Association of Maternal First Trimester Serum Levels of Free Beta Human Chorionic Gonadotropin and Hypospadias: A Population Based Study.

PURPOSE: Human chorionic gonadotropin stimulates fetal testosterone production and contributes to normal development of male genitalia. Using population based data we hypothesized that differences in maternal free beta human chorionic gonadotropin may be associated with hypospadias. MATERIALS AND METHODS: Data were obtained from the Paris Registry of Congenital Malformations (REMAPAR) (2011 to 2016). The initial study population included 3,172 pregnant women who gave birth to a singleton live born male infant with a congenital malformation. After exclusion of cases with unknown beta human chorionic gonadotropin and those with chromosomal or genetic abnormalities, the study population included 194 boys with isolated hypospadias and 1,075 controls. For cases with operative notes (125) we obtained data on type (proximal/distal) of hypospadias. Using quantile regression we compared median values of multiple of median beta human chorionic gonadotropin measured for first trimester Down syndrome screening (10th to 13th gestational weeks) for overall as well as by type of hypospadias vs controls. We also considered possible effects of placental dysfunction (maternal age, intrauterine growth retardation and preterm births) as potential confounding factors. RESULTS: Overall the median beta human chorionic gonadotropin multiple of median was comparable for women who had an infant with hypospadias vs controls (0.99 vs 0.95, p=0.3). However, proximal hypospadias was associated with a statistically significant higher median multiple of median than distal hypospadias or unspecified (1.49 vs 0.92 vs 1.05, p=0.02). The estimates were comparable after adjustment for placental dysfunction. CONCLUSIONS: Our findings support the hypothesis that an alteration in maternal beta human chorionic gonadotropin levels is associated with hypospadias. However, this association appears to be limited to proximal hypospadias.

Epidural Analgesia Decreases Narcotic Requirements in Patients with Low Level Spina Bifida Undergoing Urological Laparotomy for Neurogenic Bladder and Bowel.

PURPOSE: Concerns regarding anatomical anomalies and worsening neurological symptoms have prevented widespread use of epidural catheters in patients with low level spina bifida. We hypothesize that thoracic epidural placement in the T9 to T10 interspace is safe and decreases narcotic requirements following major open lower urinary tract reconstruction in patients with low level spina bifida. MATERIALS AND METHODS: We reviewed consecutive patients with low level spina bifida who underwent lower urinary tract reconstruction and received epidurals for postoperative pain control. Controls were patients with low level spina bifida who received single injection transversus abdominis plane blocks and underwent similar procedures. Complications of epidural placement, including changes in motor and sensory status, were recorded. Opioid consumption was calculated using equivalent intravenous morphine doses. Mean and maximum pain scores on postoperative days 0 to 3 were calculated. RESULTS: Ten patients with low level spina bifida who underwent lower urinary tract reconstruction with epidural were matched to 10 controls with low level spina bifida who underwent lower urinary tract reconstruction with transverse abdominis plane block. Groups were demographically similar. All patients had full abdominal sensation and functional levels at or below L3. No epidural complications or changes in neurological status were noted. The epidural group had decreased opioid consumption on postoperative days 0 to 3 (0.75 mg/kg vs 1.29 mg/kg, p = 0.04). Pain scores were similar or improved in the epidural group. CONCLUSIONS: Thoracic epidural analgesia appears to be a safe and effective opioid sparing option to assist with postoperative pain management following lower urinary tract reconstruction in individuals with low level spina bifida.

Use of flexible cystoscopy at time of artificial urinary sphincter placement.

