absolute postoperative changes in this score, along with mental health score and pain level, were not significant after adjusting for baseline scores and follow-up time. SF-Qualiveen scores revealed significantly worse impact of NGB in UrQoL for A-SCI than for C-SCI when adjusted for other factors. No differences in DR were seen between the groups. CONCLUSIONS: Patients with A-SCI demonstrate lower self-reported baseline physical health compared with patients with C-SCI, which may have implications in setting patient expectations when undergoing urinary diversion. In this small cohort, we found a milder self-reported postoperative impact of NGB in UrQoL in patients with C-SCI.

Posterior Urethral Reconstruction at the Time of Rectourethral Fistula Repair: Technique and Outcomes.

OBJECTIVE: To assess the impact of posterior urethral stenosis or defect on outcomes following rectourethral fistula (RUF) repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair. METHODS: We identified 130 men who underwent RUF repair at our institution between 2003 and 2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months preoperatively), and 20 men suprapubic catheter placement (median, 5.5 months preoperatively). RESULTS: RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intraoperatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%). At a median follow-up of 55.7 months (interquartile range (IQR), 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation. CONCLUSION: Posterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis or defect.

Prior male sling does not affect outcomes of artificial urinary sphincter.

OBJECTIVE: To investigate the outcomes of artificial urinary sphincter (AUS) placement in patients with post-prostatectomy urinary incontinence (PPUI) with or without a prior male sling. PATIENTS AND METHODS: We performed a retrospective chart review of patients who underwent AUS for PPUI from 2007 to 2022. The primary endpoint was to determine the proportion of patients who achieved social continence, defined as self-reported use of 0-1 pad/day. The secondary endpoints were device failure rates and device failure-free survival. RESULTS: The analysis included 210 patients, with 30 (14.3%) having had prior slings and 180 (85.7%) without prior slings. After AUS insertion, 80.0% of patients with prior slings and 76.7% of those without prior slings achieved continence (0-1 pad/day). There were six (20.0%) and 53 (29.4%) device failures in patients with and without prior slings, respectively. The median device failure-free survival was not reached in patients with prior slings and was 8.9 years in patients without prior slings (P = 0.048). Limitations include retrospective nature and small sample size. CONCLUSIONS: The efficacy and safety of AUS in patients with prior slings are similar to those without. Prior sling is associated with a longer device failure-free survival. AUS remains a viable option in patients who have persistent PPI after prior slings.

Causes of death among people with myelomeningocele: A multi-institutional 47-year retrospective study.

PURPOSE: This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD. METHODS: A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics. RESULTS: Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47). CONCLUSION: COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.

Estimated Glomerular Filtration Rate Using Cystatin C is a More Sensitive Marker for Kidney Dysfunction in Nonweight-bearing Individuals.

PURPOSE: Individuals with neuromuscular disorders and neurogenic lower urinary tract dysfunction are commonly nonweight-bearing with lower lean muscle mass than the general population. We sought to compare estimated glomerular filtration rate equations that include creatinine, cystatin C, or both, in nonweight-bearing individuals and matched ambulatory controls. MATERIALS AND METHODS: Records were reviewed for individuals with serum creatinine (Cr) and cystatin C (Cys) and diagnosis consistent with nonweight-bearing status, and matched ambulatory controls. The 2021 CKD-EPI (Chronic Kidney Disease-Epidemiology Collaboration) race agnostic equations were used to calculate estimated glomerular filtration rate. Renal function was compared by equation in the overall cohorts and in a patient subset with imaging and/or urinalysis evidence of renal dysfunction. RESULTS: Nonweight-bearing (n = 102) and control populations (n = 204) had similar demographics. In the nonweight-bearing population, estimated glomerular filtration rate differed when calculated using CKD-EPICr, CKD-EPICr+Cys, and CKD-EPICys (107, 93, 80 mL/min/1.73 m2, respectively, P < .001). The differences in estimated glomerular filtration rate were greater in the nonweight-bearing relative to the control group regardless of CKD-EPI equation pairs compared (P < .001). In the patient subset with imaging and/or proteinuria evidence of renal dysfunction, the nonweight-bearing population again had different estimated glomerular filtration rate when calculated using CKD-EPICr, CKD-EPICr+Cys, and CKD-EPICys (P < .001). Fifty-eight percent of nonweight-bearing individuals with evidence of renal dysfunction on imaging or urinalysis were reclassified into a lower estimated glomerular filtration rate category when using estimated glomerular filtration rateCys relative to estimated glomerular filtration rateCr. CONCLUSIONS: Estimated glomerular filtration rate equations containing serum creatinine, cystatin C, or both, validated in mostly ambulatory populations, are not equivalently accurate in estimating kidney function in nonweight-bearing individuals. Comparison of these equations against gold standard glomerular filtration rate measurement is needed to determine which most closely approximates true glomerular filtration rate.

