Prospective quality of life in men choosing open vs. robotic radical prostatectomy: long-term results from a racially diverse multi-institutional database.

PURPOSE: To compare 5-year health-related quality of life (HRQoL) outcomes between prostate cancer (CaP) patients who underwent robotic-assisted laparoscopic radical prostatectomy (RALP) versus open radical retropubic prostatectomy (RRP) and assess for racial disparities between Caucasian American (CA) and African American (AA) men undergoing surgery. METHODS: A prospective cohort study of HRQoL data was conducted on patients diagnosed with CaP from 2007 to 2017 and enrolled in the Center for Prostate Disease Research (CPDR) Multicenter National Database. Using the EPIC and SF-36 instruments, changes in urinary, sexual, bowel, and hormonal domains, as well as physical and mental component summary scores were compared across surgery type (RALP versus RRP) at pre-treatment ("baseline"), and annually for 5 years. We further compared HRQoL outcomes in CA and AA men undergoing surgery. Longitudinal HRQoL patterns were modeled using generalized estimating equations (GEE), adjusting for baseline HRQoL and other characteristics. RESULTS: 448 CaP patients (22% AA) met study inclusion criteria, 66% underwent RALP and 34% underwent RRP. At baseline, HRQoL domains were comparable across treatment group (RALP vs. RRP). In the adjusted low-risk cohort, there were only three time points that met a statistically significant HRQoL difference in EPIC scores between RALP and RRP. Urinary function score during year 4 of follow-up showed a 7.5 (95% CI 3.1-11.9, P = 0.01) points difference in favor of RRP. Bowel bother scores favored RRP in year 1 with a difference of 3.1 (95% CI 0.7-5.4, P = 0.04) points, and in year 5 with a difference of 3.8 (95% CI 1.1-6.4, P = 0.03) points. In the intermediate/high-risk cohort, there were no statistically significant differences in any of the domain scores between RALP and RRP during follow-up. CONCLUSIONS: The robotic and open approach to radical prostatectomy led to comparable HRQoL outcomes at a follow-up length of 60 months. No HRQoL racial disparities were found between AA and CA men during long-term follow-up.

Standing cough test for evaluation of post-prostatectomy incontinence: a pilot study.

INTRODUCTION: We implemented a standardized Standing Cough Test (SCT) for assessment of men with post-prostatectomy incontinence (PPI) and stratified results according to an objective clinical grading scale in an attempt to facilitate male anti-incontinence surgical procedure selection. MATERIALS AND METHODS: SCT was routinely performed during the initial outpatient consultation for PPI. Incontinence severity was recorded based on a novel Male Stress Incontinence Grading Scale (MSIGS) to stratify PPI. Each patient was assigned an incontinence grade score of 0 through 4 during the SCT. Men with mild stress urinary incontinence (SUI) (grades 0-2) were offered sling surgery while those with heavier SUI (grades 3-4) were offered artificial urinary sphincter (AUS). MSIGS grade was correlated to preoperative patient-reported pads per day (PPD), and patient-reported outcomes of anti-incontinence surgery were assessed. RESULTS: Among 62 consecutive PPI patients, 20 (32%) were graded as mild based on SCT, while the majority (42/62, 68%) were graded as moderate-severe. Average time from prostatectomy to treatment was 6 years. MSIGS grade demonstrated a strong correlation with preoperative PPD (r = 0.74). Among the 53 patients who underwent surgery for PPI, 14 with mild SUI received a sling, while 39 (74%) more severe cases received an AUS. Patient-reported improvement was high overall in both groups (median 95%). CONCLUSION: Most men with chronic PPI present for definitive treatment in a delayed manner after prostatectomy despite having severe incontinence. The SCT provides immediate, objective information about the severity of PPI which strongly correlates with patient-reported pads-per-day and may expedite anti-incontinence surgical procedure selection.

Inflatable penile prosthesis as tissue expander: what is the evidence?