INTRODUCTION: Artificial urinary sphincters (AUS) are used to treat significant urinary incontinence. Flexible cystoscopy at the time of AUS placement provides relevant intraoperative feedback including confirmation that the AUS is functioning, visualization of coaptation, and evaluation for urethral injury. Current guidelines for placement of an AUS do not include flexible cystoscopy. The objective was to evaluate whether flexible cystoscopy at time of AUS placement changed cuff size at the time of surgery. MATERIALS AND METHODS: A retrospective cohort study was performed to evaluate all patients undergoing AUS placement by a single surgeon between March 2013 and March 2017. The primary endpoint of the study was change in cuff size based on cystoscopy. RESULTS: A total of 109 AUS were placed in 96 patients. In five (4.6%) cases flexible cystoscopy identified a lack of coaptation of the urethra despite appropriate sizing which resulted in down-sizing of the cuff. Five patients were identified as having a bladder neck contracture that was previously unrecognized as clinic cystoscopy was performed by the referring urologist and was reportedly normal. Three patients developed postoperative infections, two of these patients had a history of multiple AUS placement and revisions and the third patient had a history of cystectomy and neobladder. CONCLUSIONS: Flexible cystoscopy at time of AUS placement changed the cuff size in nearly 5% of cases. Flexible cystoscopy at time of AUS placement provides valuable feedback and should be recommended for low volume prosthetic surgeons.

A novel technique for direct visualization of reservoir placement for penoscrotal inflatable penile prostheses using a single incision.

INTRODUCTION: We aim to present a modified technique and outcomes of a novel method allowing for direct visualization of the reservoir placement during a penoscrotal inflatable penile prosthesis (IPP). METHODS: Out of165 patients who underwent IPP placement from August 2012 to March 2015, 157 underwent a modified technique and comprised the cohort of this study. A Deaver's retractor was placed lateral to the penis and over the pubic bone to allow for direct visualization of the tissues overlying the lower abdomen. After dissecting through the superficial layers, the Deaver's was slowly advanced, allowing for visualization of the fascia, which was incised. Using blunt dissection, a space for the reservoir was created between the bladder and the pubic bone. The reservoir was then placed safely into this space and the Deaver's retractor was removed. RESULTS: The causes of ED in the study cohort included postprostatectomy ED (n = 107), organic impotence (n = 40), Peyronie's disease (n = 3), ED following cystoprostatectomy (n = 2), ED due to spinal cord injury (n = 2), ED resulting from priapism (n = 2), and ED after pelvic injury (n = 1); all of which were refractory to medical management. The median age of study population was 66 years and the mean (standard deviation) operative time was 72.8 (14.7) min. Eighty percent of the procedures were performed on outpatient basis. Complication rates were low (<5%), with four infections, one proximal pump migration, one scrotal hematoma, and one urinary tract infection. CONCLUSION: The modified technique for placement of the IPP's spherical reservoir under direct visualization through a penoscrotal incision is quick, safe, and effective.

Neoadjuvant chemotherapy in urothelial bladder cancer: impact of regimen and variant histology.

AIM: We compared the efficacy of methotrexate/vinblastine/doxorubicin/cisplatin (MVAC) versus gemcitabine/cisplatin in urothelial cancer and neoadjuvant chemotherapy (NACT) efficacy in variant histology (VH). MATERIALS & METHODS: Radical cystectomy patients were retrospectively compared with those who received NACT. Factors associated with survival, pathologic complete response (pCR) and downstaging (pDS) were evaluated in multivariable models. RESULTS: 9% of radical cystectomy patients (84/919) received NACT, with improved survival, pCR and pDS on both regimens. MVAC lead to higher pDS without an increase in pCR. On multivariable analysis, there was a nonsignificant increase in pDS with MVAC. NACT conferred similar responses in squamous and glandular differentiation VH. CONCLUSION: NACT was associated with improved survival, pCR and pDS. Furthermore, responses to NACT were not dependent on presence of VH.

Incidental prostate cancer in Asian men: high prevalence of incidental prostatic adenocarcinoma in Chinese patients undergoing radical cystoprostatectomy for treatment of bladder cancer and selection of candidates for prostate-sparing cystectomy.