Single-Port Endorobotic Rectal Mucosa Harvest For Urethral Reconstruction.

BACKGROUND: Colorectal mucosal grafts for substitution urethroplasty are alternatives for patients when buccal mucosa is not adequate for long urethral strictures. IMPACT OF INNOVATION: This study presents the first cases of single-port endorobotic rectal mucosa harvesting for urethral reconstruction. TECHNOLOGY MATERIALS AND METHODS: The patients are 43- and 57-year-old men with medical histories of lichen sclerosis. The urethrograms demonstrated panurethral strictures requiring long mucosal grafts. The single-port robot was docked under general anesthesia in the modified lithotomy position. The procedure began with a submucosal injection of a lifting agent. After achieving an adequate lift of the mucosa, the dissection was started 2 cm proximal to the sphincter complex with a hook and continued cephalad. The semiflexible robotic platform eased and facilitated the dissection providing the required traction and counter traction. The injecting needle and aspiration device were directed with the help of a silk knot at the tip of the tools to create a handle for robot arms. The procedure was continued with a spatula tip thinner than the hook, which delivers less energy to the dissection field and creates a precise cut. The harvested graft was provided to the urology team after pinning it for measurement. The urologists prepared and completed the reconstruction of the urethra with the autograft. PRELIMINARY RESULTS: The patient had no complications related to his rectal mucosa harvest. CONCLUSIONS: We report the first 2 cases of single-port robotic rectal mucosal harvesting for long panurethral strictures with single-port endorobotic submucosal dissection technique. FUTURE DIRECTIONS: The technique seems promising to facilitate the precise submucosal dissection with meticulous control of traction and delivered energy.

Management and Outcomes of Ileal Pouch-Urethral Fistulas.

OBJECTIVE: To describe a single-center experience with the management of ileal pouch-urethral fistulas (IPUF) following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS: We retrospectively identified patients with documented IPUF managed at our institution from a urethral fistula cohort and analyzed their cases. RESULTS: Thirteen patients who underwent surgeries for IPUF management from 2005-2022 were identified. Median age at IPAA was 29 years (range 11-53). Indications for IPAA included familial adenomatous polyposis (n=3) and ulcerative colitis (n=10). Median time from IPAA to fistula diagnosis was 15 years (range 0.5-38.5). Eleven patients were initially diverted with either loop (n=8) or end ileostomy (n=3). Overall, two patients had resolution of IPUF symptoms with a loop ileostomy alone and eight eventually underwent pouch excision with end ileostomy, one of which subsequently underwent redo IPAA. Seven patients were managed with primary closure of the urethral defect at the time of pouch excision, five of which also underwent gracilis muscle interposition. With a median follow-up of 4 years (range 0.3-13 years), all patients had resolution of their fistulae without any recurrences. CONCLUSION: IPUFs are a rare complication after IPAA. In this cohort, all patients had their urinary tract preserved, but most ultimately had permanent fecal diversion. These results can help guide management of this complex issue.

Education and employment as young adults living with spina bifida transition to adulthood in the USA: A study of the National Spina Bifida Patient Registry.

