Revisiting Fournier's Gangrene: A Contemporary Epidemiological Perspective vs. Perineal Cellulitis.

INTRODUCTION: We conducted a population-based analysis of Fournier's gangrene to compare risk factors and mortality with perineal cellulitis. METHODS: We analyzed National Inpatient Sample data (2016-2020) to identify Fournier's gangrene and perineal cellulitis cases. Demographic, comorbidity, and procedural data were extracted. Logistic models assessed risk factors for Fournier's gangrene diagnosis and mortality. RESULTS: A total of 73,472 cellulitis and 9,326 Fournier's gangrene cases were identified corresponding to 74,905 (range 63,050-79,165) and 9,115 (range 7,925-11,080) median yearly weighted cases, respectively. Fournier's gangrene diagnosis vs cellulitis was positively associated with Native American race (OR 1.46, 95% CI 1.19-1.79), weekend (OR 1.12, 95% CI 1.06-1.18) or December (OR 1.33, 95% CI 1.22-1.44) admissions, diabetes mellitus (OR 2.51, 95% CI 2.38-2.64), and malignancy (OR 2.29, 95% CI 2.07-2.54). Conversely, Hispanic (OR 0.79, 95% CI 0.74-0.85), Asian/Pacific Islander races (OR 0.83, 95% CI 0.69-0.99), and the highest household income quartile (OR 0.84, 95% CI 0.78-0.90) were linked to a reduced likelihood of Fournier's gangrene diagnosis. Elevated mortality risks were observed with female gender (OR 1.33, 95% CI 1.08-1.63), Native American ethnicity (OR 2.29, 95% CI 1.14-4.57), and procedural frequency (OR 1.27, 95% CI 1.24-1.3) among Fournier's gangrene cases. CONCLUSIONS: Various patient and clinical factors are linked to the development and mortality of Fournier's gangrene compared to perineal cellulitis. Improved access to care and understanding of Fournier's gangrene can enhance patient outcomes.

Higher Morbidity and Mortality in Females With Fournier's Gangrene Compared to Males: Insights From National Inpatient Sample Data.

PURPOSE: To compare Fournier's gangrene in female and male patients, and identify mortality-associated characteristics in both. MATERIALS AND METHODS: We employed National Inpatient Sample data (2016-2020) to identify Fournier's gangrene cases and extracted demographic, comorbidity, and procedural variables. Multivariable regression models were utilized to identify mortality risk factors for both cohorts. RESULTS: We identified 2875 females (31%) and 6451 males (69%) with Fournier's gangrene corresponding to an estimated 14,375 (95% CI 13,784-14,966) and 32,255 (95% CI 31,390-33,120) cases, respectively. Females were more likely to die than males (7.1% vs 5.7%, P < .0001, respectively). Median incidence rates were 1.7 (IQR 1.5-1.8) and 4 (IQR 3.6-4.3) cases per 100,000 person-years for females and males, respectively. Females had higher median age, longer hospital stays, more charges, procedures, and fecal diversion rates, but lower routine discharges than males (P < .05). Non-White females had increased mortality odds compared to White females (odds ratio [OR] 1.49, 95% CI 1.07-2.07, P = .019). Prolonged interval until initial perineal debridement correlated with higher mortality odds in both females and males (OR 1.02, 95% CI 1-1.04, P = .034 vs OR 1.03, 95% CI 1.01-1.05, P < .0001). Diabetes lowered mortality odds in females and males (OR 0.68, 95% CI 0.47-0.99, P = .046 vs OR 0.54, 95% CI 0.41-0.7, P < .0001). CONCLUSIONS: In females, Fournier's gangrene incidence surpasses previous reports, with slightly worse outcomes compared to males, emphasizing the need for precise clinical assessment and early intensive interventions.

The Epidemiology of Genitourinary Self-Inflicted Injuries: Analysis of the National Trauma Databank.