BACKGROUND: Previous studies report a low prevalence of incidental prostate cancer in Chinese patients (3-7%). We evaluated incidental prostatic adenocarcinoma (PCa) and urothelial carcinoma (UCa) involvement of the prostate in cystoprostatectomy specimens. METHODS: We analyzed 340 cystoprostatectomy specimens from patients who underwent radical cystoprostatectomy for the treatment of bladder cancer in China from 2004 to 2014. None of the patients had known prostate cancer prior to cystoprostatectomy. RESULTS: Overall, 180 (53%) patients had either PCa or UCa in the prostate. We found that 95 (28%) had PCa and 115 (34%) had UCa involvement of prostate. The rate of incidental prostate cancer was 21% and 31%, respectively, from two study periods (2004-2008 and 2009-2014). Among the 95 patients with PCa, 19 (20%) had Gleason score of ≥7, nine (10%) had PCa tumor volume >0.5 cc, and eight (8.4%) had extracapsular extension. Of the 115 with prostatic UCa, 61 had prostatic urethra and/or periurethral prostatic duct involvement only, while 54 had prostatic stromal invasion. Age (odds ratio [OR] = 1.04, P = 0.001), increasing stage of bladder tumor (OR = 1.28, P = 0.005), multifocal tumors of bladder (OR = 3.22, P < 0.001), carcinoma in situ (CIS) in the bladder (OR = 5.52, P < 0.001), and bladder neck involvement (OR = 6.12, P < 0.001) were strongly associated with prostatic UCa. CONCLUSIONS: The rate of incidental PCa in cystoprostatectomy specimens in China has increased over the last decade. Patients with advanced age, elevated serum PSA level, advanced bladder tumor stage, multifocal bladder tumors, CIS in the bladder, and tumor location at the bladder neck should be excluded as candidates for prostate-sparing cystectomy.

Changing USA national trends for adrenalectomy: the influence of surgeon and technique.

OBJECTIVE: To explain differences over time between operative approach and surgeon type for adrenal surgery in the USA. PATIENTS AND METHODS: A retrospective cohort analysis was performed on all patients undergoing adrenalectomy between 2002 and 2011 using the Nationwide Inpatient Sample. Patients undergoing concurrent nephrectomy were excluded. Surgeon specialty was only available for 2003-2009. Descriptive analyses and multivariable logistic regression models were used to assess variables associated with minimally invasive surgery (MIS) and urologist-performed procedures. RESULTS: In all, 58,948 adrenalectomies were identified. A MIS approach was used in 20% of these operations. There was a 4% increase in MIS throughout the study period (P < 0.001). Cases performed at teaching hospitals were more likely to be MIS (odds ratio [OR] 1.47, P < 0.001). We were able to identify surgical specialty in 23,746 cases, of which 60% were performed by urologists. Cases performed in the Midwest compared with Northeast were at increased adjusted odds of being performed by urologists (OR 1.38, P = 0.11). Despite most cases being performed by urologists, adrenalectomy by urologists showed a 15% annual decrease over the analysed period (P < 0.001). CONCLUSIONS: The use of a MIS technique to perform adrenalectomy is increasing at a slower rate compared with most other surgical extirpative procedures. Further investigation to explain the decreased performance of adrenalectomy by urologists is warranted.

Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes.