AIM: To describe the education and employment transition experience of young adults with spina bifida (YASB) and investigate factors associated with employment. METHOD: We queried education and employment data from the US National Spina Bifida Patient Registry from 2009 to 2019. We applied generalized estimating equations models to analyze sociodemographic and disease-related factors associated with employment. RESULTS: A total of 1909 participants (850 males, 1059 females) aged 18 to 26 years contributed 4379 annual visits. Nearly 84% had myelomeningocele and, at last visit, the median age was 21 years (mean 21 years 5 months, SD 2 years 10 months). A total of 41.8% had at least some post-high school education, and 23.9% were employed. In a multivariable regression model, employment was significantly associated with education level, lower extremity functional level, bowel continence, insurance, and history of non-shunt surgery. This large, national sample of YASB demonstrated low rates of post-secondary education attainment and employment and several potentially modifiable factors associated with employment. INTERPRETATION: Specific sociodemographic, medical, and functional factors associated with employment are important for clinicians to consider when facilitating transition for YASB into adulthood. Additional research is needed to understand the impact of cognitive functioning and social determinants of health on transition success in YASB. WHAT THIS PAPER ADDS: There were low education attainment and employment rates in a large sample of young adults with spina bifida. Specific sociodemographic, medical, and functional factors are associated with employment. Some employment-associated factors, such as continence and self-management skills, are modifiable.

Management of prostatosymphyseal fistula following photoselective vaporization of the prostate: Case series and systematic review of the literature.

Background: This study is aimed to describe our institutional experience and review the literature to date on prostatosymphyseal fistula (PSF), or puboprostatic fistula, following bladder outlet procedures such as transurethral resection of the prostate (TURP) or laser photoselective vaporization of the prostate (PVP). Materials and methods: We retrospectively queried our institutional experience for management of PSF following PVP performed for symptomatic benign prostatic hyperplasia. We also performed a systematic literature review for PSF following PVP or TURP. Finally, we describe our surgical approach to the management of this challenging condition. Results: We identified 7 cases of PSF following PVP from our institution, as well as an additional 7 cases following PVP and 9 cases following TURP from literature review. The diagnosis of PSF was made between 0.5 and 24 months following PVP, and the most specific symptoms were pubic pain and difficulty ambulating. Most patients requiring several evaluations before the diagnosis was made using appropriate imaging studies. Seventy percent of patients required surgical intervention including fistula repair or prostatectomy. Our surgical approach has evolved, and we now routinely perform robotic fistula repair with Y-V plasty and interposition flap with excellent results. Conclusions: Puboprostatic fistula is a rare and poorly described complication of PVP or TURP. To the best of our knowledge, this case series of PSF following PVP represents the largest series to date and doubles the number of reported cases in the literature. Robotic fistula repair with interposition of either peritoneal or perivesical fat flaps appears to be a viable management strategy.

Acquired and Congenital Spinal Cord Injury is Associated With Lower Likelihood of Prostate Specific Antigen Screening.

OBJECTIVE: To evaluate prostate cancer screening occurrence in patients with spinal cord injury at our institution compared to a matched, unaffected population. MATERIALS AND METHODS: We conducted a retrospective review of patients with the criteria: male, age 50-70, and diagnosis of cerebral palsy, spina bifida, or quadriplegia. A control cohort was matched by age, race, insurance, and co-morbidities. Prostate specific antigen (PSA) screening, PSA value, prostate MRI, prostate biopsy, and biopsy outcome were compared. Multivariate logistic regression analysis was performed to determine the association between patient variables and PSA screening. RESULTS: The study cohort and control cohort included 2180 patients each. Patients with spinal cord injury had significantly lower rates of PSA screening (15% vs 24%, P <.00001), MRI (0.1% vs 0.6%, P = .02), and biopsy (0.6% vs 1.3%, P = .01) compared to control. Spinal cord injury was associated with a lower likelihood of PSA screening (OR = 0.56, CI = 0.48-0.65, P <.00001). There were no significant differences in PSA value and biopsy outcomes. CONCLUSION: Patients with spinal cord injury had a lower likelihood of PSA screening compared to a matched control population. Since PSA screening is a shared-decision making process, providers should consider the increasing life expectancy of patients with spinal cord injury and risks of under-testing for prostate cancer.

