Qualitative Analysis of Patient Experiences Reaching Urethroplasty for Recurrent Urethral Stricture Disease.

PURPOSE: Despite the inferior outcomes, urethral stricture patients often undergo multiple endoscopic procedures prior to undergoing definitive urethroplasty. We sought to qualitatively evaluate the patient experience of obtaining urethroplasty to better understand the impact of this experience on quality of life. MATERIALS AND METHODS: Patients treated with urethroplasty between September 2019 and July 2021 were identified and invited to participate in our study if they had undergone ≥ 2 endoscopic procedures prior to urethroplasty. Semistructured telephone interviews were conducted, coded, and analyzed using an iterative inductive-deductive approach. RESULTS: Of the 105 urethroplasty patients during the study period, 50 (47.6%) had undergone ≥ 2 endoscopic procedures prior (IQR 3-5), of whom 20 participated in the study. Qualitative themes related to repeat endoscopic procedures included unmet treatment expectations, dissatisfaction with catheterization and repeat procedures, and negative impacts of recurrent stricture symptoms and treatments on quality of life. External factors associated with a delay to urethroplasty included financial constraints, surgeon access, and time off work. CONCLUSIONS: A trajectory of declining quality of life and unmet treatment expectations are the primary factors driving the decision to proceed with urethroplasty. However, external factors such as recovery costs and access to specialists play important roles in delaying surgery. These findings illustrate the need for improved community provider education and patient counseling to better inform expectations of both patients and providers with various treatment outcomes. Furthermore, these data highlight the need to improve access to specialized care for urethral stricture patients.

An Evidence-Based Protocol for Antibiotic Use Prior to Cystoscopy Decreases Antibiotic Use without Impacting Post-Procedural Symptomatic Urinary Tract Infection Rates.

PURPOSE: Symptomatic urinary tract infection is a complication of office based cystourethroscopy. Studies are mixed regarding the efficacy of antibiotic prophylaxis to prevent urinary tract infections. Our aim was to develop and evaluate an evidence-based protocol that reduces unnecessary antibiotic use while avoiding an increase in urinary tract infections. MATERIALS AND METHODS: We created a clinic antibiogram based on all urology office visits performed during a 2-year period. Bacterial resistance rates, institutional risk related data and clinical guidelines were applied to create a protocol for antibiotic administration before cystourethroscopy. We then analyzed 1,245 consecutive patients without a renal transplant who underwent outpatient cystourethroscopy, including 610 after protocol initiation. Urinary tract infection rates and antibiotic use were analyzed for an association with the protocol change using the Fisher exact test. RESULTS: Cultures had an overall 20% rate of resistance to fluoroquinolones, representing 40% of the cultures that grew Escherichia coli. Before the protocol change 602 of 635 patients (94.8%) received a preprocedural antibiotic compared to 426 of 610 (69.9%) after protocol initiation (p <0.01). A total of 19 patients (3.0%) had a symptomatic urinary tract infection prior to the protocol change while 16 (2.6%) had a urinary tract infection after the change (p = 0.69). Regarding resistance, fluoroquinolone resistant organisms grew in the cultures of 12 of 19 patients (63.2%) with a urinary tract infection before the protocol change compared to 5 of 16 (31.3%) with a urinary tract infection after the change. Recent antibiotic administration, hospitalization and chronic catheterization were associated with urinary tract infection in the entire cohort (all p ≤0.01). CONCLUSIONS: A local antibiogram with infection related risk data effectively risk stratifies patients before cystourethroscopy, decreasing the use of antibiotics without increasing the rate of symptomatic urinary tract infection.

Association between Preoperative Albumin Levels and Length of Stay after Radical Cystectomy.

PURPOSE: Using contemporary population based epidemiological data we measured the relationship between the preoperative serum albumin level and hospital length of stay after cystectomy and urinary diversion. MATERIALS AND METHODS: Data were acquired from the 2014 to 2015 NSQIP® (National Surgical Quality Improvement Program®) database. We identified 1,582 adults who underwent cystectomy between January 1, 2014 and December 31, 2015, and had a documented preoperative serum albumin level. The primary outcome was time to hospital discharge and the primary exposure was preoperative serum albumin. We fit a Cox proportional hazards model to assess associations with adjustment for a set of predefined confounders. We allowed for all continuous variables to have a nonlinear relationship with the primary outcome using a restricted cubic spline with 3 knots. RESULTS: Preoperative serum albumin was independently associated with hospital length of stay after cystectomy. Increasing preoperative serum albumin below a threshold of 4 gm/dl was associated with decreased length of stay (HR 1.05, 95% CI 1.01-1.09, p <0.004). Other significant predictors associated with longer length of stay included patient age (HR 0.84, 95% CI 0.77-0.91, p <0.001), nonCaucasian race (HR 0.81, 95% CI 0.70-0.93, p = 0.003) and American College of Surgeons classification 4 (class 4 vs 3 HR 0.78, 95% CI 0.62-0.97, p = 0.008). Minimally invasive cystectomy was associated with a shorter length of stay (HR 1.23, 95% CI 1.07-1.42, p = 0.004). CONCLUSIONS: This study provides evidence that nutritional optimization prior to cystectomy shortens the length of stay after surgery but there are diminishing returns above a threshold of 4 gm/dl.

