Permanent urethral ligation after AUS cuff erosion: Is it ready for prime time?

AIMS: Although artificial urinary sphincter (AUS) has long been the gold standard treatment for severe stress urinary incontinence, poor tissue quality in patients with prior cuff erosions may preclude this option. Formal supravesical diversion and/or bladder neck closure comprise alternative salvage options but are associated with significant morbidity and mortality. We review our experience with permanent urethral ligation (PUL) among patients deemed not to be candidates for AUS replacement following cuff erosion. METHODS: From a single-center database of 396 patients undergoing AUS from 2014 to 2020, 20 men underwent PUL with suprapubic tube (SPT) diversion. Clinical characteristics and outcomes were evaluated. Quality of life (QOL) was assessed using chart review, Michigan Incontinence Symptom Index (M-ISI), and Patient Global Impression of Improvement (PGI-I). RESULTS: PUL resulted in continence in 18 (90%) men; 15 after the initial surgery and three after repeat ligation. Patients were elderly (average age 75) with significant comorbidities. A total of 11 (55.5%) patients experienced complications in the 90-day postoperative period (seven Clavien-Dindo Grade II, four Grade III). Over an average follow-up of 30.3 months (interquartile range: 15.75-48.75), four patients underwent cystectomy and one underwent perineal urethrostomy. In the remaining patients managed by PUL, 13 had satisfactory M-ISI scores and indicated overall improvement on PGI-I. CONCLUSIONS: For men with AUS cuff erosion who are poor candidates for replacement, PUL with chronic SPT drainage represents an acceptable alternative option to restore continence and improve QOL. Though complications are not uncommon, the morbidity profile still compares favorably to more invasive formal urinary diversion.

Standing cough test stratification of moderate male stress urinary incontinence.

PURPOSE: Patient-reported history of pads per day (PPD) is widely recognized as a fundamental element of decision-making for anti-incontinence procedures. We hypothesize that SUI severity is often underestimated among men with moderate SUI. We sought to compare patient history of incontinence severity versus objective in-office physical examination findings. MATERIALS AND METHODS: We retrospectively reviewed our single-surgeon male SUI surgical database from 2007-2019. We excluded patients with incomplete preoperative or postoperative data and those who reported either mild or severe SUI, thus having more straightforward surgical counseling. For men reported to have moderate SUI, we determined the frequency of upgrading SUI severity by recording the results of an in-office standing cough test (SCT) using the Male Stress Incontinence Grading Scale (MSIGS). The correlation of MSIGS with sling success rate was calculated. Failure was defined as >1 PPD usage or need for additional incontinence procedure. RESULTS: Among 233 patients with reported moderate SUI (2-3 PPD), 89 (38%) had MSIGS 3-4 on SCT, indicating severe SUI. Among patients with 2-3 PPD preoperatively, sling success rates were significantly higher for patients with MSIGS 0-2 (76/116, 64%) compared to MSIGS 3-4 (6/18, 33%) (p <0.01). CONCLUSIONS: Many men with self-reported history of moderate SUI actually present severe SUI observed on SCT. The SCT is a useful tool to stratify moderate SUI patients to more accurately predict sling success.

Acute changes to breast milk composition following consumption of high-fat and high-sugar meals.

Breast milk composition is influenced by habitual diet, yet little is known about the short-term effects of changes in maternal diet on breast milk macronutrient concentrations. Our aim was to determine the acute effect of increased consumption of sugar/fat on breast milk protein, lactose and lipids. Exclusively breastfeeding women (n = 9) were provided with a control, higher fat (+28 g fat) and higher sugar (+66 g sugar) diet over three separate days at least 1 week apart. Hourly breast milk samples were collected concurrently for the analysis of triglycerides, cholesterol, protein, and lactose concentrations. Breast milk triglycerides increased significantly following both the higher fat and sugar diet with a greater response to the higher sugar compared to control diet (mean differences of 3.05 g/dL ± 0.39 and 13.8 g/dL ± 0.39 in higher fat and sugar diets, respectively [P < 0.001]). Breast milk cholesterol concentrations increased most in response to the higher sugar diet (0.07 g/dL ± 0.005) compared to the control (0.04 g/dL) and the higher fat diet (0.05 g/dL) P < 0.005. Breast milk triglyceride and lactose concentrations increased (P < 0.001, P = 0.006), whereas protein decreased (p = 0.05) in response to the higher fat diet compared to the control. Independent of diet, there were significant variations in breast milk composition over the day; triglycerides and cholesterol concentrations were higher at end of day (P < 0.001), whereas protein and lactose concentrations peaked at Hour 10 (of 12) (P < 0.001). In conclusion, controlled short-term feeding to increase daily sugar/fat consumption altered breast milk triglycerides, cholesterol, protein and lactose. The variations observed in breast milk protein and lactose across the 12 h period is suggestive of a circadian rhythm.