OBJECTIVES: To provide insight into the epidemiologic characteristics and trends of genitourinary (GU) self-inflicted injury (SII). METHODS: We used data from the National Trauma Databank between 2017-2020. We described the characteristics of GU SII cases based on injured organ and then compared male and female injuries. RESULTS: We identified 56,463 patients with SII, of which 1,508 (2.7%) had GU involvement. Most cases were male patients (77.3%) and white (70.6%). Median age was 35 years (IQR 26 - 50). The most commonly injured GU organs was kidney (43.4%), followed by scrotum / testes (22.5%), and penis (18.2%). Most cases (89.9%) represented a single-organ injury whereas 10.1% had two or more GU organs injured. Seventy-three of those with kidney injuries (11.2%) underwent nephrectomy. Only one patient performing GU SII had a diagnosis code for transsexualism but the majority (82.2%) suffered from pre-existing conditions of which 20.5% had three or more comorbidities. More than half the population (54.9%) had preexisting diagnosed mental or personality disorder. A non-GU co-injury was present in most cases (70.8%), most commonly affecting another abdominal organ (44.3%) or fractures (41.3%). A positive drug screen was found in 30.7% of cases. Most patients survived though 15.4% died. 94% of fatal cases had a concomitant non-GU injury. CONCLUSIONS: GU injuries account for 2.6% of all SII. These patients are often young white males with known mental or personality disorders. Kidneys were most common injuried and mortality was highest in cases of kidney and bladder injuries with multi-organ trauma involving non-GU organs.

Consumer product-related female genital injuries in the USA from 2013 to 2022.

BACKGROUND: Consumer product-related genital injuries in females across all age groups are understudied. Existing research focuses primarily on paediatric populations. We aimed to determine characteristics, trends and predictors of hospitalisation. METHODS: The National Electronic Injury Surveillance System database was queried for female genital injuries from 2013 to 2022. We stratified our population into four age groups (<18, 18-34, 35-54, >54 years). Automated text matching and manual reviews were employed for variable extraction. χ2 tests and logistic regression were conducted, accounting for survey design and weights. RESULTS: 9054 cases representing a national estimate of 252 329 injuries (95% CI 188 059 to 316 599) were identified. Paediatric injuries were most common (61%) and seniors had the highest hospitalisation rates (28%). Falls were common in paediatric (51%) and senior (48%) groups, whereas self-induced and topical application injuries were more frequent among adults aged 18-34 and 35-54. Injuries predominantly involved playground equipment and bicycles in children, razors and massage devices in adults aged 18-34 and 35-54 and household structures in seniors. Hospitalisation increased over the decade from 7% to 9%; significant predictors of hospitalisation were Asian race (OR=3.39, 95% CI 1.83 to 6.30), fractures (OR=7.98, 95% CI 4.85 to 13.1) and urethral injury (OR=3.15, 95% CI 1.30 to 7.63). CONCLUSIONS: Our study identifies distinct patterns in female genital injuries across ages. In the paediatric cohort, injuries are often linked to playgrounds and bicycles. For adults, grooming products are frequently implicated. Seniors commonly suffer injuries from household structures such as bathtubs. These patterns may inform discussions on tailored preventive strategies.

Ejaculatory function after radiotherapy for prostate cancer: a systematic review and meta-analysis.

BACKGROUND: Scant data exists on the impacts of prostate radiation on ejaculatory function. We performed a systematic review and meta-analysis to assess ejaculatory outcomes in men after prostate radiation. METHODS: We queried PubMed, Embase, and Web of Science to identify 17 articles assessing ejaculatory function post-radiation. The primary outcome was anejaculation rate and secondary outcomes included ejaculatory volume (EV), ejaculatory discomfort, and mean decline in ejaculatory function scores (EFS). We assessed study quality with the Newcastle-Ottawa scale. We calculated pooled proportions using inverse variance and random effects models. RESULTS: We identified 17 observational studies with 2156 patients reporting ejaculatory profiles post-radiation. Seven studies utilized external beam radiation therapy, 7 brachytherapy, 1 stereotactic RT and 2 utilized either external or brachytherapy. Ten studies reported an anejaculation rate. Pooled proportion of patients having anejaculation, decreased EV and EjD were 18% (95% CI, 11-36%), 85% (95% CI, 81-89%) and 24% (95% CI, 16-35%), respectively. Five studies reported decline in EFS post-radiation. CONCLUSIONS: Patients receiving radiation treatment may experience significant changes in their ejaculation, such as the absence of ejaculation, reduced EV, and EjD. It is important to counsel them about these potential side effects.