OBJECTIVE: Many patients who undergo inflatable penile prosthesis (IPP) replacement are often upsized to larger cylinders, suggesting the IPP may serve as a tissue expander and increase internal penile length. The objective of this study is to evaluate whether cylinder length increases with subsequent IPP insertion. MATERIALS AND METHODS: We queried American Medical Systems and Coloplast Patient Information Form databases to identify patients who underwent IPP placement and replacement between 2004-2013. Patients were grouped by device type and time to replacement (<2 or ≥2 years). We selected the 2-year mark for subgroup analysis to allow time for tissue expansion to occur and to exclude patients who underwent early explantation (e.g. erosion or infection). RESULTS: Two thousand, seven hundred and forty nine patients (1,532 AMS 700 LGX, 717 AMS 700 CX, and 500 Coloplast Titan) met the inclusion criteria. Mean time between implants was earlier for LGX (29 months) than CX (39 months) and Titan (48 months) patients (p<0.001). Patients who underwent device replacement at <2 years did not experience an increase in mean cylinder length. On the contrary, patients who underwent device replacement at ≥2 years did experience significant increases in mean cylinder length (LGX 1.2 cm, CX 1.1 cm, and Titan 0.9 cm, p<0.001). The mean increases in length at ≥2 years were similar between the 3 devices (p=0.20). Sixty percent of patients demonstrated increases of >0.5 cm and 40% demonstrated increases of ≥1 cm. CONCLUSIONS: As demonstrated, the IPP may provide tissue expansion over time. Further evaluation is needed to determine if increased cylinder length correlates to increased functional length and patient satisfaction.

Rapid excision of massive localized lymphedema of the male genitalia with vessel sealing device.

INTRODUCTION: To present a series of patients who underwent surgical treatment for massive localized lymphedema (MLL) of the male genitalia and explore the utility of the LigaSure hemostatic vessel sealing device (VSD) for resection of advanced cases. MATERIALS AND METHODS: Although conservative and microsurgical treatments have been reported, MLL of the male genitalia requires open surgical resection with primary reconstruction. We reviewed our prospectively maintained database of all lymphedema excisions performed between January 2007 and December 2014 comparing resection with Bovie electrocautery to resection with the LigaSure VSD. Our analysis focused on any significant differences in rate of resection, estimated blood loss (EBL), and recurrence. RESULTS: Nineteen patients with MLL of the male genitalia underwent excision with either LigaSure (8 patients) or conventional Bovie electrocautery (11 patients). Rate of resection was significantly faster with LigaSure compared to Bovie (33.74 g/min versus 5.32 g/min, p = .035). Additionally, estimated EBL per gram of tissue resected was decreased in the LigaSure group (0.41 mL/g versus 0.17 mL/g, p = .057). Two of the 11 Bovie patients (18%) had recurrence of lymphedema requiring repeat resection, while none of the LigaSure patients developed recurrence. CONCLUSIONS: Resection of genital lymphedema using the LigaSure device offers promising results in managing advanced MLL of the male genitalia with the potential for faster resections, less EBL per tissue resected, and a lower rate of recurrence.

Repeat Excision and Primary Anastomotic Urethroplasty for Salvage of Recurrent Bulbar Urethral Stricture.

PURPOSE: We compared the results of initial excision and primary anastomosis urethroplasty to the excision and primary anastomosis outcomes of other challenging reoperative clinical settings, including secondary cases (prior urethroplasty of any technique other than excision and primary anastomosis) and repeat cases (prior excision and primary anastomosis). MATERIALS AND METHODS: We reviewed our database of patients who underwent excision and primary anastomosis urethroplasty for bulbar urethral stricture at our tertiary referral center from 2007 to 2014. Patients without available data and those with a history of lichen sclerosus, radiation, pelvic fracture urethral injuries, distal strictures and/or hypospadias were excluded from analysis. Patient characteristics and outcomes were compared between those undergoing initial, secondary, and repeat excision and primary anastomosis urethroplasty for bulbar urethral stricture. RESULTS: Among 898 urethroplasties performed during the study period we identified 305 men who underwent excision and primary anastomosis urethroplasty of the bulbar urethra, including an initial procedure in 268 of 305 (88%) and reoperation in 37 (12%). Of patients with reoperation 18 of 37 (49%) underwent secondary excision and primary anastomosis following a different type of prior urethroplasty and 19 (51%) underwent repeat excision and primary anastomosis. Repeat excision and primary anastomosis in the bulbar urethra was successful in 18 of 19 patients (95%), which was comparable to the success rate of initial bulbar excision and primary anastomosis (251 of 268 or 94%) as well as secondary bulbar excision and primary anastomosis (17 of 18 or 94%, p = 0.975) with a similar mean stricture length. Mean followup for all patients was 41.5 months (range 6 to 90) and mean followup in each group was greater than 30 months. CONCLUSIONS: Repeat excision and primary anastomosis urethroplasty has excellent results for short bulbar strictures, comparable to those achieved in the initial and secondary setting.