Artificial Urinary Sphincter Cuff Erosion Heat Map Shows Similar Anatomical Characteristics for Transcorporal and Standard Approach.

PURPOSE: We describe and compare artificial urinary sphincter cuff erosion sites and associated clinical implications. MATERIALS AND METHODS: We retrospectively reviewed men who presented with artificial urinary sphincter erosion treated by a single surgeon between 2007 and 2019 at a tertiary medical center. Transcorporal indications included complications of prior anti-incontinence procedures and prior urethral reconstruction. Location of artificial urinary sphincter cuff erosion defects was assessed by cystoscopy prior to device explantation, and findings were stratified into patients who had transcorporal vs standard artificial urinary sphincter placement. RESULTS: Out of 723 artificial urinary sphincter cases in 611 patients we identified 54 (7.5%) cuff erosions. Erosion developed in 15 of 82 (18.3%) cases of transcorporal artificial urinary sphincter and 39 of 641 (6.1%) cases of standard artificial urinary sphincter (p <0.05). Artificial urinary sphincter cuff erosions occurred predominantly ventrally in both groups (66.7% for transcorporal and 79.5% for standard artificial urinary sphincter, p=0.4) followed by lateral urethral location (33.3% transcorporal and 20.5% standard, p=0.3). Dorsal erosions were rare in both groups (20% transcorporal and 5.1% standard, p=0.1). History of artificial urinary sphincter and previous erosion were associated with transcorporal artificial urinary sphincter erosion. History of radiotherapy, prior urethroplasty, hypogonadism and urethral cuff size were similar between groups. CONCLUSIONS: Artificial urinary sphincter cuff erosions appear to occur ventrally and laterally in most patients regardless of cuff placement. Dorsal erosions were the least common in both groups. The protective effect of transcorporal artificial urinary sphincter could not be conclusively demonstrated.

Avoiding deep pelvic complications using a 'Five-Step' technique for high submuscular placement of inflatable penile prosthesis reservoirs.

OBJECTIVES: To compare our extended experience with high submuscular (HSM) reservoir placement to traditional space of Retzius (SOR) placement and to present our current, refined 'Five-Step' technique (FST) for HSM placement. PATIENTS AND METHODS: Data were retrospectively collected on patients undergoing inflatable penile prosthesis (IPP) placement between January 2009 and June 2019. Re-operative cases were excluded. Reservoir-related complications and subsequent revisions were compared between SOR (2009-2012) and HSM reservoir groups (2012-2019). HSM patients were subdivided into two cohorts: 'Initial Technique' (2012-2014) and FST (2014-2019). The refined FST protocol was developed in 2014 to optimise outcomes and includes the following steps: (i) Position and Access; (ii) Develop Lower HSM Pocket; (iii) Develop Upper HSM Pocket; (iv) Reservoir Delivery (fill and fine-tune); (v) Confirm and Connect. RESULTS: Between January 2009 and June 2019, 733 total IPP procedures (586 HSM, 147 SOR) were performed by a single surgeon at our institution, 561 of which were virgin cases (430 HSM, 131 SOR) and included in this analysis. Overall, surgical revision was required in 10/430 (2.3%) HSM cases (one delayed bowel obstruction, nine herniations) and six of 131 (4.6%) SOR cases (one bladder erosion, two vascular injuries, and three herniations, P = 0.22). When comparing the FST to the Initial Technique, we noted a significant decrease in complications requiring surgical revision (P = 0.01). Among 133 cases performed with the Initial Technique, seven (5.3%) required surgical revision (one bowel obstruction after placement into the peritoneal cavity, six herniations). Among 297 FST cases, three (1.0%) required revision, all due to herniation. CONCLUSION: HSM placement of IPP reservoirs is a safe alternative to traditional SOR placement. Major deep pelvic reservoir complications were minimised using our current refined FST.

