Long term results of augmentation cystoplasty and urinary diversion in multiple sclerosis.

INTRODUCTION: There is a paucity of data about augmentation cystoplasty (AC) in multiple sclerosis (MS) patients with refractory lower urinary tract symptoms (LUTS). The aim of this study is to evaluate the long term outcomes and morbidity of these procedures in MS patients. MATERIALS AND METHODS: This is a retrospective observational study of consecutive patients (1984-2017) with MS and refractory LUTS who underwent AC with or without a continent/incontinent abdominal stoma or urinary diversion. Pre and postoperative evaluations included routine labs, videourodynamic studies (VUDS), cystoscopy, and upper tract imaging. Long term outcomes and complications were assessed by validated questionnaires and/or chart review. RESULTS: There were 17 patients (12 women, 5 men) ranging in age from 34-77 years. Thirteen patients were wheelchair-bound (10 quadriplegics, 3 paraplegics). Indications included neurogenic detrusor overactivity (NDO) in two, low bladder compliance (LBC) in 13 and both NDO and LBC in two. One patient committed suicide at 3 months, and one was lost to follow up. Of the remaining 15, median follow up was 13 years (range 4-22), and 11 were followed up until death. Overall, 14/15 (93%) had a successful outcome based on the Patient Global Impression of Improvement (PGI-I). With respect to incontinence, 14/15 (93%) had a successful outcome based on the Simplified Urinary Incontinence Score (SUIS). Median bladder capacity increased from 180 mL to 605 mL (p < 0.001). Median maximum detrusor pressure decreased from 63 cm H2 O to 18 cm H2O (p < 0.003). Two patients underwent stomal stenosis revisions, four patients had pyelonephritis, and two patients developed de novo bladder stones. CONCLUSIONS: AC is a major surgical procedure with high potential morbidity, but these data suggest that AC is efficacious in the long term with acceptable morbidity and mortality. We believe it is an underutilized procedure for refractory LUTS in MS patients.

CT and MR Imaging Features of Artificial Urinary Sphincters, Penile Prostheses, and Other Devices in the Male Lower Genitourinary Tract.

Urinary incontinence and erectile dysfunction are relatively common conditions in the aging male population. Surgical interventions for urinary incontinence include placement of an artificial urinary sphincter (AUS), perineal sling, or sacral nerve stimulator and injections of periurethral bulking agents. Erectile dysfunction can be treated surgically with placement of a penile prosthesis. The complications of these devices can be broadly categorized as device component malposition, malfunction, and infection. This article focuses on AUSs, penile prostheses, and their complications. Familiarity with these devices and their complications allows the radiologist to effectively describe these implants in radiologic reports and to recognize complications when they occur. This article reviews the normal cross-sectional radiologic appearance of the most common implants used to surgically treat male urinary incontinence and erectile dysfunction, as well as the potential complications associated with these devices. ©RSNA, 2018.

Electrosurgical transurethral resection of the prostate and transurethral incision of the prostate (monopolar techniques).

INTRODUCTION: We summarize the current guidelines, techniques, efficacy and complications associated with monopolar transurethral resection of the prostate (TURP) and transurethral incision of the prostate (TUIP) for benign prostatic hyperplasia (BPH). Patients who elect to have endoscopic surgical bladder outlet reduction are faced with an abundance of evolving treatment options. As new technology comes and goes, TURP and TUIP remain the gold standard for which new treatments are compared. MATERIALS AND METHODS: A review of past and contemporary data including American and European guidelines was performed. Techniques, efficacy, durability, short term and long term complications of TURP and TUIP are summarized. RESULTS: Small prostate sizes < 30 mL without a median lobe can be effectively treated with TUIP with decreased perioperative complications and sexual side effects compared to TURP. Monopolar TURP demonstrates significant improvements in IPSS, peak flow rate (Qmax), and quality of life (QoL) with durable (8 year-22 year) outcomes. Secondary intervention increases by 1%-2% annually. Thirty-day mortality rate is low (0.1%) as well as incidence of TUR syndrome (< 1.1%). Short term and long term complications include bleeding requiring transfusion, clot retention, acute urinary retention (AUR), and urinary tract infections as well as incontinence, bladder neck contracture, urethral stricture, and sexual dysfunction. CONCLUSIONS: Monopolar TURP and TUIP are effective endoscopic treatments for BPH with durable long term results. While the short term and long term complication rates are acceptable, new technologies aim to increase tolerability of bladder outlet reduction by decreasing treatment related morbidity.