Does Pressure Regulating Balloon Location Make a Difference in Functional Outcomes of Artificial Urinary Sphincter?

PURPOSE: We compared functional outcomes in patients who received an artificial urinary sphincter in the space of Retzius vs the same device placed at a high submuscular location. MATERIALS AND METHODS: We reviewed a prospectively maintained database of patients who received an artificial urinary sphincter between July 2007 and December 2014. After cuff placement was completed via a perineal incision, a 61 to 70 cm H2O pressure regulating balloon was placed through a separate high scrotal incision in the space of Retzius or in a high submuscular tunnel. Demographics, perioperative comorbidities and functional outcomes were compared between the groups. RESULTS: A total of 294 consecutive patients underwent artificial urinary sphincter placement. Mean followup was 23 months. Space of Retzius and high submuscular placement was performed in 140 (48%) and 154 patients (52%), respectively. Functional outcomes were similar between the groups, including the continence rate (defined as 0 or 1 pad daily) in 81% vs 88% (p = 0.11), the erosion rate in 9% vs 8% (p = 0.66) and the explantation rate in 10% vs 11% (p = 0.62). Artificial urinary sphincter revision for persistent incontinence was required in a similar proportion of the 2 groups (13% vs 8%, p = 0.16) with a comparable mean followup (24 vs 23 months, p = 0.30). Kaplan-Meier analysis revealed no difference between the groups in the rate of explantation (p = 0.70) or revision (p = 0.06). CONCLUSIONS: High submuscular placement of a pressure regulating balloon at artificial urinary sphincter surgery is a safe, effective alternative with functional outcomes equivalent to those of traditional placement in the space of Retzius.

3.5 cm artificial urinary sphincter cuff erosion occurs predominantly in irradiated patients.

PURPOSE: We analyzed our initial 100-case experience with the 3.5 cm artificial urinary sphincter cuff to identify risk factors for cuff erosion. MATERIALS AND METHODS: We reviewed the records of a single surgeon, consecutive series of patients treated with 3.5 cm artificial urinary sphincter cuff placement from September 2009 to August 2013. Each patient underwent single perineal cuff placement via standardized technique. Preoperative characteristics, technical considerations and postoperative outcomes were analyzed and compared to those in a cohort of patients in whom a larger (4.0 cm or greater) artificial urinary sphincter cuff was placed during the same period. We identified clinical factors associated with an increased risk of 3.5 cm artificial urinary sphincter cuff erosion. RESULTS: Of the 176 men who met study inclusion criteria during the 4-year period 100 (57%) received the 3.5 cm artificial urinary sphincter cuff and 76 (43%) received a larger cuff (4.0 cm or greater). The continence rate (83% vs 80%, p = 0.65) and mean followup (32 vs 25 months, p = 0.14) were similar in the 2 groups. Erosion developed in 16 of the 176 patients (9%) during the study period, of whom 13 had the 3.5 cm cuff. Of the 100 patients with the 3.5 cm cuff 52 (52%) had a history of radiation, including 11 (21%) with erosion. Cuff erosion developed only rarely in nonirradiated men (2 of 48 or 4%, p = 0.01). A history of radiation was the only significant risk factor associated with 3.5 cm cuff erosion (OR 6.2, 95% CI 1.3-29.5). CONCLUSIONS: Men with a history of radiation who underwent placement of a 3.5 cm artificial urinary sphincter cuff experienced an increased (21%) risk of cuff erosion.

Malleable penile prosthesis is a cost-effective treatment for refractory ischemic priapism.