Favourable multi-institutional experience with penoscrotal decompression for prolonged ischaemic priapism.

OBJECTIVES: To report our multi-institutional experience using penoscrotal decompression (PSD) for the surgical treatment of prolonged ischaemic priapism (PIP). MATERIALS AND METHODS: We retrospectively reviewed clinical records for patients with PIP treated with PSD between 2017 and 2020. Priapisms were confirmed as ischaemic based on clinical presentations and cavernosal blood gas abnormalities. Treatment with irrigation and injection of α-agonists in all patients had failed prior to PSD. Patient characteristics, peri-operative variables and outcomes, and changes in International Index of Erectile Function (IIEF) scores were evaluated. RESULTS: We analysed 25 patients who underwent a total of 27 PSD procedures. The mean duration of priapism at initial presentation was 71.0 h. Irrigations and injections in all patients had failed, while corporoglanular shunt treatment in 48.0% of patients (12/25) had also failed prior to PSD. Of the 10 patients who underwent unilateral PSD, two (20.0%) had priapism recurrence. Both were treated with bilateral PSD, with prompt and lasting detumescence. Among the 15 patients undergoing primary bilateral PSD, none had priapism recurrence. Of the 15 patients with documented sexual function status at last follow-up, nine (60%) reported spontaneous erectile function adequate for penetration, while six (40%) reported erectile dysfunction. The median (interquartile range) decrease in IIEF-5 score was 3.5 (0-6.75) points after PSD. Two patients underwent uneventful inflatable penile prosthesis placement following PSD. CONCLUSIONS: Penoscrotal decompression presents a simple, safe, highly effective and easily reproducible procedure for resolution of PIP. PSD should be considered as a viable salvage or alternative strategy to corporoglanular shunt procedures.

Explantation of High Submuscular Reservoirs: Safety and Practical Considerations.

BACKGROUND: Over the past decade, high submuscular (HSM) placement of inflatable penile prosthesis (IPP) reservoirs has emerged as a viable alternative to space of Retzius (SOR) placement; however, data comparing the feasibility and complications of HSM vs SOR reservoir removal do not presently exist. AIM: To present a comparison of the safety, feasibility, and ease of removal of HSM vs SOR reservoirs in a tertiary care, university-based, high-volume prosthetic urology practice. METHODS: Data were retrospectively collected on patients who underwent IPP reservoir removal between January 2011 and June 2020. Cases were separated into 2 cohorts based on reservoir location. Statistical analysis was performed using Fisher's exact and Chi-squared tests for categorical variables and Student's t-test for continuous variables. Timing from IPP insertion to explant was compared between the HSM and SOR groups using the Mann-Whitney U test. OUTCOMES: Time from IPP insertion to explant, operative time, intraoperative and postoperative complications, and need for a counter incision were compared between the HSM and SOR groups. RESULTS: Between January 2011 and June 2020, 106 (73 HSM, 33 SOR) patients underwent IPP removal or replacement by a single surgeon at our institution. Average time from IPP insertion to removal was 43.6 months (24.2 HSM, 52.7 SOR, P = .07)-reservoir removal occurred at the time of device explant in 70 of 106 (66%) cases. More HSM reservoirs were explanted at the time of IPP removal compared with the SOR cohort (54 of 73, 74% HSM vs 16 of 33, 48.5% SOR, P = .01). Similar rates of complications were noted between the HSM and SOR groups (1.9% vs 6.3%, P = .35). There was no significant difference in need for counter incision between the 2 groups (24 [42%] HSM vs 4 [25%] SOR, P = .16) or in average operative times (76.5 ± 38.3 minutes HSM vs 68.1 ± 34.3 minutes SOR, P = .52). CLINICAL IMPLICATIONS: Our experience with explanting HSM reservoirs supports the safety and ease of their removal. STRENGTHS AND LIMITATIONS: Although the absolute cohort size is relatively low, this study reflects one of the largest single-institution experiences examining penile implant reservoir removal. In addition, reservoir location was not randomized but was instead determined by which patients presented with complications necessitating reservoir removal during the study period. CONCLUSIONS: HSM reservoir removal has comparable perioperative complication rates and operative times when compared with SOR reservoir removal. Kavoussi M, Bhanvadia RR, VanDyke ME, et al. Explantation of High Submuscular Reservoirs: Safety and Practical Considerations. J Sex Med 2020;17:2488-2494.

Muskrats as a bellwether of a drying delta.