OBJECTIVE: To evaluate the utility of robotic repair of injuries to the ureter or bladder from obstetrical and gynaecological (OBGYN) surgery PATIENTS AND METHODS: A retrospective review of all patients from four different high-volume institutions between 2002 and 2013 that had a robot-assisted (RA) repair by a urologist after an OBGYN genitourinary injury. RESULTS: Of the 43 OBGYN operations, 34 were hysterectomies: 10 open, 10 RA, nine vaginally, and five pure laparoscopic. Nine patients had alternative OBGYN operations: three caesarean sections, three oophorectomies (one open, two laparoscopic), one RA colpopexy, one open pelvic cervical cerclage with mesh and one RA removal of an invasive endometrioma. In all, 49 genitourinary (GU) injuries were sustained: ureteric ligation (26), ureterovaginal fistula (10), ureterocutaneous fistula (one), vesicovaginal fistula (VVF; 10) and cystotomy alone (two). In all, 10 patients (23.3%) underwent immediate urological repair at the time of their OBGYN RA surgery. The mean (range) time between OBGYN injury and definitive delayed repair was 23.5 (1-297) months. Four patients had undergone prior failed repair: two open VVF repairs and two balloon ureteric dilatations with stent placement. In all, 22 ureteric re-implants (11 with ipsilateral psoas hitch) and 15 uretero-ureterostomies were performed. Stents were placed in all ureteric cases for a mean (range) of 32 (1-63) days. In all, 10 VVF repairs and two primary cystotomy closures were performed. Drains were placed in 28 cases (57.1%) for a mean (range) of 4.1 (1-26) days. No case required open conversion. Two patients (4.1%) developed ureteric obstruction after RA repair requiring dilatation and stenting. The mean (range) follow-up of the entire cohort was 16.6 (1-63) months. CONCLUSIONS: RA repair of GU injuries during OBGYN surgery is associated with good outcomes, appears safe and feasible, and can be used successfully immediately after injury recognition or as a salvage procedure after prior attempted repair. RA techniques may improve convalescence in a patient population where quick recovery is paramount.

The changing reality of urothelial bladder cancer: should non-squamous variant histology be managed as a distinct clinical entity?

OBJECTIVES: To assess the effect of non-squamous differentiation (non-SQD) variant histology on survival in muscle-invasive bladder urothelial cancer (UC). PATIENTS AND METHODS: A cohort of 411 radical cystectomy (RC) cases performed with curative intent for muscle-invasive primary UC was identified between 2008 and June 2013. Survival analysis was evaluated using Kaplan-Meier methodology comparing non-variant (NV) + SQD histology to non-SQD variant histology (non-SQD variants). Multivariable cox proportional hazards regression assessed all-cause and disease-specific mortality. RESULTS: Of the 411 RC cases, 77 (19%) had non-SQD variant histology. The median overall survival (OS) for non-SQD variant histology was 28 months, whereas the NV+SQD group had not reached the median OS at 74 months (log-rank test P < 0.001). After adjusting for sex, age, pathological stage, and any systemic chemotherapy, patients with non-SQD variant histology at RC had a 1.57-times increased adjusted risk of all-cause mortality (P = 0.027) and 1.69-times increased risk of disease-specific mortality (P = 0.030) compared with NV+SQD patients. CONCLUSIONS: While SQD behaves similarly to NV, non-SQD variant histology portends worse OS and disease-specific survival regardless of neoadjuvant or adjuvant chemotherapy and pathological stage. Non-SQD variants of UC could perhaps be considered a distinct clinical entity in UC with goals for developing new treatment algorithms through novel clinical trials.

Three-tiered nodal classification system for bladder cancer: a new proposal.

AIM: To evaluate a three-tiered prognostic stratification using one, two to five and >five positive lymph nodes (LNs) and this nodal staging system performs across different pelvic LN dissection (PLND) templates and adjuvant chemotherapy status. METHODS: We evaluated 244 patients with positive LN urothelial cancer who underwent radical cystectomy and PLND between 2000 and 2011. Survival analyses utilizing the Kaplan-Meier method and log rank test were performed. Median follow-up was 55.3 months (range: 0.4-141). Multivariable Cox proportional hazards models were built to evaluate the prognostic stratification. RESULTS: Extended PLND template was performed on 152 (62.3%) patients and standard on 92 (37.7%). The median number of LNs resected was 14 in the standard group vs 22 in the extended group (p < 0.01) and positive LNs was 2 vs 3 (p = 0.09), respectively. Stratification in patients with: one positive LN, two to five positive LNs or >five positive LNs lead to 5-year recurrence-free survival of: 48.6, 34.5 and 15.9% for each group, while the 5-year overall survival was: 43.0, 22.1 and 11.3%, respectively. Stratification in the three groups was also verified irrespective of PLND template and adjuvant chemotherapy. Two multivariable models confirmed the findings when controlling for demographic features and known pathologic risk factors. CONCLUSION: Three-tiered nodal classification system using the number of metastatic LNs (one, two to five and >five) stratifies patients with lymphatic disease into distinct prognostic groups.