INTRODUCTION: Refractory ischemic priapism (RIP) can be difficult to treat, consuming significant healthcare-related resources. Acute insertion of a malleable penile prosthesis (MPP) has been reported as an effective therapy that treats the priapism and restores sexual function. AIM: We report our 6-year, urban public hospital experience with acute insertion of MPP in patients with RIP. METHODS: We retrospectively reviewed the records of patients receiving MPPs for RIP from 2007 to 2013. Data analyzed included duration of erection, number of emergency room (ER) visits, hospital admissions, days of hospitalization, and postoperative course. Costs were estimated using standard Medicare reimbursement rates. MAIN OUTCOME MEASURE: Healthcare-related costs of treatment of RIP episodes in men presenting to our institution. RESULTS: During the study period, 14 men underwent MPP placement acutely for refractory priapism. Thirteen presented with RIP, and one had stuttering priapism over a 14-day hospitalization. Etiologies included sickle cell anemia (4/13, 29%), medication-induced (3/14, 21%), and idiopathic (7/14, 50%). Average preoperative duration of RIP was 82 hours with considerable consumption of health-care resources (average US $83,818 estimated cost, 4 ER visits [range 1-27], 2 hospital admissions [range 1-5], 1.5 shunt procedures [range 1-3], 5 irrigation and drainage procedures using phenylephrine injection [range 2-20], and 5 hospital admission days [range 2-14]). All patients were discharged within 24 hours of MPP surgery. CONCLUSIONS: The management of RIP is associated with multiple ER visits, prolonged hospital admissions, and significant resource utilization. MPP insertion is efficacious for the immediate resolution of refractory priapism, with potential cost and resource benefits.

A case of Fournier's gangrene necessitating total penectomy.

Fournier's gangrene is an uncommon necrotizing infection affecting the genital and perineal area. Penile involvement in particular is rare owing to its rich vascular supply. In this report, we document a case of Fournier's gangrene involving penile and urethral tissue requiring multiple debridements resulting in significant penile deformity and a non-healing wound. Eventually, the patient underwent penectomy and perineal urethrostomy creation. In this case, penectomy and perineal urethrostomy provide a functional outcome for highly refractory and complex patients with Fournier's gangrene involving penile tissue.

'7-flap' perineal urethrostomy: an effective option for obese men with devastated urethras.

INTRODUCTION: To present an updated experience using our previously reported lateral perineal '7-flap' technique for perineal urethrostomy (PU), highlighting its role in a variety of patients with advanced urethral stricture disease. MATERIALS AND METHODS: All patients who underwent 7-flap PU from 2009-2013 were reviewed. PU was constructed by advancing a "7"-shaped laterally based perineal skin flap into a spatulated, amputated bulbomembranous urethra. The contralateral side of the amputated proximal urethra was then matured to the advanced perineal skin. Patients were stratified by body mass index (BMI) and outcomes were compared. RESULTS: Among 748 patients undergoing urethroplasty during the study period, 22 men (2.9%; mean age 61, range 31-80) received a 7-flap PU for advanced stricture disease (mean follow up 32 months). A majority of patients (14/22, 64%) were obese (BMI = 30). Disease etiologies consisted primarily of lichen sclerosus (9/22, 41%) while 6/22 (27%) had failed prior urethral reconstructions elsewhere. Mean operative time was 108 min (range 54-214), mean estimated blood loss (EBL) was 76 cc (30-200), and all patients were discharged immediately after surgery. Urethrostomy creation was possible in all patients regardless of BMI (mean 33, range 22-43), and there were no differences with regards to EBL (p = 0.71), operative time (p = 0.38), or success rate (p = 0.76) in obese versus non-obese patients undergoing 7-flap PU. Nearly all patients (21/22, 95%) are voiding spontaneously on follow up without the need for any additional procedure. CONCLUSION: In our updated experience, performance of 7-flap urethrostomy has resulted in durable long term success with acceptable performance in technically challenging cases.

Unintended negative consequences of primary endoscopic realignment for men with pelvic fracture urethral injuries.