Wetlands worldwide are under threat from anthropogenic impacts. In large protected North American areas such as Yellowstone and Wood Buffalo National Parks, aquatic habitats are disappearing and wetland-dependent fauna are in decline1-3. Here we investigate population dynamics of an indicator species in Canada's Peace-Athabasca Delta ("the delta"), a World Heritage Site. Based on population surveys, habitat mapping and genetic data from 288 muskrats, we use agent-based modeling and genetic analyses to explain population expansion and decline of the semi-aquatic muskrat (Ondatra zibethicus). Simulations quantify a large population (~500,000 individuals) following flood-induced habitat gains, with decreased size (~10,000 individuals) during drying. Genetic analyses show extremely low long-term effective population size (Ne: 60-127), supporting a legacy of population bottlenecks. Our simulations indicate that the muskrat population in the delta is a metapopulation with individuals migrating preferentially along riparian pathways. Related individuals found over 40 km apart imply dispersal distances far greater than their typical home range (130 m). Rapid metapopulation recovery is achieved via riparian corridor migration and passive flood-transport of individuals. Source-sink dynamics show wetland loss impacts on the muskrat metapopulation's spatial extent. Dramatic landscape change is underway, devastating local fauna, including this generalist species even in a protected ecosystem.

Plication for Correction of Congenital Penile Curvature: With or Without Degloving?

INTRODUCTION: Previously, incisionless plication (IP) for correction of congenital penile curvature (CPC) has been performed after penile degloving via a circumscribing incision. AIM: To describe our experience with non-degloving incisionless penile plication (NDIP) for correction of CPC and compare these outcomes with those of men who underwent degloving incisionless penile plication (DIP). METHODS: We conducted a retrospective review of men ≤ 45 years of age who underwent incisionless penile plication for correction of CPC between 2008 and 2020 at two adult tertiary hospitals. Patients underwent either NDIP, performed through a 2-3 cm longitudinal incision along the proximal-to-mid shaft opposite the point of maximum penile curvature, or DIP via a sub-coronal circumscribing incision. MAIN OUTCOME MEASURES: Surgical and patient-reported outcomes were compared between the non-degloving and degloving groups. RESULTS: Among the 38 men (mean age, 26 years) who met the inclusion criteria, 25 underwent NDIP, including 6 patients with biplanar curvature (2 Ventral, 4 Dorsal, 6 Lateral). Thirteen patients underwent DIP, including 1 patient with biplanar curvature (1 ventral, 1 lateral). Curvature reduction was 50 ± 23 degrees for the NDIP group and 36 ± 10 degrees for the DIP group (P = .04). Five (20%) patients in the NDIP group and nine (69%) patients in the DIP group experienced a reduction in stretched penile length following plication (SPL) (P = .01). One patient in the NDIP group underwent an additional plication for recurrent curvature. CONCLUSION: Both NDIP and DIP are safe and highly efficacious techniques for the correction of CPC. Kusin SB, Khouri RK, Dropkin BM, et al., Plication for Correction of Congenital Penile Curvature: With or Without Degloving?. Sex Med 2021;9:100462.

Extended Primary Anastomosis With Penile Plication (EPAPP): A Promising New Alternative to Perineal Urethrostomy for Reconstruction of Long Urethral Strictures.

OBJECTIVE: At present, excision and primary anastomosis (EPA) urethroplasty is a highly reliable method of reconstruction for short bulbar urethral strictures. Longer strictures are often managed with grafting techniques to ensure a tension-free repair. Here we report our initial experience with a new, extended anastomotic technique for long bulbar strictures that incorporates plication of the ventral corporal bodies to reduce the distance between the urethral ends and obviates the need for grafting. METHODS: We reviewed records for all urethroplasties performed by a single surgeon at our institution between January 2018 and February 2020. We identified a cohort of older patients with complex strictures who underwent Extended Primary Anastomosis with Penile Plication (EPAPP). Patient demographics, stricture characteristics, perioperative 75 parameters, and postoperative outcomes were evaluated. RESULTS: Of 346 urethroplasty records reviewed, 10 patients (2.9%) underwent EPAPP. Mean stricture length was 3.75 ± 1.4 cm. EPAPP patients were older than those repaired by other techniques (mean age 66.6 vs 55.6, P = .024), and most were not sexually active preoperatively. Postoperative voiding cystourethrogram confirmed urethral patency without extravasation in all patients. At a median follow up of 9.7 months (IQR 8.5-11.5) 8 patients remained asymptomatic after EPAPP alone and 2 patients required a single balloon dilation for stricture recurrence. CONCLUSION: EPAPP is a promising alternative option for the management of long bulbar strictures among appropriately selected patients.

