Retrospective Multicenter Observational Study of Immediate Voiding at End of Urinary Sphincter Surgery (REMOVE).

PURPOSE: Patients may remain catheterized after artificial urinary sphincter surgery to prevent urinary retention, despite a lack of evidence to support this practice. Our study aims to evaluate the feasibility of outpatient, catheter-free continence surgery using a multi-institutional database. We hypothesize that between catheterized controls and patients without a catheter, there would be no difference in the rate of urinary retention or postoperative complications. MATERIALS AND METHODS: We conducted a retrospective review of patients undergoing first-time artificial urinary sphincter placement from 2009-2021. Patients were stratified by postoperative catheter status into either no-catheter (leaving the procedure without a catheter) or catheter (postoperative indwelling catheter for ∼24 hours). The primary outcome, urinary retention, was defined as catheterization due to subjective voiding difficulty or documented postvoid residual over 250 mL. RESULTS: Our study identified 302 catheter and 123 no-catheter patients. Twenty (6.6%) catheter and 9 (7.3%) no-catheter patients developed urinary retention (P = .8). On multivariable analysis, controlling for age, cuff size, radiation history and surgeon, there was no statistically significant association between omitting a catheter and urinary retention (OR: 0.45, 95% CI: 0.13-1.58; P = .2). Furthermore, at 30 months follow-up, Kaplan-Meier survival analysis revealed that device survival was 70% (95% CI: 62%-76%) vs 69% (95% CI: 48%-82%) for the catheter and no-catheter group, respectively. CONCLUSIONS: In our multi-institutional cohort, overall retention rates were low (7%) in groups with a catheter and without. Obviating postoperative catheterization facilitates outpatient incontinence surgery without altering reoperation over medium-term follow-up.

Concomitant laparoscopic and vaginal excision of duplicated collecting system.

INTRODUCTION AND HYPOTHESIS: A duplicated collecting system is the most common birth defect related to the urinary tract and is more common in women. Approximately 0.7% of the healthy adult population and 2-4% of patients with urinary tract symptoms have duplicated ureters. This video discusses the presentation, evaluation, and treatment of duplicated urinary collecting systems, and presents a case of duplicated collecting system with ectopic ureteral implantation at the vaginal introitus. METHODS: We present the case of a 56-year-old presenting with a history of incontinence and recurrent urinary tract infections starting in adolescence and her workup for a duplicated collecting system, as well as subsequent surgical management with narrated footage. The patient was counseled that a distal ectopic ureter remnant could serve as a nidus for infection and the patient elected to undergo complete excision of the distal ectopic ureter. CONCLUSION: Duplicated urinary collecting systems are the most common birth defect related to the urinary tract and can be frequently encountered by the pelvic surgeon. Knowledge of the presentation and workup of a suspected duplicated collecting system is important in carrying out appropriate treatment.

Vesicovaginal fistula repair at the time of colpocleisis.

INTRODUCTION AND HYPOTHESIS: The objectives of this video are to discuss the presentation, evaluation, and surgical management of a patient with a vesicovaginal fistula at the time of colpocleisis. METHOD: We present the case of an 83-year-old woman with a history of stage IV prolapse who had had a pessary device removed. Urine had been noted to be in the vaginal vault, leading to suspicion of a vesicovaginal fistula. Following evaluation, the patient decided to proceed with surgical management. The patient underwent a vesicovaginal fistula repair with concomitant colpocleisis. A cystoscopy was performed at the conclusion of the case where the bilateral ureteral stents were removed and a strong efflux was noted at both ureteral orifices. RESULTS: At the patient's 1-month follow-up, she had no complaints of prolapse or vaginal leaking. CONCLUSION: Neglect of a vaginal pessary can lead to serious complications, indicating the importance of patient education and careful follow-up. Surgical planning is a key component in effectively managing a vesicovaginal fistula with ureteral presentation in order to preserve ureteral integrity. Concomitant vesicovaginal repair and colpocleisis can be performed safely with effective cure of a vesicovaginal fistula and stage IV prolapse.

Erectile and Ejaculatory Dysfunction After Urethroplasty.

PURPOSE OF THE REVIEW: The goal of this paper was to evaluate the impact on erectile and ejaculatory function after anterior and posterior urethroplasty. RECENT FINDINGS: With a rise in the use of urethroplasty, its impact on sexual function has come into question. For anterior urethroplasties, some degree of erectile dysfunction is common, but this tends to be transient, with most patients having a resolution of any de novo dysfunction by 12 months. Patients with posterior urethral strictures have a very high rate of erectile dysfunction prior to surgery and may show improvement after urethroplasty. Ejaculatory function tends to improve in patients due to alleviation of obstruction while some patients notice degradation in force of ejaculation. While urethroplasty has a minimal permanent effect on sexual function for most patients, there are some patients who notice improvement and others worsening. Patients should be counseled on these risks prior to urethroplasty.