PURPOSE: We evaluated the clinical course of patients with pelvic fracture urethral injury referred to our institution to elucidate the differences between initial management strategies. MATERIALS AND METHODS: We retrospectively reviewed our institutional review board approved, prospectively maintained urethroplasty database from 2007 to 2013. Patients with pelvic fracture urethral injury were stratified into 2 groups based on initial treatment before referral. Group 1 (21 of 38, 55%) was treated with suprapubic tube placement alone followed by elective bulbomembranous anastomotic urethroplasty and group 2 (17 of 38, 45%) underwent early primary endoscopic realignment. We recorded the number of endoscopic interventions and time from injury to successful definitive treatment. Data regarding stricture length, reconstruction technique and treatment outcomes were analyzed. RESULTS: Among 766 urethroplasties performed during the study interval 38 (5%) consecutive pelvic fracture urethral injury cases were identified with complete information available and all underwent repair with excision with primary anastomosis. For suprapubic tube/bulbomembranous anastomotic urethroplasty cases the mean time to definitive resolution of stenosis was dramatically shorter (7 months, range 3 to 15) compared to primary endoscopic realignment cases (122 months, range 4 to 574; p <0.01). The majority of patients treated with primary endoscopic realignment required multiple endoscopic urethral interventions (median 4, range 1 to 36; p <0.01) and/or experienced various other adverse events which were rarely noted in the suprapubic tube/bulbomembranous anastomotic urethroplasty group (14 of 17 [82%] vs 2 of 21 [10%], p <0.05). CONCLUSIONS: Treatment of pelvic fracture urethral disruption injuries with primary endoscopic realignment appears to be associated with unintended negative consequences including additional interventions and a prolonged clinical course.

Immediate urethral repair during explantation prevents stricture formation after artificial urinary sphincter cuff erosion.

PURPOSE: We compare stricture outcomes in patients with artificial urinary sphincter cuff erosion managed with and without synchronous urethral repair. MATERIALS AND METHODS: Records of patients who underwent artificial urinary sphincter removal for cuff erosion from 2007 to 2013 were retrospectively reviewed. Two cohorts of patients were evaluated, with those in group 1 treated with in situ urethroplasty and those in group 2 treated with a Foley catheter only. We compared demographic, clinical and radiological data to assess resultant stricture disease, and compared operative times between the cohorts. RESULTS: Of the 26 artificial urinary sphincter cuff erosion cases identified 13 underwent in situ urethroplasty while 13 did not. Mean patient age was 73 years (range 61 to 83) with a mean followup of 24 months (range 8 to 69). The rate of urethral stricture formation after artificial urinary sphincter explantation was significantly reduced among patients treated with in situ urethroplasty (5 of 13, 38%) compared to those treated with Foley catheter only (11 of 13, 85%; p=0.047). Mean operative times were similar at 78 minutes (50 to 133) for the in situ urethroplasty group vs 70 minutes (51 to 92) for the Foley catheter only group (p=0.39). Those treated with in situ urethroplasty underwent significantly fewer procedures per patient before artificial urinary sphincter replacement (0.4 vs 1.1, p=0.004) and had a much higher rate of eventually undergoing secondary artificial urinary sphincter implantation (7 of 13, 54% vs 2 of 13, 15%, p=0.04) compared to those with cuff erosion treated with Foley catheter only. CONCLUSIONS: Urethral repair at the time of artificial urinary sphincter explantation for cuff erosion appears to prevent stricture development, thus facilitating successful artificial urinary sphincter replacement.

Decreasing need for artificial urinary sphincter revision surgery by precise cuff sizing in men with spongiosal atrophy.