High Submuscular IPP Reservoir Placement: The "Five-Step" Technique.

BACKGROUND: High submuscular (HSM) placement of inflatable penile prosthesis (IPP) reservoirs is a promising new FDA approved alternative to traditional space of Retzius reservoir placement. In 2011, we began placing all reservoirs in a HSM position at our tertiary center. In 2014, we proposed a refined, "Five-Step" HSM reservoir placement technique (FST) to prevent deep pelvic complications. OBJECTIVES: To describe our HSM technique and report on our extended experience. MATERIAL: Our refined FST was developed to optimize outcomes and includes the following steps: (1) Position and Access; (2) Develop Lower HSM Pocket; (3) Develop Upper HSM Pocket; (4) Reservoir Delivery (Fill and Fine-Tune); (5) Confirm and Connect. Data was retrospectively collected on patients undergoing reservoir placement by FST between January 2014 and June 2019. A survey analyzing subjective outcomes and patient satisfaction was performed among 100 randomly selected patients. RESULTS: We placed 297 consecutive HSM IPP reservoirs via FST during this time period. Three patients (1.0%) required surgical revision (all for herniation). No deep pelvic (vascular, bladder, bowel) complications were reported. Of the 100 patients that were randomly surveyed, 86% of patients reported no palpability of the reservoir, and 95% of patients reported satisfaction with the procedure and would recommend the procedure to a friend. CONCLUSION: The FST for HSM reservoir placement is a simple and safe procedure with good outcomes and excellent patient satisfaction. This technique appears to effectively eliminate the risks of deep pelvic complications.

Artificial Urinary Sphincter Outperforms Sling for Moderate Male Stress Urinary Incontinence.

OBJECTIVES: To determine the role of slings and artificial urinary sphincters (AUS) in the management of mild and moderate stress urinary incontinence (SUI). METHODS: A retrospective review of our single-surgeon male SUI database was completed. Men having AUS or AdVance sling procedures between 2008 and 2019 were included in the analysis. Those with severe incontinence and/or incomplete pre- or postoperative data were excluded. All patients were evaluated by standing cough test and stratified according to the Male Stress Incontinence Grading Scale. Scores of 0-1 and 2-3 defined mild and moderate SUI, respectively. We performed 2 analyses: (a) sling outcomes were compared between mild vs moderate SUI patients, and (b) for men with moderate SUI, we compared outcomes between slings and AUS. Treatment failure was defined as >1 pad per day or need for subsequent incontinence procedure. RESULTS: Among 202 sling cases, those with mild SUI had significantly higher success rate (69/88, 78%) than those with moderate SUI (72/114, 63%; P = .02). Among the 179 men with moderate SUI, those who underwent AUS had significantly higher success rate (52/65, 80%) than those who underwent sling (72/114, 63%; P = .02). CONCLUSION: Male slings are more effective for men with mild SUI than for men with moderate SUI. Men with moderate SUI have a higher success rate with AUS than with sling.

Balloon dilation performs poorly as a salvage management strategy for recurrent bulbar urethral strictures following failed urethroplasty.

BACKGROUND: The optimal management strategy for recurrent urethral stricture disease (USD) following urethroplasty remains undefined. We aim to evaluate the role and efficacy of endoscopic urethral balloon dilation in temporizing recurrent USD after failed urethroplasty. METHODS: Between 2007-2018 at our institution, 80 patients underwent balloon dilation procedures for bulbomembranous urethral strictures. Balloon dilation was performed with an 8-cm, 24-French UroMax Ultra™ balloon dilator, under direct vision, guided by a 16-French flexible cystoscope. Patients who underwent concomitant open or endoscopic urethral procedures were excluded. Treatment failure was defined as the need for subsequent surgical intervention for stricture recurrence. Stricture characteristics including etiology, length, location, severity stage, and prior surgical procedures were compared between patients with and without treatment failure. RESULTS: Failure cases were more likely to have strictures following urethroplasty (21/27, 78%) [vs. the no-failure group (27/53, 51%)]. Among the 27/80 (33.8%) failures with a median follow-up of 8.4 months (IQR, 3.9-22.5 months), median time to recurrence was 4 months (IQR, 2-12 months). These patients had a greater incidence of prior stricture intervention in general (P=0.01) and prior urethroplasty specifically (P=0.03). On multivariable analysis, the number of prior treatments specifically independently remained associated with treatment failure. Complications of balloon dilation were uncommon (6/80, 7.5%) and minor in nature. CONCLUSIONS: Endoscopic balloon dilation performs poorly as a salvage strategy after failed open urethral reconstruction in addition to prior urethral dilations.