Robotic Surgery for Urologic Deep Infiltrating Endometriosis: A Review and Case Presentations.

Urologic involvement is seen in 1.2-3.9% of women with endometriosis. The bladder (84%) is the most common location of urinary tract endometriosis and the retro-trigone and dome of the bladder are the most frequently affected sites. Ureteral involvement is commonly extrinsic and leads to compression and fibrosis of peri-ureteral tissue, leading to obstruction. Robotic-assisted laparoscopy provides additional advantages of 3D visualization, shorter learning curve compared to conventional laparoscopy, improved dissection in tight pelvic spaces, and facilitation of suturing techniques. In this review, we present the multidisciplinary management of four cases of deep infiltrating endometriosis of the urinary tract in a tertiary referral center of expertise and a review of the literature.

Ureteral replacement and onlay repair with reconfigured intestinal segments.

PURPOSE: Ureteral loss represents a surgical challenge to provide low pressure drainage while avoiding urinary stasis and reflux. The ideal replacement should optimize drainage while minimizing absorption, allowing for ureteral repair of varied lengths and locations with maximal preservation of the urinary tract. We reviewed our experience with ureteral repair, focusing on the use of reconfigured intestine. We report what is to our knowledge the novel use of reconfigured intestine as an onlay flap on the preserved ureteral segment and as a circumferential interpositioned segment. MATERIALS AND METHODS: A total of 16 ureters were repaired in 4 men and 9 women using reconfigured ileum, colon or appendix. Mean patient age was 45 years (range 26 to 66). The etiology of the ureteral defect was iatrogenic in 8 patients, retroperitoneal fibrosis in 3, trauma in 3 and ureteritis cystica in 1. Mean defect length was 10 cm (range 5 to 20) in the 10 right and 6 left ureters, and the defect was proximal in 3, mid in 4, distal in 7 and panureteral in 2. Ureteral replacement was performed using a segment of ileum in 13 cases or colon in 1. The segment was detubularized and reconfigured according to the Yang-Monti principle and used as a complete retubularized interposed segment in 7 cases or as an onlay flap on the opened ureter without resection in 7. Also, 2 ureters were reconstructed with an incised appendiceal flap onlayed over the preserved ureteral plate. At a mean followup of 44 months (range 12 to 78) all patients underwent antegrade nephrostogram, followed by renal scan and upper tract imaging. RESULTS: All patients tolerated the procedure without initial bowel or urinary tract complications. In 1 patient who had received radiation a ureteral fistula developed to a blind Hartmann pouch at 9 months, requiring repair. Ultimately, cystectomy was done for irradiation cystitis (onlay group). Another patient with bilateral obstruction at presentation lost unilateral renal function during 5 years. Urinary drainage was achieved in all 14 remaining renal units with preservation of function, as shown on renal scan. Patients reported minor mucous production without renal colic or stone formation. CONCLUSIONS: Long ureteral defects require tissue replacement when bladder flaps do not suffice. Ureteral replacement can be achieved by reconfigured intestinal segments, which are readily mobilized and secured as interposed segments or as an onlay flap on the preserved ureter. A relatively short segment can be used to repair a lengthy defect along any segment of ureter, also allowing for nonrefluxing reimplantation.

A Randomized Clinical Trial Evaluating Indigo Carmine as a Visualization Aid for Evaluating Ureteral Patency.

OBJECTIVE: To determine whether intravenous indigo carmine provides a visualization advantage compared to saline in the evaluation of ureteral patency in a randomized, controlled clinical trial. METHODS: Patients undergoing urological or gynecological surgical procedures in which the patency of the ureter was to be assessed received a saline injection and were randomized to receive 2.5 mL or 5.0 mL of indigo carmine. Blinded video assessments were conducted by independent reviewers using a conspicuity scale ranked 1 (poorest) to 5 (best), and subjects with scores ≥3 and at least a + 1-point difference from saline were considered responders. Time to visualization was recorded for indigo carmine. A responder analysis evaluated whether indigo carmine showed improved visualization. RESULTS: There were 96 ureters evaluated with the 5.0 mL dose of indigo carmine, 92 with the 2.5 mL dose, and 180 with saline. Most ureters were scored a 4 or higher on the conspicuity scale following indigo carmine; both doses were significantly better than saline (P < .0001). Overall, 92.3% of patients were rated as a responder for either ureter. The median time to visualization of blue color was not significantly different (6.0 minutes in the 5.0 mL group and 5.9 minutes in the 2.5 mL group). There were no adverse events related to indigo carmine use. CONCLUSION: Both dose levels of indigo carmine were significantly better than saline as a visualization aid for ureter patency.