Risk factors associated with 30 day hospital readmission following partial nephrectomy.

INTRODUCTION: To assess risk factors for unplanned readmission following open and minimally invasive partial nephrectomy (PN). MATERIALS AND METHODS: From the National Surgical Quality Improvement Program database, patients with renal malignancy undergoing PN in 2011 or 2012 were reviewed. Using multivariable logistic regression, we identified variables associated with 30 day hospital readmission. RESULTS: Of the 2124 patients identified who underwent PN, 1253 (59%) were minimally invasive PN (MIPN) and 871 (41%) open PN (OPN). There were no differences in preoperative comorbidities between MIPN and OPN patients. The rate of unplanned hospital readmission for the entire cohort was 5%, which varied from 7% for OPN to 4% for MIPN. Seven percent of OPN and 2% of MIPN patients developed a Clavien grade III-V complication. For OPN, developing an in-hospital Clavien grade III-V complication was associated with a 6-fold increase in the odds of requiring subsequent readmission (95% CI 2.22-14.47, p < 0.001). For MIPN, an in-hospital Clavien grade III-V complication was associated with nearly 16 times increased odds of unplanned readmission (95% CI 6.08-41.65, p<0.001) and history of chronic anticoagulation was associated with a five times increased odds of unplanned readmission (95% CI 1.44-18.25, p = 0.012). Finally, operative time for MIPN was associated with increased odds of readmission (OR 1.08, 95% CI 1.04-1.16, p < 0.001). Patient comorbidities and ASA score were not associated with unplanned readmission for OPN or MIPN. CONCLUSIONS: Patients developing high grade complications are at increased risk of subsequent unplanned readmission. These patients who develop significant in-hospital complications may benefit from increased post-discharge contact with healthcare providers and from preoperative counseling regarding their risk of unplanned readmission.

Differentiating reconstructive techniques in partial nephrectomy: a propensity score analysis.

INTRODUCTION: To assess whether volumetric measurements can differentiate functional changes between reconstructive techniques after partial nephrectomy. MATERIALS AND METHODS: One hundred and fifty-six patients undergoing partial nephrectomy for a single renal mass were retrospectively studied between 2008 and 2012. Computed tomography scans were available for volume calculations on 56 (18 non-renorrhaphy and 38 renorrhaphy). Institutional review board approval was obtained. The primary outcome was %volume loss in the operated kidney, which was calculated from three-dimensional reconstructions using a semiautomatic segmentation algorithm. Multivariable regression and propensity score analysis was performed. RESULTS: Volumetric analysis detected a difference in mean %volume loss between two-layer reconstruction (cortical renorrhaphy and base-layer) and base-layer only (15.6% versus 3.8%, p < 0.001). The mean %glomerular filtration rate (GFR) loss was also greater in the two-layer group (8.9% versus 2.4%, p = 0.03). Demographics were similar between groups except the two-layer group was older, had more males, and increased ischemia time. On multivariable regression the presence of two-layer closure (ß = -15.2%, p < 0.001) and tumor diameter (ß = -7.4, p = 0.004) were significant predictors of %volume loss while ischemia time (p = 0.88) was not. Two-layer closure remained a predictor on propensity-adjusted analysis (ß = -14.3, p = 0.004). The base-layer only group had two (5.3%) urine leaks and two (5.3%) bleeding complications. The two-layer group had two (1.7%) urine leaks and three (2.5%) bleeding complications (p = 0.23, 0.41). CONCLUSIONS: Volume loss calculated from CT scans can be used to monitor postoperative renal function. Techniques for renal reconstruction and tumor diameter are associated with volume and functional loss after partial nephrectomy and should be controlled for in future studies.