Long-term sequelae of inflatable penile prosthesis: clinical characteristics of patients who develop distal cylinder tip extrusion.

BACKGROUND: Impending distal cylinder tip extrusions (DCTE) make up approximately 5-33% of all inflatable penile prosthesis (IPP) reoperations. While there have been a few case reports of DCTE in patients with diabetes and trauma, the current literature regarding risk factors for DCTE is limited. In this study, we examined the long-term sequelae among a large cohort of IPP patients to identify clinical risk factors for impending DCTE. METHODS: A retrospective review was completed of our single surgeon IPP database of 797 IPP placement cases from the years 2007 to 2018. We identified those who had a surgical intervention for a confirmed DCTE. Infected prostheses were excluded. The primary clinical end point of this study was to identify the time to extrusion repair from original penile prosthesis placement. Secondary clinical end points included location of extrusion and presence of corporal fibrosis. RESULTS: Between the years 2007 to 2018, 26 cases (3%) of impending or complete cylinder extrusions were identified in our IPP database (n=797). The mean age at initial IPP placement was 58 years, compared to a mean of 66 years at the time of extrusion. The mean time from initial placement to extrusion repair surgery was 8.4 years (median 5.5 years). Most patients (15/26, 57.7%) had a history of prior IPP placement, five of whom had two or more prior prostheses. Location among the 26 extrusions varied-12 (46.2%) lateral, 9 (34.6%) distal urethra, 2 (7.7%) glanular, 2 (7.7%) mid-shaft, and 1 (3.8%) coronal sulcus. Concomitant pathologies identified include Peyronie's disease (7, 26.9%), idiopathic corporal fibrosis (7, 26.9%) and sickle cell disease with priapism induced erectile dysfunction (3, 11.5%). CONCLUSIONS: The risk of IPP extrusion appears to be associated with increased time from initial prosthesis placement, prior history of IPP placement, and the presence of corporal fibrosis or deformity. Patients should be counseled to recognize this important long-term sequela of IPP surgery.

An update on oxidized regenerated cellulose (fibrillar™) in reducing postoperative corporal bleeding following inflatable penile prosthesis surgery.

BACKGROUND: Scrotal hematoma formation is a dreaded complication of penile prosthesis surgery that increases patient pain and healthcare costs, as well the risk for eventual device infection and failure. The efficacy of hemostatic agents in reducing the incidence of scrotal hematoma development has not been extensively studied in urologic prosthetic surgery. In this paper we further evaluate our experience with oxidized regenerated cellulose (ORC; Surgicel Fibrillar™) as an adjunct to standard hemostatic practices in inflatable penile prosthesis (IPP) implantation. METHODS: From April 2016 onward, intracorporal ORC pledgets were placed during corporotomy closure in all patients undergoing IPP implantation or revision by a single surgeon using an identical surgical technique. Perioperative parameters and outcomes-primarily postoperative cumulative drain output, secondarily patient phone calls in the postoperative period-were compared among successive cases with ORC (April 2016 to February 2019) and without ORC (April 2013 to March 2016). RESULTS: A total of 274 men underwent IPP implantation during the study period; 175 (64%) had ORC included in their corporotomy closures. Median drain output was significantly reduced in the ORC patients relative to the non-ORC group (50 vs. 65 mL; P=0.0001). A significant reduction in patient-initiated phone calls regarding scrotal pain, swelling, or discomfort in the first 4 weeks following surgery was also observed in the ORC group (average 0.69 vs. 1.1 calls per patient; P=0.03). A total of 9 patients underwent IPP explantation during the study period, all due to device infection; 5 of these were in the ORC group, while 4 were in the non-ORC group (P=0.73). ORC use did not constitute any additional infection risk. CONCLUSIONS: Bilateral incorporation of ORC pledgets during corporotomy closure in IPP surgery significantly decreases postoperative scrotal drain output, a well-documented risk factor for scrotal hematoma formation.