Efficacy of Pudendal Nerve Blocks and Ultrasound-Guided Superior Hypogastric Plexus Blocks for the Management of Refractory Interstitial Cystitis: A Case Series.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is characterized by chronic pelvic, perineal, or bladder pain in addition to lower urinary tract symptoms. The etiology of this condition is not fully understood, which presents a challenge for effective therapeutic intervention. Current treatment guidelines recommend the use of multimodal pain management strategies including behavioral/non-pharmacologic, oral medications, bladder instillations, procedures, and major surgery. However, the safety and efficacy of these modalities vary, and there is currently no optimal treatment for the management of IC/BPS. The pudendal nerves and superior hypogastric plexus, which together mediate visceral pelvic pain and bladder control, are not addressed in the current guidelines but may serve as a therapeutic target. Here, we report improvements in pain, urinary symptoms, and functionality following bilateral pudendal nerve blocks and/or ultrasound-guided superior hypogastric plexus blocks in three patients with refractory IC/BPS. Our findings provide support for the use of these interventions in patients with IC/BPS unresponsive to prior conservative management.

Safety of Xiaflex® (Collagenase Clostridium histolyticum) Treatment for Adult Anterior Urethral Stricture Disease.

Male urethral stricture disease is highly prevalent and difficult to treat due to potential complications. Minimally invasive treatments tend to have high recurrence rates, keeping urethroplasty as the gold standard. Collagenase Clostridium histolyticum (CCH) has been used in humans to treat fibrosis in a minimally invasive manner. Herein, we present the preliminary results from treatments of three males with urethral stricture as a feasibility and safety evaluation of the first-in-human CCH treatment for male urethral stricture disease.

Cutaneous ureterostomy technique for adults and effects of ureteral stenting: an alternative to the ileal conduit.

PURPOSE: We present surgical modifications that improved the outcome of cutaneous ureterostomies. MATERIALS AND METHODS: A total of 310 patients with a median age of 71 years (range 38 to 88) underwent cutaneous ureterostomy as urinary diversion. Median followup was 25 months (range 1 to 172). The technique included 1) transposition of the left ureter above the inferior mesenteric artery, 2) mobilization of the ileocecal segment with repositioning above each terminal ureter, 3) abdominal wall hiatus fixation with 4 angle sutures and 4) YV plasty of the ureters with edge-to-edge anastomosis for stomal creation. In the 161 group 1 patients (59.1%) the Double-J® stents were removed in less than 3 months. Stents remained longer than 3 months in the 111 group 2 patients (40.8%). RESULTS: Of the 272 patients ureteral obstruction developed in 36 (13.2%). Ureteral obstruction was on the right side in 6 patients (2.2%), on the left side in 27 (9.9%) and bilateral in 3 (1.1%). Ureteral obstruction was treated with restenting in 20 cases (55.4%), stomal revision in 12 (33.3%) and conversion to a conduit in 4 (11%). Ureteral obstruction developed on the right side, on the left side and bilaterally in 3.7%, 13.7% and 1.82% of the patients in group 1, and in 0%, 4.5% and 0%, respectively, of those in group 2. Stenting time impacted only the left ureter with less obstruction in the group with longer stent placement (greater than 3 months) (p = 0.01). CONCLUSIONS: As with other types of urinary diversion, left ureteral obstruction is a common complication of bilateral cutaneous ureterostomies. Long-term stenting for greater than 3 months and the applied surgical modifications improved the clinical outcome of this type of urinary diversion.

Surgical management of lymph-node-positive prostate cancer: improves symptomatic control.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? There is a paucity of data regarding symptomatic local progression of patients treated with radical prostatectomy in the setting of lymph-node-positive prostate cancer. Our retrospective study shows that radical prostatectomy with adjuvant hormonal therapy improves local control of patients in this cohort. OBJECTIVE: • To assess the impact of primary surgical therapy on local control for patients with lymph-node-positive prostate cancer. METHODS: • A retrospective analysis from January 1982 to January 2001 identified 192 patients treated by radical retropubic prostatectomy (RRP, N= 87), hormonal ablative therapy (ADT, N= 74), or RRP plus adjuvant hormones (RRP + ADT, N= 31). • Statistical analyses were conducted using the Kruskal-Wallis test, chi-squared or Fisher's exact test, log-rank test and logistic regression with the statistical significance level set at P < 0.05. RESULTS: • The incidence of local relapse in the three treatment groups (RRP, ADT and RRP + ADT) was 40.2%, 59.5% and 12.9%, respectively. • Among those with local relapse, the incidence of symptomatic local relapse (defined as local symptoms secondary to locally recurrent prostate cancer) was 25.7%, 75.0% and 50.0%, respectively. • Logistic regression analysis used to identify predictors of local relapse indicated that patients treated with ADT (OR = 1.96; P= 0.270) had higher odds of having a local relapse whereas patients treated with RRP + ADT (OR = 0.20; P= 0.032) had significantly lower odds of having a local relapse compared with patients treated with RRP (reference group) after adjusting for other significant predictors such as increases in serum PSA at diagnosis (OR = 1.09; P= 0.018) and biochemical failure after primary therapy (OR = 48.3; P < 0.001). • Logistic regression analysis used to identify predictors of symptomatic local relapse, among patients having had a relapse, indicated that patients treated with RRP + ADT (OR = 2.90; P= 0.322) had higher odds of having a symptomatic local relapse whereas patients treated with ADT alone (OR = 8.67; P < 0.001) had significantly higher odds of having a symptomatic local relapse compared with patients treated with RRP (reference group). CONCLUSIONS: • Radical prostatectomy (with adjuvant hormonal therapy) provides improved local control in patients with lymph-node-positive prostate cancer. • This important endpoint must be considered when determining the optimal treatment of patients with node-positive disease.