Injuries With Electric vs Conventional Scooters and Bicycles.

Importance: Micromobility, the use of small vehicles (primarily scooters and bicycles), has become a standard transportation method in the US. Despite broad adoption of electric micromobility vehicles, there is a paucity of data regarding the injury profiles of these vehicles, particularly in the US. Objective: To characterize micromobility injury trends in the US, identify demographic characteristic differences in users of electric and conventional vehicles, and identify factors associated with hospitalization. Design, Setting, and Participants: This cross-sectional study queried the National Electronic Injury Surveillance System, a comprehensive database that collates injury data associated with consumer products from emergency departments across the US to provide national estimates, from calendar year 2017 to 2022. Data on micromobility vehicle injuries (bicycles, scooters, electric bicycles [e-bicycles], and electric scooters [e-scooters]) were obtained. Main Outcomes and Measures: Trends in injury and hospitalization counts, injury characteristics, and factors associated with hospitalization. Results: From 2017 to 2022, the US recorded 2 499 843 bicycle (95% CI, 1 948 539-3 051 147), 304 783 scooter (95% CI, 232 466-377 099), 45 586 e-bicycle (95% CI, 17 684-73 488), and 189 517 e-scooter (95% CI, 126 101-252 932) injuries. The median age of the riders was 28 (IQR, 12-51) years; 72% were male, 1.5% Asian, 13% Black, 12% Hispanic, and 49% White. Annual e-bicycle and e-scooter injuries increased from 751 (95% CI, 0-1586) to 23 493 (95% CI, 11 043-35 944) and injuries increased from 8566 (95% CI, 5522-11 611) to 56 847 (95% CI, 39 673-74 022). Compared with conventional vehicles, electric vehicle accidents involved older individuals (median age, 31 vs 27 years; P < .001) and a higher proportion of Black riders (25% vs 12%; P < .001). Helmet use was less in electric vehicle incidents compared with conventional vehicles (43% vs 52%; P = .02), and injuries were more common in urban settings (83% vs 71%; P = .008). Age-adjusted odds of hospitalization among all Black individuals compared with White individuals was 0.76 (95% CI, 0.59-0.98; P = .04). Conclusions and Relevance: In this cross-sectional study of micromobility vehicles, an increased number of injuries and hospitalizations was observed with electric vehicles compared with conventional vehicles from 2017 to 2022. These findings suggest the need for change in educational policies, infrastructure, and law to recenter on safety with the use of micromobility vehicles.

Patient Perception of Physician Reimbursement by Medicare for Artificial Urinary Sphincter Placement.

INTRODUCTION: Patient perceptions of physician reimbursement commonly differ from actual reimbursement. This study aims to improve health care cost transparency and trust between patients, physicians, and the health care system by evaluating patient perceptions of Medicare reimbursement for artificial urinary sphincter (AUS) placement. METHODS: We identified patients who underwent AUS placement at a single institution from 2014 to 2023. After obtaining informed consent, we administered a telephone survey to ask patients about their perceptions of Medicare reimbursement for AUS surgery and the amount they felt the physician should be compensated. RESULTS: Sixty-four patients were enrolled and completed the survey. On average, patients estimated Medicare physician reimbursement to be $18,920, 25 times the actual average procedure reimbursement. Once informed that the actual amount was $757.52, 97% of respondents felt that the reimbursement was "somewhat lower" (13%) or "much lower" (84%) than what they considered fair. The average amount that patients felt the physician should be paid was $8,844, 12 times the actual average procedure reimbursement. Fifty-four percent of patients estimated their physician's reimbursement to be higher than what they later reported as being "fair," representing a presurvey belief that their physician was overpaid. CONCLUSIONS: Patient perceptions of physician reimbursement for AUS are vastly different than the actual amount paid. The discordance between patient perception and actual reimbursement could impact how patients view health care costs and the relationship with their provider.