Gunshot wounds to the scrotum: a large single-institutional 20-year experience.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Penetrating trauma to the scrotum often requires operative intervention, with testicular salvage only possible when enough testicular tissue can be re-approximated in the traumatic setting. The present report represents the largest series of gunshot wound trauma to the scrotum in the literature. Further, it validates recommendations of the European Association of Urology guidelines on urological trauma that advocate operative intervention due to minimal rates of patient morbidity and the inherent limitations of scrotal ultrasonography in discerning testicular compromise. OBJECTIVE: To report our 20-year experience of gunshot wounds (GSWs) to the scrotum and outline the management of this traumatic injury. PATIENTS AND METHODS: We queried our institutional database for patients presenting with GSWs to the scrotum between 1985 and 2006. All patients underwent the standard trauma evaluation upon presentation, including physical examination of the external genitalia. Management was dictated by the presence or absence of a penetrating injury to the scrotum and associated traumatic injuries. Nonoperative and operative management of traumatic injury to the scrotum were used. Testicular salvage was performed when anatomically feasible. If testicular salvage was not feasible, an orchiectomy was performed. RESULTS: Scrotal exploration was performed in 91 (94%) patients while six (6%) patients were treated nonoperatively. Testicular injury was found in 44 (48%) patients undergoing exploration, six (7%) of whom had bilateral testicular injuries, which gave a total of 50 injured testicles. Of the injured testicles, 24 (48%) could not be salvaged and required orchiectomy, while 26 (52%) were debrided and repaired. The most common associated genitourinary (GU) injuries were to the corpora cavernosum (n= 20 [21%]) and urethra (n= 10 [10%]). Soft tissue injury of the extremities occurred in 54 patients (56%), representing the most common non-GU-associated injury. Postoperative complications occurred infrequently: one patient (1%) returned for abscess drainage and one (1%) for haematoma evacuation. CONCLUSIONS: The present report confirms that any patient with a penetrating injury to the scrotum should undergo immediate scrotal exploration. A low clinical suspicion for performing additional studies to rule out associated urethral and/or penile injury is clinically warranted. Testicular loss occurs in ≈50% of injured testicles.

Detrusor overactivity leak point pressure in women with urgency incontinence.

INTRODUCTION AND HYPOTHESIS: When incontinence accompanies detrusor overactivity (DO), the pressure at which it occurs may have important predictive value and should be termed DO leak point pressure (DOLPP). METHODS: A retrospective review of our video urodynamics database (n = 222) including validated questionnaires was performed. DOLPP was defined as detrusor pressure the moment DO incontinence occurred. Statistical analysis was performed using Student's t-test. RESULTS: Women with DO leakage (47) and with DO without leakage (15) were analyzed. Urgency and urgency incontinence (UUI) were greater among patients with DO leakage. A link between sphincter deficiency and greater severity of UUI was noted. Among patients with DO leakage, those with subjective mixed incontinence had a lower mean DOLPP than those with pure UUI (p = 0.004). The detrusor pressure at peak flow was lower in the DO leakage group (versus DO alone, p = 0.05) likely reflecting a measure of outlet resistance. CONCLUSION: DOLPP has predictive meaning in women and should be further studied for possible inclusion in standard urodynamic terminology.

Decreasing electrosurgical transurethral resection of the prostate surgical volume during graduate medical education training is associated with increased surgical adverse events.

PURPOSE: In the United States the numbers of electrosurgical transurethral prostate resection procedures have been decreasing. Since electrosurgical transurethral resection of the prostate is a difficult procedure to master, we hypothesized that recent residents are lacking in training for this procedure. We used summary case log information provided by the Accreditation Council for Graduate Medical Education to determine if the number of electrosurgical transurethral prostate resection procedures performed by graduating chief residents has decreased and if there has been an increase in surgical adverse events. In addition, we investigated whether the increased number of laser procedures impacted the rate of adverse events. MATERIALS AND METHODS: Summary operative data from graduating chief resident case logs were provided by the Accreditation Council for Graduate Medical Education for academic years 2001 to 2007. The numbers of electrosurgical transurethral prostate resection procedures, laser procedures and procedures for adverse events were recorded for each year. RESULTS: The number of electrosurgical transurethral prostate resection procedures performed by graduating chief residents has steadily decreased from 58 in 2001 to 43 in 2007. Conversely the number of laser procedures started increasing in 2004. The rate of procedures for adverse events as a percentage of electrosurgical transurethral resection of the prostate procedures increased during the study period (from 3% in 2001 to 6% in 2007), and as a percentage of electrosurgical transurethral resection of the prostate and laser procedures the rate increased until 2005 and subsequently started decreasing. CONCLUSIONS: The rate of surgical adverse events, as measured by the need for subsequent procedures, has increased during the last 7 years. However, when laser procedures are accounted for, it appears that adverse events have recently started trending down as an increasing number of laser procedures started being performed.