Ureteral reconstruction for complex strictures: a review of the current literature.

PURPOSE: Frequently employed procedures for ureteral reconstruction include balloon dilation, pyeloplasty and ureteral re-implants. However, these procedures do not work for complex ureteral disease. The goal of this literature review is to report on techniques and success rates for the following techniques: buccal graft ureteroplasty, appendiceal interposition, transureteroureterostomy, ileal ureter and autotransplantation. METHODS: A comprehensive literature search for English-language original and review articles was conducted using PubMed. The following terms were queried: "ureteral reconstruction", "buccal graft", "appendiceal interposition", "ileal ureter", "transureteroureterostomy", "autotransplantation". RESULTS: Procedures involving the buccal mucosa or appendix offer minimally invasive techniques and low morbidity with good short-term success. Drawbacks to appendiceal interposition include the availability and length of appendix, and 10-20% of patients may have insufficient appendix upon intra-operative assessment. Transureteroureterostomy is typically limited to extensive exonerations due to concerns of injury to the contralateral kidney, even with reported success rates > 90%. Ileal ureter may carry a risk of metabolic acidosis in patients with renal insufficiency along with bowel-related complications. Ileal ureter and autotransplantation are reserved for the most severe cases due to their high morbidity but do offer options for the complex patient. CONCLUSION: Ureteral stricture disease not amenable to pyeloplasty, ureteroureterostomy or ureteroneocystostomy offers a challenge to urologist. Careful patient selection with pre-operative assessment of renal and bladder is vital to a successful operation with minimal complications.

Prostatic artery embolization for bladder outlet obstruction in the setting of prior posterior urethroplasty.

This case presents a patient with a remote history of complex posterior urethral repair related to a prior motorcycle accident who presented to the urology clinic in urinary retention with associated lower urinary tract symptoms. Due to his altered anatomy, traditional outlet procedures were deferred due to significant reported risks of post treatment urinary incontinence. Decision was made to proceed with prostatic artery embolization, and at follow up he reported resolution of his urinary retention and significant symptomatic improvement in his voiding without development of urinary incontinence.

Bladder cancer: a review of non-muscle invasive disease.

BACKGROUND: Bladder cancer is one of the most common cancers affecting men and women and thus has a profound impact on health care. The majority of patients (75%) with newly diagnosed urothelial tumors have non-muscle invasive disease confined to the bladder mucosa or the lamina propria. METHODS: The authors review the literature as well as recently published clinical guidelines regarding the bladder cancer risk and causative factors, diagnostic and pathologic evaluation, prognostic variables, and management strategies for patients with non-muscle invasive bladder cancer. RESULTS: Recurrence and progression remain problematic for many patients and are dependent on multiple clinical and pathological features, the most important of which are tumor stage, grade, multifocality, size, recurrence patterns, and the association with carcinoma in situ. Accurate assessment of clinical stage and tumor grade is critical in determining management and surveillance strategies. Intravesical therapies positively influence tumor recurrence rates. Disease progression rates may be impacted in high-risk patients who receive both induction bacille Calmette-Guérin (BCG) and a maintenance BCG regimen. Cystectomy still plays a pivotal role in patients with high-risk tumors and in patients who fail more conservative attempts to eradicate non-muscle invasive disease. CONCLUSIONS: Non-muscle invasive bladder cancers represent a broad group of tumors with varying biologic potential. Successful treatment depends on the careful integration of diagnostic and surveillance tests, macroablation through transurethral resection, accurate assessment of clinical stage, and the timely and appropriate delivery of intravesical chemotherapeutic and immunomodulatory agents.