Management of Urosymphyseal Fistula and Pelvic Osteomyelitis: A Comprehensive Institutional Experience and Improvements in Pain Control.

BACKGROUND: Urosymphyseal fistula (USF) is an uncommon but painful and devastating condition typically occurring after radiotherapy for pelvic malignancy, with a delayed diagnosis and a risk of opioid dependence. OBJECTIVE: To characterize our institutional experience and determine the impact of intervention for USF on pain control and opioid use. DESIGN, SETTING, AND PARTICIPANTS: We evaluated data for 33 adult patients diagnosed with USF and managed at a quaternary institution between 2009 and 2021. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We assessed chronic opioid use, pain scores, prior therapy for pelvic malignancy, prior endoscopic procedures, microbiology and histology congruence, and postoperative complications. For comparative analyses we used a χ2 test or Fisher's exact test for categorical variables and a Wilcoxon signed-rank test for continuous variables. RESULTS AND LIMITATIONS: Nearly 94% of the patients had received prior pelvic radiotherapy and >80% occurred in 2016-2021 but were not diagnosed until a median of 10 mo (interquartile range [IQR] 3.5-19.5) following endoscopic procedure(s). Osteomyelitis was suspected in 78.8% of imaging reports and nearly 70% had a positive preoperative urine culture. Over 90% of patients underwent cystectomy, pubic bone debridement or resection, and a soft-tissue pedicle flap. Preoperative urine cultures were concordant with 60% of intraoperative tissue/bone cultures. Histologic osteomyelitis was identified in 85% and concordant with 80% of preoperative imaging. Clavien-Dindo grade ≥3 complications occurred in 15.6%. The median pain score decreased from 4 (IQR 0-8) preoperatively to 0 (IQR 0) postoperatively (p < 0.001). Chronic opioid use decreased from 39.4% to 21.2% (p = 0.02). CONCLUSIONS: Pelvic osteomyelitis may complicate USF and commonly manifests with severe, persistent pain. USF incidence may be increasing or at least increasingly recognized, but diagnosis is delayed. Definitive management results in significant improvements in pain perception and a decrease in chronic opioid use. PATIENT SUMMARY: We examined features of urinary fistulas, which are abnormal openings or connections between part of the urinary tract and another structure. Patients with a urinary fistula involving the pelvic bones can present with severe pain, but diagnosis of the condition is often delayed. Removal of some pelvic bone with bladder removal or repair can result in a decrease in long-term pain and in the use of opioid drugs for pain relief.

The Dilemma of Penile Prosthesis Implantation in Sex Offenders.

BACKGROUND: Penile prosthesis surgeons face an ethical dilemma when confronted with a sex offender who seeks surgical management of erectile dysfunction. AIM: To provide practice guidelines to screen and manage patients with a history of sexual violence prior to surgery. METHODS: Three urologists with expertise in penile prosthesis surgery and 1 medical bioethicist were asked to contribute their opinions and provide recommendations to address this controversial topic. OUTCOMES: Expert opinion supported by analysis of available literature and institutional experience. RESULTS: The authors review current United States legislation, published literature on sex offender registration, and institutional data on the prevalence of sex offenders among men seeking penile prosthesis placement. Within a context established by medical bioethical principles, the authors propose a practice guideline for screening sex offenders prior to penile implantation surgery and referral for trained psychological evaluation prior to surgical management. STRENGTHS & LIMITATIONS: Strengths: multidisciplinary approach in data acquisition including bioethical and legal review. LIMITATIONS: Lack of available evidence regarding recidivism risk in sex offenders who undergo penile prosthesis placement. CONCLUSION: Sex offenders exist among the population of patients seeking surgical placement of a penile prosthesis. A standardized practice guideline for management of this population should be employed with the intention to reduce future harm. Zhang JH, DeWitt-Foy M, Jankowski J, et al. The Dilemma of Penile Prosthesis Implantation in Sex Offenders. J Sex Med 2021;18:1826-1829.