A novel human cadaver model to investigate a retrourethral transobturator male sling procedure.

Purpose: To develop a cadaver model for the assessment of a male transobturator male sling (retrourethral transobturator sling [RTS], AdVance™; Boston Scientific, USA) to investigate its effect on a simulated abdominal and retrograde leak point pressures (ALPP, RLPP) and the urethral pressure profile (UPP). Materials and Methods: Three fresh frozen human male cadaver specimens were obtained. A suprapubic tube was inserted into the bladder and connected to a digital manometer to measure bladder pressure. Manual suprapubic pressure was then applied to generate an increase in intraabdominal pressure and measure a simulated ALPP. Subsequent measurements of RLPP and UPP were recorded. All measurements were undertaken prior to and following insertion of a RTS. Results: The placement of the RTS consistently increased the simulated ALPP for all three cadaver specimens when compared to baseline measures. No leaks occurred at simulated ALPP's of 170 cm H2O for specimen 1, 160 cm H2O for specimen 2, and 170 cm H2O for specimen 3. There was minimal or no change in the RLPP's and UPP's following insertion of the RTS when compared to respective baseline. Conclusions: A model using fresh unfixed cadavers that incorporates a simulated measurement of ALPP is feasible for male stress urinary incontinence surgical intervention investigations.

Nonseminomatous germ cell tumor of the testis 9 years after a germ cell tumor of the pineal gland: case report and review of the literature.

Extragonadal germ cell tumors are extremely rare and account for only 3%-5% of all germ cell tumors. These tumors are rarely associated with metachronous primary testicular germ cell tumors. We report the fourth case of a primary germ cell tumor occurring after the treatment of a primary CNS germ cell tumor in a 27 year-old male with embryonal cell carcinoma of the testicle 9 years after the treatment of a germ cell tumor of the pineal gland. This represents the first case of a non-seminomatous germ cell tumor of the testicle after a CNS germ cell tumor. This case illustrates the importance of long term follow-up and self-examination in patients with extragonadal germ cell tumors.

Prostatitis: updates on diagnostic evaluation.

Prostatitis accounts for almost 2 million office visits to urologists and primary care physicians. The label "prostatitis" refers to a diverse constellation of symptoms and disease processes. The diagnosis and treatment of this disorder present numerous challenges for the physician, including a lack of abnormal findings on physical examination, laboratory tests, and radiographic images. In this article, we offer a review of the current literature and recommendations for the evaluation and diagnosis of the patient presenting with prostatitis.

Primary Seminal Vesicle Adenocarcinoma Presenting With Bilateral Orbital Metastasis: A Case Report.

Seminal vesicle (SV) adenocarcinoma is a rare and poorly understood malignancy. Symptoms are non-specific and prognosis is extremely poor. Herein we present a case report of a primary SV clear cell adenocarcinoma with bilateral orbital metastases at the time of initial presentation treated with multimodal therapy including radiotherapy and multi-drug chemotherapy.

Urodynamics in male LUTS: when are they necessary and how do we use them?

In this article, the value of urodynamic studies in the evaluation of treatment of male lower urinary tract symptoms is appraised based on current evidence. The information gained by urodynamics can be a valuable tool for counseling patients considering invasive outlet reduction procedures.

Overactive bladder in the male patient: epidemiology, etiology, evaluation, and treatment.

The urologist's approach to the diagnosis and treatment of lower urinary tract symptoms (LUTS) in male patients has changed significantly over the past decade. Advances in the basic science arena combined with a wealth of clinical data have pointed to the importance of bladder pathophysiology in the development of urinary symptoms. Historically, men with LUTS were diagnosed with "prostatism," an all-encompassing term that includes both voiding and storage symptoms that may or may not be related to prostatic obstruction. Parallel to the scientific advances in the field, the urologic lexicon began to evolve and has allowed us to more specifically describe, and therefore investigate and treat, different aspects of male LUTS. It is now well recognized that many men suffer from storage symptoms that may be more related to bladder dysfunction than to prostatic obstruction. It will be critical to integrate our knowledge of prostatic growth and obstruction, the bladder response to outlet obstruction, environmental and lifestyle factors, and age-related changes to fully understand the complex pathophysiology of male LUTS, specifically overactive bladder syndrome.