PURPOSE: Many patients with persistent incontinence after an artificial urinary sphincter procedure gain improved continence after cuff downsizing. In 2010 a new, smaller (3.5 cm) artificial urinary sphincter cuff was introduced. We hypothesized that men with spongiosal atrophy previously treated with a 4.0 cm cuff would now show a decreased rate of revision surgery due to more accurate cuff sizing. MATERIALS AND METHODS: We evaluated the outcome in men who received identical 4.0 cm cuff sizes in 2 eras, before (2007 to 2009) and after (2010 to 2013) the introduction of the 3.5 cm artificial urinary sphincter cuff. Patients with a history of cuff erosion or those undergoing tandem, transcorporal, or 4.5 cm or greater cuff placement were excluded from analysis. We validated our institutional results using the nationwide AMS® PIF (Patient Information Form) database from identical time frames. RESULTS: Of 236 men who underwent artificial urinary sphincter placement at our institution during the study period 170 with a mean age of 67 years met study inclusion criteria, of whom 88 (52%) received a 4.0 cm artificial urinary sphincter cuff. Mean followup was 34 months. Ten of 45 patients (22.2%) who had a 4.0 cm cuff placed from 2007 to 2009 required cuff downsizing for persistent incontinence while only 2 of 43 (4.7%) who received a 4.0 cm cuff from 2010 to 2013 required revision (p <0.001). Nationally patients with a 4.0 cm cuff underwent fewer revisions during the latter era (16.2% vs 7.5%, p = 0.001). In local and national cohorts Kaplan-Meier analysis revealed improved survival of the 4.0 cm cuff after the introduction of the 3.5 cm cuff (p <0.05). CONCLUSIONS: The incidence of artificial urinary sphincter revision surgery in patients with a 4.0 cm cuff has decreased since the availability of the 3.5 cm cuff. This suggests that precise cuff sizing appears to be beneficial in men with spongiosal atrophy.

Ureteral strictures and reconstruction in the cancer survivor.

PURPOSE OF REVIEW: Ureteral stricture disease commonly affects the cancer patients. This report will review the recent literature regarding both the causes and treatment options currently available for the cancer patients with ureteral obstruction. RECENT FINDINGS: Open ureteral reconstruction continues to have durable long-term results, whereas robotic approaches to repair have also demonstrated technical feasibility with equivalent short-term outcomes. SUMMARY: Stricture formation in the distal ureter is a common consequence of treatment for patients with pelvic malignancies. In experienced hands, minimally invasive approaches to ureteral reconstruction have proven to be feasible with short-term outcomes that are equivalent to more traditional, open techniques. Additionally, laparoscopic or robotic surgeries offer added benefits of earlier convalescence, decreased blood loss, as well as decreased pain. Nevertheless, open ureteral repair remains a viable option with durable long-term outcomes.

High submuscular versus space of Retzius placement of inflatable penile prosthesis reservoirs: results of a surgeon survey.

INTRODUCTION: High submuscular (HSM) inflatable penile prosthesis (IPP) reservoir insertion is a new technique that involves placing the reservoir high beneath the muscles of the abdominal wall. We queried a variety of surgeons to assess their impressions of how HSM reservoir placement compares with traditional space of Retzius (SOR) placement. MATERIALS AND METHODS: A nationwide group of urologists trained in HSM reservoir placement was surveyed to assess preferences and concerns compared to SOR placement. Using a Likert scale survey, we compared HSM to traditional SOR placement with regard to ease of implementation, surgical preference, and patient safety. Results were analyzed according to numbers of implants performed by the surgeons. RESULTS: A total of 25 urologists from eight states participated in this survey (12 residents and 13 attending surgeons). Overall, surgeons report that HSM placement is safer (p < 0.001). The participants believed it conveyed lower risk to visceral (p < 0.001) and vascular (p < 0.001) structures. Moreover it was easier to learn (p = 0.008) and to teach (p = 0.002). The majority (17/25, 68%) prefer HSM reservoir placement, while 4/25 (16%) are neutral, and 4/25 (16%) prefer SOR. Among high volume implanters (> 20 implants/year), 7/9 (78%) prefer the HSM technique and report that it is safer (p = 0.001) with lower risk of visceral (p = 0.010) and vascular (p < 0.001) injuries. CONCLUSIONS: Urologists trained in HSM reservoir placement report that this technique is readily implemented, strongly preferred, and safer for patients.

Early aggressive treatment of lichen sclerosus may prevent disease progression.