Urosymphyseal fistulas in women: identification and characterization of a previously undescribed phenomenon.

Urosymphyseal fistula (USF) is a very uncommon but catastrophic condition which typically occurs in the setting of previous radiation treatment for prostate cancer. As a result, USF has only been described in male populations. For the first time, we characterize this phenomenon in a series consisting of four women managed at our quaternary institution. We found that most patients presented with pubic pain and all were diagnosed with USF on CT or MRI. Imaging commonly demonstrated features suggesting osteomyelitis which was confirmed on histology. Patients experienced significant decreases in peri-operative pain scores following extirpative surgery with urinary diversion, bone debridement/resection and tissue interposition. This case series highlights the rarity of USF in women in order to help promote increased recognition and timely management.

Age-related urologic problems in the complex urologic patient.

PURPOSE: Improved medical care throughout childhood and adolescence has enabled patients with complex urological abnormalities to live longer into adulthood. These patients are now at risk of developing common, age-related, urological conditions. This review aims to review existing data and make recommendations in areas where expert opinion is currently lacking METHODS: This review represents the joint SIU-ICUD (Société Internationale d'Urologie-International Consultation on Urological Disease) consultation on congenital lifelong urology. The results of this analysis were first presented at a joint consultation of the ICUD and SIU at the 2018 SIU annual conference in Seoul, South Korea. RESULTS: BPH may present differently in patients with neurogenic bladder. Thorough assessment of neurological status, bladder and sphincter function is required before offering any bladder outlet surgery. Prostate specific antigen screening should be offered to men aged 50-69 with neurogenic bladders if they have good life expectancy. Multi-parametric MRI and transperineal biopsy would be the investigations of choice if feasible. Surgery for localized disease should only be done by surgeons with the relevant expertise. Bladder cancer in this patient group is more likely to present at a later stage and have a worse prognosis. Parenthood is achievable for most, but often requires assistance with conception. Pregnant women who have had previous urogenital reconstructive surgery should be managed in appropriate obstetric units with the involvement of a reconstructive urologist. CONCLUSIONS: Most evidence regarding complex urogenital abnormalities comes from the pediatric population. Evidence regarding common, age-related urological issues is generally from the 'normal' adult population. As patients with complex congenital urological conditions live longer, more data will become available to assess the long-term benefits of intervention.

The Role of Postoperative Imaging after Ventral Onlay Buccal Mucosal Graft Bulbar Urethroplasty.

PURPOSE: Our primary objective was to determine the incidence of extravasation on imaging at the time of catheter removal after ventral onlay buccal mucosal graft urethroplasty. MATERIALS AND METHODS: This is a single center retrospective cohort study of patients who underwent ventral onlay buccal mucosal graft bulbar urethroplasty from 2007 to 2017. Patients with imaging at the time of catheter removal were included. Urethroplasty success was defined as the ability to pass a 17Fr cystoscope at the time of followup cystoscopy. RESULTS: A total of 229 patients met the inclusion criteria, including 110 with a ventral onlay buccal mucosal graft and 119 with an augmented anastomotic urethroplasty with a mean stricture length of 4.4 cm. Imaging consisted of a voiding cystourethrogram in 210 and retrograde urethrogram in 19 patients at a median of 21.7 days after surgery. The incidence of extravasation was 3.1% (7/229). Of patients who had a documented followup cystoscopy (60%, 137/229), those with extravasation on imaging had a worse urethroplasty success rate (60%, 3/5) compared to those who did not (94%, 117/130) (p=0.047). On multivariate analysis those who had 5 or more endoscopic interventions were 9.6 times more likely to demonstrate extravasation (OR 9.6, p=0.0080). CONCLUSIONS: The incidence of radiological extravasation after ventral onlay using a single buccal mucosal graft, with or without augmented anastomotic urethroplasty, is 3.1%. Given this low rate it is reasonable to omit routine imaging at the time of Foley removal in this population. It appears that extravasation may be associated with a worse cystoscopic patency rate but does not lead to more complications.

Patterns of inpatient care for prostate cancer in men with spina bifida.