Does robotic assistance confer an economic benefit during laparoscopic radical nephrectomy?

PURPOSE: While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit. MATERIALS AND METHODS: From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique and those with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges. RESULTS: We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001). CONCLUSIONS: Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy.

Incidence and risk factors of parastomal hernia in patients undergoing radical cystectomy and ileal conduit diversion.

PURPOSE: We evaluate the incidence and risk factors of parastomal hernia formation in patients undergoing radical cystectomy and ileal conduit urinary diversion. MATERIALS AND METHODS: We retrospectively reviewed the Indiana University cystectomy database between 2001 and 2011, and identified 516 patients who underwent radical cystectomy and ileal conduit diversion. Overall 199 patients had a clinical followup of at least 12 months and all underwent postoperative staging computerized tomography to confirm the presence of parastomal hernia. The incidence of parastomal hernia is reported with correlations made to demographic, patient level and perioperative risk factors. RESULTS: A parastomal hernia developed in 58 patients (29%) at a median followup of 27 months (range 12 to 125). Of these patients 26 (45%) underwent surgical repair due to abdominal discomfort (58%), acute strangulation or obstruction of the small bowel (15%), partial small bowel obstructions (15%) and elective repair for other intra-abdominal procedures (12%). Prior exploratory laparotomy (adjusted HR 1.98, 95% CI 1.97-3.36, p = 0.011) and severe obesity (adjusted HR 4.26, 95% CI 1.52-11.93, p = 0.006) were predictive of parastomal herniation. The cumulative risk of parastomal hernia formation at 1 and 2 years after cystectomy was 12.2% and 22.5%, respectively. CONCLUSIONS: We demonstrated that parastomal hernia will develop in nearly a third of patients after radical cystectomy with ileal conduit diversion. Prior laparotomy and severe obesity are independent risk factors. Preoperative counseling and preventative measures regarding parastomal hernia formation should be emphasized, particularly in these at risk patients.

Infection and venous thromboembolism in patients undergoing colorectal surgery: what is the relationship?

BACKGROUND: There is evidence demonstrating an association between infection and venous thromboembolism. We recently identified this association in the postoperative setting; however, the temporal relationship between infection and venous thromboembolism is not well defined OBJECTIVE: We sought to determine the temporal relationship between venous thromboembolism and postoperative infectious complications in patients undergoing colorectal surgery. DESIGN, SETTING, AND PATIENTS: A retrospective cohort analysis was performed using data for patients undergoing colorectal surgery in the National Surgical Quality Improvement Project 2010 database. MAIN OUTCOME MEASURES: The primary outcome measures were the rate and timing of venous thromboembolism and postoperative infection among patients undergoing colorectal surgery during 30 postoperative days. RESULTS: Of 39,831 patients who underwent colorectal surgery, the overall rate of venous thromboembolism was 2.4% (n = 948); 729 (1.8%) patients were diagnosed with deep vein thrombosis, and 307 (0.77%) patients were diagnosed with pulmonary embolism. Eighty-eight (0.22%) patients were reported as developing both deep vein thrombosis and pulmonary embolism. Following colorectal surgery, the development of a urinary tract infection, pneumonia, organ space surgical site infection, or deep surgical site infection was associated with a significantly increased risk for venous thromboembolism. The majority (52%-85%) of venous thromboembolisms in this population occurred the same day or a median of 3.5 to 8 days following the diagnosis of infection. The approximate relative risk for developing any venous thromboembolism increased each day following the development of each type of infection (range, 0.40%-1.0%) in comparison with patients not developing an infection. LIMITATIONS: We are unable to account for differences in data collection, prophylaxis, and venous thromboembolism surveillance between hospitals in the database. Additionally, there is limited patient follow-up. CONCLUSIONS: These findings of a temporal association between infection and venous thromboembolism suggest a potential early indicator for using certain postoperative infectious complications as clinical warning signs that a patient is more likely to develop venous thromboembolism. Further studies into best practices for prevention are warranted.