Urethral atrophy is now a rare cause for artificial urinary sphincter revision surgery in the contemporary 3.5 cm cuff era.

BACKGROUND: Urethral atrophy has long been suggested as the leading cause of artificial urinary sphincter (AUS) revision. Since the introduction of the 3.5 cm AUS cuff in 2010, precise cuff sizing primarily has been suggested to reduce revisions due to urethral atrophy. We evaluated a large contemporary series of reoperative AUS cases to determine reasons for revision surgery. METHODS: We retrospectively reviewed our tertiary referral center database of male AUS procedures performed by a single surgeon from 2007-2019. AUS revision or replacement procedures were included for analysis. Cuff sizes and reasons for reoperation were recorded based on intraoperative findings and evaluated for temporal trends. Patients with cuff erosion or lacking follow-up were excluded. RESULTS: Among 714 AUS cases, 177 revisions or replacements were identified. Of these, 137 met inclusion criteria [mean age 71.7 years, median follow-up 52.7 months (IQR 22.3-94.6 months)]. Urethral atrophy was cited as the cause of AUS failure in 8.0% (11/137) of cases overall, virtually never among those with a 3.5 cm cuff placement (1/51, 2.0%). In those with ≥4.0 cm cuffs, urethral atrophy was the reason for revision in 10/86 (11.6%). Pressure regulating balloon (PRB) failure was the most frequently cited cause of failure (47/137, 34.3%). Cuff-related failure (23/137, 16.8%) and mechanical failure of unspecified device component (16/137, 11.8%) were the next most frequent causes of failure. CONCLUSIONS: Urethral atrophy has become a rare cause of AUS revision surgery since the availability of smaller cuffs. PRB-related failure is now the leading cause of AUS reoperation.

Dutasteride in the long-term management of stuttering priapism.

BACKGROUND: The objective of this study is to review our 12-year experience with the 5-α reductase inhibitor dutasteride as a potential long-term treatment option for stuttering priapism. Dutasteride has a uniquely long half-life of 35 days which offers a theoretical advantage as a chronic therapy for management of stuttering priapism. METHODS: We retrospectively reviewed patients with stuttering priapism in our database from 2006-2018 treated with dutasteride. Men with concurrent use of medications other than dutasteride to treat stuttering priapism were excluded. Patients were started on a dose of 0.5 mg daily and tapered to a more infrequent dosing schedule, ranging from 0.5 mg every other day to once weekly. The frequency of priapism episodes before and after initiation of dutasteride therapy was analyzed. RESULTS: Among 21 cases, 13 patients met our inclusion criteria (mean age 43 years). Median follow-up on daily dutasteride was 79 days, and median follow-up on tapered dutasteride was 607 days. A total of 11/13 (85%) men treated with dutasteride had some degree of improvement-5/13 (38%) had complete resolution of their symptoms and 6/13 (46%) had reduced frequency and/or severity of their episodes. Among 5/13 (38%) men who had >2 emergency room (ER) visits for ischemic priapism prior to therapy, most (3/5, 60%) did not require any ER visits while on dutasteride therapy. Among the five men who received chronic, tapered-dose therapy, all reported continued suppression of priapistic episodes. Among 4 patients with sickle cell disease (SCD), 3/4 (75%) ultimately chose more invasive therapy including androgen deprivation therapy (ADT) and penile prosthesis. Side effects were minimal and included gynecomastia (8%), decreased libido (8%), and fatigue (8%). CONCLUSIONS: In patients with stuttering priapism, daily dutasteride therapy is a promising treatment option to reduce the frequency and severity of priapistic episodes without significant side effects. Therapy can effectively be tapered to once weekly dosing without a reduction in efficacy.

Age ≤40 is an independent predictor of anastomotic urethroplasty and successful repair of bulbar urethral strictures.