Robotic-assisted laparoscopic repair of a congenital rectourethral fistula with duplicated urethra.

OBJECTIVE: To describe our experience with robot-assisted laparoscopic transperitoneal repair of a congenital rectourethral fistula in a pediatric patient with a urethral duplication. METHODS: The patient is a 2-year-old male with a past medical history of Tetralogy of Fallot presenting with a febrile urinary tract infection (UTI). He was diagnosed with urethral duplication and a rectourethral fistula by voiding cystourethrogram (VCUG). The parents were counseled on various options and agreed to proceed with a robotic repair. RESULTS: Robotic-assisted transperitoneal rectourethral fistula repair was performed. The procedure time was 229 min with an estimated blood loss (EBL) of 15 mL. His postoperative course was unremarkable. At his 2-week follow-up, the urethral catheter was removed and the patient was voiding normally and having normal bowel movements. CONCLUSION: Congenital rectourethral fistula with urethral duplication is a rare anomaly with only a few reports in the literature. Pediatric robotic-assisted transperitoneal rectourethral fistula repair is a technically feasible approach in infants with minimal morbidity that allows for excellent visualization and avoids open repair.

Expectant Management of Blunt Grade III Renal Injuries: Early Discharge Outcomes From a Level I Trauma Center.

OBJECTIVES: To determine whether patients with American Association for the Surgery of Trauma (AAST) grade III blunt renal injuries discharged within 48 hours of admission have increased rates of readmission for renal-related complications compared to patients observed for over 48 hours. METHODS: Renal trauma patients from 2005 through 2020 were identified from our institutional trauma registry. Patients with AAST III blunt renal injuries who survived beyond 48 hours of admission were included. Univariable analysis was used to identify variables associated with discharge within 48 hours. Reasons for readmission were compared between patients discharged before and after 48 hours of admission. RESULTS: Of the 1751 renal trauma patients, 377 (21.5%) met inclusion criteria. Sixty-five of 377 (17.2%) AAST III injuries were discharged within 48 hours of admission. Forty (10.6%) patients required readmission, 3 in the early discharge group and 37 in the standard discharge group. No patient required readmission for renal-related complications. CONCLUSION: Patients with AAST grade III blunt renal injuries are not at increased risk for early renal-related complications if discharged within 48 hours of admission and should be considered for early discharge. The very low rate of renal-related complications for AAST III blunt renal injuries supports their categorization as "low-grade" renal trauma.

Impact of Health Literacy on Satisfaction Following Male Prosthetic Surgery.

OBJECTIVE: To determine whether a patient's health literacy impacts patient satisfaction following inflatable penile prosthesis (IPP) or artificial urinary sphincter (AUS) placement. MATERIALS AND METHODS: A retrospective study of patients who underwent IPP or AUS between January 1, 2016 and July 31, 2020 was performed. A telephone questionnaire assessed overall satisfaction and if patients would undergo surgery again. Health literacy was measured using the Brief Health Literacy Screen (BHLS). Multivariate ordinal logistic regression was used to assess the association between health literacy and patient satisfaction. RESULTS: At a median follow up of 2.4 years, 113 (70%) of the 162 IPP patients were either satisfied or very satisfied with their procedure and 120 (74%) patients would undergo surgery again. Of the 76 AUS patients, 65 (86%) were either satisfied or very satisfied with their procedure and 65 (86%) patients would undergo surgery again. After adjustment for potential confounders, increasing BHLS score was significantly associated with satisfaction for both IPP (OR 1.31, 95% CI 1.11-1.54; P = .001) and AUS surgery (OR 1.25, 95% CI 1.02-1.56; P = .034), as well as with likelihood of undergoing IPP surgery again (OR 1.53, 95% CI 1.25-1.87; P <.001). BHLS was not associated, however, with likelihood of undergoing AUS surgery again (P = .403). CONCLUSION: Men with lower health literacy are less likely to be satisfied following prosthetic surgery. The BHLS is an important tool that can be used to identify patients who may benefit from increased preoperative counseling to improve patient expectations and quality of life following prosthetic surgery.