Emerging trends in robotic pyeloplasty for the management of ureteropelvic junction obstruction in adults.

PURPOSE: We evaluated trends and associated characteristics in the use of robotics for pyeloplasty as treatment for ureteropelvic junction obstruction. MATERIALS AND METHODS: Data from the Nationwide Inpatient Sample were used to evaluate pyeloplasty trends from 2005 to 2010. Patients treated with pyeloplasty and procedure method (robotic, laparoscopic or open) were identified by ICD-9-CM codes. Coding for robotics was initiated in the fourth quarter of 2008. Multivariable analysis was performed to examine characteristics affecting the odds of undergoing robotic pyeloplasty vs other approaches to pyeloplasty. RESULTS: We identified 3,947 pyeloplasties performed between 2005 and 2010, including 1,642 since the fourth quarter of 2008. There was a statistically significant increase in the number of robotic pyeloplasties (p <0.001). Mean total charges for robotic vs nonrobotic procedures were $40,200 vs $37,817 (p = 0.106). Characteristics related to undergoing a robotic procedure included surgery at a teaching hospital (OR 1.29, 95% CI 1.04-1.59, p = 0.021) and in the Northeast (OR 1.54, 95% CI 1.17-2.04, p = 0.002) or Midwest (OR 1.62, 95% CI 1.23-2.12, p <0.001) compared with the South. When the primary payer was Medicaid vs private insurance, patients were 46% less likely to undergo the procedure robotically (p <0.001). There was no significant difference in charges between robotic and open pyeloplasty. CONCLUSIONS: The number of robotic pyeloplasties performed quarterly in the United States is increasing, although there are disparities in the adoption of the robotic approach among geographic regions and hospital types.

Identification of endogenous acyl amino acids based on a targeted lipidomics approach.

Using a partially purified bovine brain extract, our lab identified three novel endogenous acyl amino acids in mammalian tissues. The presence of numerous amino acids in the body and their ability to form amides with several saturated and unsaturated fatty acids indicated the potential existence of a large number of heretofore unidentified acyl amino acids. Reports of several additional acyl amino acids that activate G-protein coupled receptors (e.g., N-arachidonoyl glycine, N-arachidonoyl serine) and transient receptor potential channels (e.g., N-arachidonoyl dopamine, N-acyl taurines) suggested that some or many novel acyl amino acids could serve as signaling molecules. Here, we used a targeted lipidomics approach including specific enrichment steps, nano-LC/MS/MS, high-throughput screening of the datasets with a potent search algorithm based on fragment ion analysis, and quantification using the multiple reaction monitoring mode in Analyst software to measure the biological levels of acyl amino acids in rat brain. We successfully identified 50 novel endogenous acyl amino acids present at 0.2 to 69 pmol g(-1) wet rat brain.

Impact of obesity on male urethral sling outcomes.

BACKGROUND: The impact of obesity on AdVance male urethral sling outcomes has been poorly evaluated. Anecdotally, male urethral sling placement can be more challenging due to body habitus in obese patients. The objective of this study was to evaluate the impact of obesity on surgical complexity using operative time as a surrogate and secondarily to evaluate the impact on postoperative pad use. METHODS: A retrospective cohort analysis was performed using all men who underwent AdVance male urethral sling placement at a single institution between 2013 and 2019. Descriptive statistics comparing obese and non-obese patients were performed. RESULTS: A total of 62 patients were identified with median (IQR) follow up of 14 (4-33) months. Of these, 40 were non-obese and 22 (35.5%) were obese. When excluding patients who underwent concurrent surgery, the mean operative times for the non-obese versus obese cohorts were 61.8 min versus 73.7 min (p = 0.020). No Clavien 3-5 grade complications were noted. At follow up, 47.5% of the non-obese cohort and 63.6% of the obese cohort reported using one or more pads daily (p = 0.290). Four of the five patients with a history of radiation were among the patients wearing pads following male urethral sling placement. CONCLUSION: Obese men undergoing AdVance male urethral sling placement required increased operative time, potentially related to operative complexity, and a higher proportion of obese compared with non-obese patients required postoperative pads for continued urinary incontinence. Further research is required to better delineate the full impact of obesity on male urethral sling outcomes.