BACKGROUND: Advances in medical care have increased the long-term survival of patients with spina bifida. Despite this growing population, limited knowledge is available on age-related illnesses in adults with spina bifida, particularly prostate cancer for which there is no published data. OBJECTIVE: Our aim was to describe inpatient care for prostate cancer in men with spina bifida in the United States. METHODS: We performed a descriptive, retrospective study utilizing the 1998 to 2014 National Inpatient Sample from the Healthcare Cost and Utilization Project. Weights were applied to the sample to make national level inferences. We identified all adult encounters (≥18 years old) with prostate cancer and spina bifida. RESULTS: We identified 253 encounters (mean age 64.9 years). Most were Caucasian (67.5%) and had public insurance (61.6%). 44% of encounters included a major urologic procedure. 38.4% of encounters included prostatectomies, 28.3% included lymph node dissections, and 7.8% included cystectomies. Robotic surgery was performed in 9.4%. Mean length of stay was 5.6 days (95% CI: 3.7, 7.5). The average total cost was $14,074 (95% CI: $8990.3, $19,158.6). CONCLUSIONS: In this first-ever exploration of inpatient care for prostate cancer in men with spina bifida, we found that length of stay and total costs were higher in men with spina bifida. Almost half of encounters included a prostatectomy, cystectomy, and/or lymph node dissection. More detailed investigations are necessary to assess comparative treatment outcomes and complications, including prevalence and mortality rates of prostate cancer among adult men with SB.

Urologic provider experiences in transitioning spina bifida patients from pediatric to adult care.

PURPOSE: The lack of precedent in transitioning from pediatric to adult care poses a challenge to providers for patients with spina bifida (SB). The purpose of this study was to summarize perceptions about best practices for the care of adult spina bifida patients. MATERIALS AND METHODS: A national survey was electronically distributed to 174 urologists who are current members of the Spina Bifida Association Network and AUA Working Group on Urologic Congenitalism. De-identified voluntary responses were assessed for implementation of and barriers to interdisciplinary adult SB clinics, continuity of care, and practices for transitioning from pediatric to adult care. RESULTS: The response rate was 40% with urologists practicing pediatrics, genitourinary reconstruction, female pelvic medicine and general urology. Patients undergoing transition or who have transitioned were seen in a multidisciplinary clinic (14%), regular adult clinic (34%), combined adult-pediatric multidisciplinary care (20%), or pediatric multidisciplinary clinic (28%). A majority believed transitioning to adult care should occur at 18 (24%) or 21 years (22%). In the absence of acute changes, providers followed adult SB patients annually with upper tract imaging (typically renal ultrasound) and serum creatinine. Acute urologic changes were preferentially managed with urodynamic testing and cystoscopy. Providers identified a need for multidisciplinary care in adult life, with neurosurgery/neurology (87%), social work (84%), and orthopedics (73%). CONCLUSIONS: Potential solutions to improve the urologic care of this population suggest additional national provider resources, standardized guidelines, multidisciplinary collaboration, access to care, and an advanced-training pathway to improve care of adult patients with spina bifida.

Rectoneovaginal Fistula in a Transgender Woman Successfully Repaired Using a Buccal Mucosa Graft.

BACKGROUND: Rectoneovaginal fistulae (RnVFs) are abnormal connections between the rectum and a surgically created neovagina. Although very uncommon, they confer significant morbidity in patients and may require a multidisciplinary team approach to the repair. Risk factors for RnVF include rectal injury at the time of neovaginoplasty, malignancy in the neovagina, trauma (iatrogenic or otherwise), radiation, and neovaginal revision surgery. CASE DESCRIPTION: The patient is a 64-year-old transgender woman with recurrent RnVF following penile skin inversion neovaginoplasty, which was complicated by an intraoperative rectal injury. After failing an initial attempt at repair, the fistula was successfully repaired with a buccal mucosa graft. CONCLUSIONS: In some cases, RnVFs following vaginoplasty surgery for gender affirmation may be repaired successfully with a buccal mucosa graft.