Fragility of overactive bladder medication clinical trials: A systematic review.

PURPOSE: Overactive bladder (OAB) syndrome significantly impairs quality of life, often necessitating pharmacological interventions with associated risks. The fragility of OAB trial outcomes, as measured by the fragility index (FI: smallest number of event changes to reverse statistical significance) and quotient (FQ: FI divided by total sample size expressed as a percentage), is critical yet unstudied. MATERIALS AND METHODS: We conducted a systematic search for randomized controlled trials on OAB medications published between January 2000 and August 2023. Inclusion criteria were trials with two parallel arms reporting binary outcomes related to OAB medications. We extracted trial details, outcomes, and statistical tests employed. We calculated FI and FQ, analyzing associations with trial characteristics through linear regression. RESULTS: We included 57 trials with a median sample size of 211 participants and a 12% median lost to follow-up. Most studies investigated anticholinergics (37/57, 65%). The median FI/FQ was 5/3.5%. Larger trials were less fragile (median FI 8; FQ 1.0%) compared to medium (FI: 4; FQ 2.5%) and small trials (FI: 4; FQ 8.3%). Double-blinded studies exhibited higher FQs (median 2.9%) than unblinded trials (6.7%). Primary and secondary outcomes had higher FIs (median 5 and 6, respectively) than adverse events (FI: 4). Each increase in 10 participants was associated with a +0.19 increase in FI (p < 0.001). CONCLUSIONS: A change in outcome for a median of five participants, or 3.5% of the total sample size, could reverse the direction of statistical significance in OAB trials. Studies with larger sample sizes and efficacy outcomes from blinded trials were less fragile.

Electric Bicycle Injuries and Hospitalizations.

This cross-sectional study investigates injury trends associated with electric bicycles in the US from 2017 to 2022.

Real-World Complications of the SpaceOAR Hydrogel Spacer: A Review of the Manufacturer and User Facility Device Experience Database.

OBJECTIVE: To characterize adverse events related to use of the perirectal spacing agent SpaceOAR, we examined the Manufacturer and User Facility Device Experience (MAUDE) database. METHODS: The MAUDE database was queried for "SpaceOAR" and "Augmenix" from June 2015 (when SpaceOAR was approved by the Food and Drug Administration) to October 2022. Reports were reviewed for adverse events (AEs), operative procedures performed because of the AE, and changes to the radiation plan. AEs were categorized using Common Terminology Criteria for Adverse Events (CTCAE), version 5.0. RESULTS: Six hundred fifty-four reports were reviewed. Eighty-four were excluded and 4 reports reviewed 2 separate cases of SpaceOAR administration. Five hundred seventy-four cases were ultimately included. Three deaths were reported (0.5% of all AEs). One point six percent of cases represented CTCAE grade 4 injuries (life-threatening consequences; urgent intervention indicated), 15.9% grade 3 (severe but not immediately life-threatening; hospitalization), 24.2% grade 2 (moderate; local/noninvasive intervention), and 57% of events were CTCAE grade 1 (mild; asymptomatic or mild symptoms). Bowel diversion occurred in 29 cases (9%). CONCLUSION: Both asymptomatic (n = 311) and debilitating (n = 12) complications of SpaceOAR hydrogel use were identified. Death, gel embolization, anaphylaxis, rectal ulcerations, and infections requiring bowel or urinary diversions were among the complications reviewed. Providers should consider these potential complications before perirectal spacer administration and during patient counseling.