Surgical management and outcomes of adult acquired buried penis with and without lichen sclerosus: a comparative analysis.

PURPOSE: Adult acquired buried penis (AABP) can present with concomitant Lichen Sclerosus (LS), a chronic dermatosis that may affect surgical outcomes. Our aim was to evaluate outcomes of patients undergoing AABP repair with and without LS. METHODS: A retrospective cohort study was performed for AABP repair patients at a single institution from 1/1991 to 12/2017. Patient characteristics and surgical and peri-operative outcomes, including success, erectile function, and complications, were collected. RESULTS: Sixty-seven AABP patients with mean follow-up of 16.1 ± 20.4 months were identified. Overall surgical success was 91%. Overall surgical complication rate was 50.7% (23.9% Clavien-Dindo ≥ 3). Forty-two (62.7%) patients had concomitant LS. A higher proportion of patients with LS required a STSG (90% vs 60%, p = 0.005). There was no difference in surgical success (90.5% vs 92.0%, p = 0.999), overall complication rate (57.1% vs 40.0%, p = 0.212), Clavien-Dindo ≥ 3 complications (23.8% vs 24.0%, p = 0.999) or early complications (35.7% vs 32.0%, p = 0.797) between patients with and without LS, respectively. However, a higher proportion of patients with LS experienced late complications (33.3% vs 8.0%, p = 0.020), which were mainly related to wound healing. Satisfaction with erectile function was higher among patients with LS (59.5% vs 320%, p = 0.043). CONCLUSION: AABP patients with LS behave somewhat differently than their non LS counterparts. They are more likely to require skin graft during surgical treatment. Though surgical success and complications are similar, they do experience a higher rate of late complications from impaired wound healing. Work on improving wound healing in this population should be considered.

Robotic and open partial nephrectomy for intermediate and high complexity tumors: a matched-pairs comparison of surgical outcomes at a single institution.

Objective: To compare peri-operative factors and renal function following open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN) for intermediate and high complexity tumors when controlling for tumor and patient complexity.Methods: A retrospective review of 222 patients undergoing partial nephrectomy was performed. Patients with intermediate (nephrometry score NS 7-9) or high (NS 10-12) complexity tumors were matched 2:1 for RPN:OPN using NS, Charlson Comorbidity Index (CCI), and BMI. Patient demographics, peri-operative values, renal function, and complication rates were analyzed and compared.Results: Seventy-four OPN patients were matched to 148 RPN patients with no difference in patient demographics. Estimated blood loss in OPN patients was significantly higher (368.5 vs 210.5 mL, p < 0.001) as was transfusion rate (17% vs 1.6%, p < 0.001). Warm ischemia time was longer in OPN (25.5 vs 19.7 min, p = 0.001) while operative time was reduced (200.5 vs 226.5 min, p = 0.010). RPN patients had significantly shorter hospitalizations (5.3 vs 3.0 days, p < 0.001). GFR decrease after one month was not statistically significant (12.9 vs 6.6 ml/min, p = 0.130). Clavien III-V complications incidence was higher for OPN compared to RPN although not significantly (20.3% vs 10.8%, p = 0.055).Conclusion: When matching for tumor and patient complexity, RPN patients had fewer high grade post-operative complications, decreased blood loss, and shorter hospitalizations. RPN is a safe option for patients with intermediate and high complexity tumors.