BACKGROUND: Among men with bulbar strictures, we aimed to analyze stricture characteristics, repair type, and treatment success in younger versus older patient cohorts. METHODS: We retrospectively reviewed our single surgeon database with patients undergoing bulbar urethroplasty from 2007 to 2017. This population was then age-stratified into ≤40 and >40-year-old cohorts. Exclusion criteria included patients with penile strictures and those with history of hypospadias. Patient characteristics, surgical approach, and outcome were compiled by medical record and database review. Criterion for success included functional emptying and lack of repeat surgical intervention. Parameters associated with failure were included in multivariate logistic regression models. RESULTS: Eight hundred and fifty-three patients with bulbar strictures were identified, 231 patients (27.1%) ≤40 years old and 622 patients (72.9%) >40 years old. Mean stricture length was significantly longer in older men (2.3 vs. 2.7 cm, P=0.005). Excision and primary anastomosis (EPA) were more commonly utilized when managing younger compared to older patient groups (87% in ≤40 group, 77% in >40, P=0.0009). Younger men underwent significantly fewer endoscopic stricture treatments than older men (2.1 vs. 4.9, P=0.001). Traumatic etiology was more commonly attributable in the younger group (48% vs.17%, P<0.0001). Younger men presented less frequently with diabetes (1.7% vs. 21.7%, P<0.0001), coronary artery disease (0.4% vs. 19.1%, P<0.0001), and erectile dysfunction (11.5% vs. 29.2%, P<0.0001) relative to older men. Over a median follow-up of 52.4 months, success rates were higher in the ≤40 cohort (97.4%) than the >40 cohort (87.3%, P<0.0001). On multivariate logistic regression, independent predictors of urethroplasty success include younger age), utilization of EPA, and lack of pelvic radiation. CONCLUSIONS: Although men ≤40 years old have a higher incidence of traumatic etiology, bulbar urethroplasty has a higher success rate when compared to patients >40 years old. Bulbar strictures are more amenable to EPA in the younger population, likely due to fewer endoscopic treatments and favorable tissue characteristics.

Outpatient buccal mucosal graft urethroplasty outcomes are comparable to inpatient procedures.

BACKGROUND: We sought to compare outcomes between inpatient and outpatient buccal mucosal graft (BMG) urethroplasty among a large tertiary referral center series. METHODS: A retrospective review of consecutive patients who underwent BMG urethroplasty between 2007 and 2018 was performed, including only first stage and one stage graft procedures. Patients were divided into inpatient and outpatient groups. Demographic and outcome data were collected and analyzed, with success defined as no need for further endoscopic or open reoperative management. RESULTS: Of 143 patients undergoing BMG urethroplasty during the study period, 87 cases (60.8%) were performed on an inpatient basis, and 56 (39.2%) on an outpatient basis. Patient characteristics such as age, BMI, prior endoscopic procedures and co-morbid factors were similar between inpatient and outpatient groups. Perioperative characteristics such as estimated blood loss were also similar between groups, but the inpatient cohort had a longer operative time (157.6 vs. 123.1 min, P<0.0001). Operative success was comparable in the two groups (74.7% inpatient vs. 76.8% outpatient, P=0.7) as were rates of complications (29.9% inpatient vs. 26.8% outpatient, P=0.07). CONCLUSIONS: BMG urethroplasty can be safely performed in an ambulatory setting without increased complications or compromised outcomes.

Comparison of 3.5 cm and transcorporal cuffs in high-risk artificial urinary sphincter populations.

BACKGROUND: The transcorporal (TC) artificial urinary sphincter (AUS) has traditionally been utilized in high-risk patients with urethral atrophy or prior urethral erosion. The 3.5 cm AUS cuff has been developed for use in a similar population. We compared the outcomes of TC AUS and 3.5 cm cuff patients to assess whether the TC approach was protective against urethral complications. METHODS: We performed a retrospective review for all men who underwent TC AUS and 3.5 cm AUS implantation by a single surgeon from 2007 to 2018 at a tertiary medical center. Demographic and outcomes data were collected and analyzed after database review to evaluate for rates of urethral erosion. Multivariate logistic regression was performed to identify co-morbid factors associated with urethral erosion. RESULTS: In our database of 625 AUS patients, we identified 59 (9%) men with TC AUS and 168 (27%) having a 3.5 cm cuff. Over a median follow-up time of 49 months, 28 (47%) men with TC cuffs developed urethral erosion compared with 25 (15%) men with a 3.5 cm cuff. On univariate analysis, a TC cuff was associated with increased odds of erosion (OR 6.65, 95% CI: 3.20-14.4, P<0.0001) when compared with a 3.5 cm cuff. On multivariate analysis, TC cuffs continued to portend significantly increased odds of cuff erosion. CONCLUSIONS: With longer follow up, TC AUS may not be as protective against urethral complications as previously described.