Reimagining Ambulatory Care in Urology: Conversion of the Urology Clinic into a Procedure Center Improves Patient's Experience.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic made it necessary to practice social distancing and limited in-person encounters in health care. These restrictions created alternative opportunities to enhance patient access to care in the ambulatory setting. We hypothesized that by transforming clinics into centers that prioritize procedures and transitioning ambulatory appointments to telehealth, we could establish a secure, streamlined, and productive method for providing patient care. Methods: Clinic templates were restructured to allow the use of the physical space to perform procedure-based clinics exclusively, while switching to virtual telemedicine for all nonprocedural encounters. Staff members were given specific roles to support one of the patient care modalities for a given day (Procedures vs. Telehealth). Performance and patient satisfaction metrics were collected between two periods of time defined as P1 (February-June 2019) and P2 Post-COVID (February-June 2020) and compared. These served as proxies of periods when the clinic workflow and templates were structured in the traditional versus the emerging way. Statistical analysis was performed using bivariate analyses. Results: The percentage of procedures performed among all in-person visits were higher in P2 compared to P1 (45% vs. 29%, p < 0.001). Although total charges and relative value units were lower in P2, the overall revenue generated was higher compared to P1 ($4,597,846 vs. $4,517,427$, respectively). This increase in revenue was mainly driven by the higher relative income generated by procedures. Patient experience, reflected through patient-reported outcomes, was more favorable in P2 where patients seemed more likely to "Recommend this provider office" (90% vs. 85.7%, p = 0.01), report improved "Access overall" (56% vs. 49%, p = 0.02), and felt they were "Moving through your visit overall" (59% vs. 51%, p = 0.007). Conclusions: Our data suggest that reorganizing urology clinics into a space that is centered around outpatient procedures can represent a model that improves the patient's access to care and clinical experience, while simultaneously improving operational financial strength. This efficient care model could be considered for many practice settings and drive high-value outpatient care.

Oral phosphodiesterase type 5 inhibitors and priapism: A VigiBase analysis.

PURPOSE: To explore the differences of priapism events among a diverse cohort taking erectogenic medicines (i.e., phosphodiesterase type 5 inhibitors [PDE5i] and intracavernousal drugs). METHODS: We queried the World Health Organization global database of individual case safety reports (VigiBase) for records of the adverse drug reactions (ADR) with sildenafil, tadalafil, avanafil, vardenafil, papaverine, and alprostadil. Disproportionality analyses (case/non-case approach) were performed to assess the reporting odds ratio (ROR) of priapism reporting in PDE5i consumers compared to intracavernousal drug recipients. RESULTS: From a total of 133 819 ADR events for erectogenic medications, 632 were priapism (PDE5is: n = 550, 0.41%; intracavernousal drugs: n = 82, 9.92%). Priapism disproportionality signals from intracavernousal drugs were 25 times stronger than PDE5is (ROR = 34.7; confidence interval [CI] 95%: 27.12-43.94 vs. ROR = 1.38; 95% CI: 1.24-1.54). For all PDE5i agents, the 12-17 years age group had the highest ROR (9.49, 95% CI: 3.76-19.93) followed by 2-11 years (4.31, 95% CI: 1.57-9.4). Disproportionality signals for consumers under 18 for both all PDE5is as a whole (ROR = 4.57, 95% CI: 2.48-7.73) and sildenafil (ROR = 4.89, 95% CI: 2.51-8.62) were stronger than individuals 18 or older (ROR = 1.06, 95% CI: 0.93-1.21 and ROR = 1.08, 95% CI: 0.91-1.26, respectively). CONCLUSIONS: PDE5i use shows disproportionate priapism signals which are higher in young patients.

Conservative Management of Penile and Urethral Lichen Sclerosus: A Systematic Review.

PURPOSE: We evaluate the efficacy and safety profiles of currently available conservative management options for penile and urethral lichen sclerosus. MATERIALS AND METHODS: A systematic review of existing literature on lichen sclerosus was conducted utilizing the PubMed, Embase, and Web of Science databases. References were assessed for relevance to nonsurgical management of male genital lichen sclerosus by title and abstract by 3 independent reviewers, then reviewed in full and in duplicate by 5 independent reviewers. RESULTS: Seventeen studies describing conservative management of histologically confirmed penile and urethral lichen sclerosus in male patients were included in the final review. We present available evidence supporting the use of 4 major treatment modalities represented in the existing literature: topical corticosteroids, tacrolimus, platelet-rich plasma, and CO2 laser. We also briefly discuss the limited studies on the use of oral acitretin and polydeoxyribonucleotide injections. Outcomes assessed include symptoms, clinical appearance, quality of life, sexual satisfaction, adverse effects, and long-term efficacy of treatment. CONCLUSIONS: Topical corticosteroids remain the mainstay of conservative management of penile and urethral lichen sclerosus, with current literature supporting the use of other therapies such as tacrolimus and platelet-rich plasma as alternatives or adjuvant treatments when escalation of treatment is necessary. Future research should further explore the efficacy and safety of newer therapies through additional controlled clinical trials in the targeted population.