PURPOSE: When not recognized and treated aggressively, lichen sclerosus may progress and cause debilitating symptoms. It also may result in significant morbidity in patients undergoing treatment for urethral strictures because unrecognized, it may result in rapid and severe recurrence after surgical treatment. We present our experience treating patients with lichen sclerosus in an equal access health care system. MATERIALS AND METHODS: We performed an institutional review board approved retrospective review of all adult men with lichen sclerosus treated at our institution during a 10-year period. We analyzed all patients diagnosed with lichen sclerosus, and recorded patient demographics and therapies. We recorded characteristics of the disease process including external and internal manifestations. We also recorded the various treatments, and whether the patients experienced recurrence. RESULTS: A total of 43 patients were diagnosed with lichen sclerosus during the review period. Of those patients presenting with more severe (urethral) involvement and undergoing 1 or 2-stage urethroplasties, we noted 7 with recurrence. In the remainder of patients presenting with less severe disease who were treated aggressively with clobetasol and/or minor procedures, no recurrences were noted on followup examination, and all of these patients had documented normal flow patterns on noninvasive urodynamics. CONCLUSIONS: Our data suggest that early aggressive topical therapy plus minimally invasive surgical therapy to relieve high pressure voiding may prevent the progression of lichen sclerosus in patients who present with limited disease involving the skin and meatus.

Content and construct validation of a robotic surgery curriculum using an electromagnetic instrument tracker.

PURPOSE: Rapid adoption of robot-assisted surgery has outpaced our ability to train novice roboticists. Objective metrics are required to adequately assess robotic surgical skills and yet surrogates for proficiency, such as economy of motion and tool path metrics, are not readily accessible directly from the da Vinci® robot system. The trakSTAR™ Tool Tip Tracker is a widely available, cost-effective electromagnetic position sensing mechanism by which objective proficiency metrics can be quantified. We validated a robotic surgery curriculum using the trakSTAR device to objectively capture robotic task proficiency metrics. MATERIALS AND METHODS: Through an institutional review board approved study 10 subjects were recruited from 2 surgical experience groups (novice and experienced). All subjects completed 3 technical skills modules, including block transfer, intracorporeal suturing/knot tying (fundamentals of laparoscopic surgery) and ring tower transfer, using the da Vinci robot with the trakSTAR device affixed to the robotic instruments. Recorded objective metrics included task time and path length, which were used to calculate economy of motion. Student t test statistics were performed using STATA®. RESULTS: The novice and experienced groups consisted of 5 subjects each. The experienced group outperformed the novice group in all 3 tasks. Experienced surgeons described the simulator platform as useful for training and agreed with incorporating it into a residency curriculum. CONCLUSIONS: Robotic surgery curricula can be validated by an off-the-shelf instrument tracking system. This platform allows surgical educators to objectively assess trainees and may provide credentialing offices with a means of objectively assessing any surgical staff member seeking robotic surgery privileges at an institution.

Mechanism of Action of the Transobturator Sling for Post-Radical Prostatectomy Incontinence: A Multi-institutional Prospective Study Using Dynamic Magnetic Resonance Imaging.

OBJECTIVE: To compare the length of the membranous (functional) urethra in male patients who underwent the male transobturator sling (TOS) for postradical prostatectomy urinary incontinence (PPI). The TOS is in established use for treatment of PPI; however, the precise mechanism of action is unknown. MATERIALS AND METHODS: This is a prospective case-controlled study on men undergoing male TOS surgery from 2008 to 2014. The comparison arm included patients without incontinence after radical prostatectomy. All participants underwent dynamic magnetic resonance imaging (MRI) at baseline and this was repeated after TOS placement for those who underwent the procedure. Three standardized points were measured using MRI and compared in both groups in addition to clinical measures. RESULTS: Thirty-nine patients were enrolled and 31 patients completed the protocols. The controls (N = 14) had a longer vesicourethral anastomosis to urethra measured at the penile bulb (functional urethral length) distance compared to the pre-TOS group at rest (1.92 cm controls vs 1.27 cm pre-TOS, P = .0018) and at Valsalva (2.13 cm controls vs 1.72 cm pre-TOS, P = .0371). Placement of the sling (N = 17) increased the functional urethral length distance at rest (1.92 cm control vs 1.53 cm post-TOS, P = .09) and at Valsalva (1.94 cm post-TOS vs 2.13 cm control, P = .61), so that the difference was no longer statistically significant. CONCLUSION: We identified that one possible mechanism in improvement in stress urinary incontinence post-TOS placement is the lengthening of the vesicourethral anastomosis to bulbar-urethra distance. This is the first such study utilizing dynamics MRI in post prostatectomy controls, incontinent pre-TOS, and post-TOS to assess and show these findings.