Urethral Slings for Irradiated Patients With Male Stress Urinary Incontinence: A Meta-analysis.

OBJECTIVE: To systematically compare success, cure and complication rates of urethral sling surgeries in stress urinary incontinence patients with and without a history of pelvic radiotherapy (RT). MATERIALS AND METHODS: We searched PUBMED, EMBASE, and Web of Science to identify relevant articles. The primary outcomes were the success and cure rates. The secondary outcomes included the rates of infection, urethral erosion, total complications, explantation, and satisfaction. Outcomes were analyzed using a random-effects model to calculate the unadjusted odds ratio (OR) in patients with a history of RT compared with those without prior RT. RESULTS: On pooled analysis, we found significantly lower odds of success (OR 0.68; 95% confidence interval [CI] 0.53-0.87, P < .001) and cure (OR 0.67; 95% CI 0.55-0.82, P < .001) in radiated patients than in nonirradiated patients. Subgroup analysis by type of sling showed significantly lower odds of success in Advance subgroup (OR 0.66; 95% CI 0.45-0.95, P < .001) and significantly lower odds of cure in Advance (OR 0.59; 95% CI 0.36-0.95, P < .001) and Atoms subgroups (OR 0.70; 95% CI 0.54-0.93, P < .001). We also found significantly greater odds of sling explantation (OR 2.93; 95% CI 1.62-5.29, P < .001) and infection (OR 3.06, 95% CI 1.03-9.07, P < .001) in radiated patients than in nonradiated patients. CONCLUSION: Patients with a history of pelvic RT have lower odds of success and cure and higher odds of infection and sling explantation than those without a history of pelvic RT.

Haemorrhagic cystitis: a review of management strategies and emerging treatments.

Haemorrhagic cystitis (HC) is characterised by persistent haematuria and lower urinary tract symptoms following radiotherapy or chemotherapy. Its pathogenesis is poorly understood but thought to be related to acrolein toxicity following chemotherapy or fibrosis/vascular remodelling after radiotherapy. There is no standard of care for patients with HC, although existing strategies including fulguration, hyperbaric oxygen therapy, botulinum toxin A, and other intravesical therapies have demonstrated short-term efficacy in cohort studies. Novel agents including liposomal tacrolimus are promising targets for further research. This review summarises the incidence and pathogenesis of HC as well as current evidence supporting its different management strategies.

Comparative analysis of partial versus radical nephrectomy for renal cell carcinoma: Is oncologic safety compromised during nephron sparing in higher stage disease?

Objectives: Over the past 20 years, the utility of partial nephrectomy (PN), compared to radical nephrectomy (RN), for the management of localized renal cell carcinoma (RCC) has progressively increased, particularly for larger and more complex masses. We sought to compare the recurrence-free survival (RFS) outcomes of PN versus RN in a single-institution cohort. Methods: Between 2002 and 2017, 228 patients underwent RN or PN for lcT1a-T2b, N0M0 RCC at a single tertiary referral center, performed by five surgeons. The clinical end point result was (local or distant) RFS. Univariate and multivariate (cox regression) models were used to evaluate the association between type of surgery (PN vs. RN) and RFS, in the overall cohort and in a subgroup of patients with cT1b. Results: The median age was 59 (interquartile range [IQR] 48-66), and the median tumor size was 4.5 cm (IQR 3-7). There were 128 PN and 100 RN. Over a median follow-up of 4.2 years (IQR 2.2-6.9), the Kaplan-Meier analysis showed no significant RFS difference between PN and RN (logrank P = 0.53). On multivariate analysis, pathologic stage ≥T2a, Fuhrman Grade ≥3, and chromophobe histology were associated with a worse RFS. PN was not significantly associated with diminished RFS (Hazard ratio [HR] 1.78, 95% confidence interval [CI] 0.74-4.3, P = 0.199) in the overall cohort compared to RN. However, in the cT1b subgroup, PN was associated with a significant increase in recurrence compared to RN (HR = 12.4, 95% CI 1.45-133.4, P = 0.038). Conclusions: Our institutional data highlight the possibility of compromise in RFS for clinically localized RCC treated with PN compared to RN, particularly for larger and more complex masses. These data raise concern, especially in light of the nonproven association of survival benefit of PN over RN, warranting future randomized prospective studies for further evaluation.

Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study.

PURPOSE: To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management. METHODS: We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery). RESULTS: Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found. CONCLUSION: Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

Clinical and postoperative characteristics of stentless ureteroscopy patients: a prospective analysis from ReSKU.

INTRODUCTION: To evaluate the clinical characteristics as well as the postoperative course of urolithiasis patients undergoing a ureteroscopy (URS) without stent placement. MATERIALS AND METHODS: This was a prospective case cohort study utilizing data collected in the Registry for Stones of the Kidney and Ureter (ReSKU) from a single institution between October 2015 and December 2020. We identified all consecutive patients undergoing URS for stone disease and analyzed data encompassing demographics, medical history, intra and postoperative characteristics, including complications and postoperative symptoms. Univariate and multivariate logistic regression analyses were performed based on the presence or absence of an indwelling ureteral stent. RESULTS: A total of 470 patients were included for analysis, 92 patients in the stentless group (19.5%). Factors associated with stentless ureteroscopy were a lower stone burden (p < 0.001), the pre-existence of a ureteral stent (37.4% vs. 27.9% p = 0.011), absence of an access sheath (14.6% vs. 69.5% p < 0.001), and a shorter operative time (31 vs. 58 min p < 0.001). Postoperative gross hematuria and lower urinary tract symptoms (LUTS) were reported less frequently in stentless patients (p = 0.02, p = 0.01, respectively). There was no difference in postoperative complications between both groups (15.2% vs. 12.0%, p = 0.385). On multivariate analysis, the risk of postoperative complications was associated with obesity, stone burden ≥ 1 cm, and positive preoperative urine culture. There was no patient who required emergent stent placement in the stentless group. CONCLUSION: Our data show that, in well selected patients, omitting ureteral stent placement after URS can decrease postoperative gross hematuria and LUTS without increasing postoperative complications.

The Effect of Bike Seat Models on Perineal Pressure During Cycling: Implications for Patients After Lower Genitourinary Reconstructive Surgery.

OBJECTIVE: To understand the effect of bicycle saddle shape and size on the pressure transmitted to the perineum, as prolonged perineal pressure and microtrauma amongst avid cyclists may increase the risk for complications following lower genitourinary surgery. METHODS: We tested five seats (Bontrager, Waterloo, WI) with varying levels of padding and morphology (comfort, fitness, fitness gel, race, and performance) for two different riders. The seats were installed on a Peloton stationary exercise bike (New York City, NY). Force measurements were performed using a 9833E-50 Large F-Socket Sensor (Tekscan, South Boston, MA). We measured total and perineal forces in three conditions at the same resistance: (a) at rest (not pedaling); (b) at 8mph; (c) at 15mph. RESULTS: Significant differences across the bicycle seats were observed with fitness gel seats providing the lowest perineal pressure. In all measurements, perineal forces were significantly lower at 15mph compared to 8mph (P < .001). When a rider used an oversized seat, less force was exerted compared to the appropriate size at both 8mph (P < .001) and 15mph (P < .001) speeds. Conversely, an undersized seat significantly increased perineal pressures at both 8mph (P = .018) and 15mph (P = .007). CONCLUSION: Larger seats constructed of more impressionable materials absorb a greater total force and act to distribute the subject's weight thereby delivering less force to the perineum. More perineal pressure is delivered at lower speeds and at rest likely due to the cyclist lifting off the seat during times of strenuous activity.