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PURPOSE: There is a paucity of reported long-term outcomes after contemporary urethroplasty. Our objective is to determine the long-term success of modern urethroplasty and identify factors associated with stricture recurrence in this context. MATERIALS AND METHODS: Patients undergoing urethroplasty from July 2003 to May 2013 with at least 100 months of follow-up were identified. Long-term outcomes including stricture recurrence and patient satisfaction were evaluated by review of regional/provincial electronic records and telephone interview. Urethroplasty failure was defined as a recurrent stricture (<16F) confirmed on cystoscopy. Cox regression was used to evaluate variables associated with long-term stricture recurrence. RESULTS: A total of 733 patients were identified with ≥ 100 months follow-up. Median patient age was 45 years, stricture length was 4.7 cm, and 85.8% failed prior endoscopic treatment. At a median follow-up of 12.3 years, 89 recurrences were observed. Cumulative incidence of stricture recurrence was 6%, 10%, and 12% after 1, 5, and 10 years, respectively. From a patient-reported perspective, 89% of patients reported being satisfied with the outcome of surgery. On multivariable analyses, increasing stricture length (HR 1.1, 95% CI 1.05-1.15; P < .001) and stricture etiology (P < .001), in particular lichen sclerosus (HR 4.46, 95% CI 2.25-9.53), radiation (HR 4.25, 95% CI 1.65-10.9), and infectious strictures (HR 5.27, 95% CI 2.03-13.7), were independently associated with stricture recurrence. CONCLUSIONS: This study affirms the widely held belief that modern urethroplasty provides high long-term patency and patient-reported satisfaction. Patients with longer strictures as well as those with lichen sclerosus, radiation, and infectious etiologies have a higher hazard of stricture recurrence in the long term.
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Líquen Escleroso e Atrófico , Estreitamento Uretral , Humanos , Pessoa de Meia-Idade , Masculino , Constrição Patológica/cirurgia , Estreitamento Uretral/cirurgia , Estreitamento Uretral/complicações , Resultado do Tratamento , Líquen Escleroso e Atrófico/complicações , Líquen Escleroso e Atrófico/cirurgia , Estudos Retrospectivos , Uretra/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversos , Mucosa Bucal , RecidivaRESUMO
PURPOSE: The purpose of this study was to determine the incidence of 90-day complications after urethroplasty and identify factors associated with them. MATERIALS AND METHODS: A single-institution, 2-surgeon retrospective review was performed on patients undergoing urethroplasty from August 2003-June 2020. Variables included the incidence, type and Clavien-Dindo grade of complications, patient age, individual comorbidities, comorbidity component of the Charlson Comorbidity Index (CCI), smoking status, obesity (body mass index ≥35 kg/m2), bacteriuria, type of urethroplasty, stricture etiology, length, location, prior endoscopic procedures, previous urethroplasty and preoperative suprapubic catheterization. The primary outcome was the incidence of significant 90-day complications defined as Clavien grade ≥2. Descriptive statistics were used to summarize the results and binary logistic regression was used to examine the factors associated with 90-day complications. RESULTS: Of the 1,611 patients included in the analysis, 90-day complications (Clavien ≥2) occurred in 7.9% (128/1,611) and were wound related (3.5%), urinary tract infection (3.4%), cardiovascular (0.4%), catheter-related (0.2%), hematuria (0.1%) or retention (0.1%). On univariable binary logistic regression stricture location (p=0.04), stricture length (p=0.009), CCI (p <0.0001), prior urethroplasty (p=0.01) and bacteriuria (p=0.002) were associated with complications, while age (p=0.3), etiology (p=0.2), smoking (p=0.2), obesity (p=0.3), failed endoscopic treatment (p=0.8), indwelling suprapubic catheter (p=0.7) and type of urethroplasty (p=0.09) were not. On multivariable analysis, increasing CCI (Odds Ratio 1.31, 95% CI 1.10-1.56; p=0.003), prior urethroplasty (OR 1.86, 95% CI 1.09-3.17; p=0.02) and preoperative bacteriuria (OR 1.67, 95% CI 1.14-2.45; p=0.009) remained associated with 90-day complications. CONCLUSIONS: Patients with increased comorbidities, prior urethroplasty and preoperative bacteriuria are at higher risk for complications after urethroplasty and should be counseled accordingly in a shared decision-making model of care.
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Bacteriúria , Estreitamento Uretral , Bacteriúria/epidemiologia , Comorbidade , Constrição Patológica/etiologia , Humanos , Incidência , Masculino , Obesidade , Estudos Retrospectivos , Resultado do Tratamento , Uretra/cirurgia , Estreitamento Uretral/epidemiologia , Estreitamento Uretral/etiologia , Estreitamento Uretral/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversos , Procedimentos Cirúrgicos Urológicos Masculinos/métodosRESUMO
PURPOSE: Our primary objective was to determine the incidence of extravasation on imaging at the time of catheter removal after ventral onlay buccal mucosal graft urethroplasty. MATERIALS AND METHODS: This is a single center retrospective cohort study of patients who underwent ventral onlay buccal mucosal graft bulbar urethroplasty from 2007 to 2017. Patients with imaging at the time of catheter removal were included. Urethroplasty success was defined as the ability to pass a 17Fr cystoscope at the time of followup cystoscopy. RESULTS: A total of 229 patients met the inclusion criteria, including 110 with a ventral onlay buccal mucosal graft and 119 with an augmented anastomotic urethroplasty with a mean stricture length of 4.4 cm. Imaging consisted of a voiding cystourethrogram in 210 and retrograde urethrogram in 19 patients at a median of 21.7 days after surgery. The incidence of extravasation was 3.1% (7/229). Of patients who had a documented followup cystoscopy (60%, 137/229), those with extravasation on imaging had a worse urethroplasty success rate (60%, 3/5) compared to those who did not (94%, 117/130) (p=0.047). On multivariate analysis those who had 5 or more endoscopic interventions were 9.6 times more likely to demonstrate extravasation (OR 9.6, p=0.0080). CONCLUSIONS: The incidence of radiological extravasation after ventral onlay using a single buccal mucosal graft, with or without augmented anastomotic urethroplasty, is 3.1%. Given this low rate it is reasonable to omit routine imaging at the time of Foley removal in this population. It appears that extravasation may be associated with a worse cystoscopic patency rate but does not lead to more complications.
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Cistoscopia/efeitos adversos , Extravasamento de Materiais Terapêuticos e Diagnósticos/epidemiologia , Cuidados Pós-Operatórios/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Estreitamento Uretral/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversos , Adulto , Cistoscopia/estatística & dados numéricos , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico , Extravasamento de Materiais Terapêuticos e Diagnósticos/etiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Mucosa Bucal/transplante , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento , Uretra/diagnóstico por imagem , Uretra/cirurgia , Estreitamento Uretral/patologia , Cateterismo Urinário/instrumentação , Procedimentos Cirúrgicos Urológicos Masculinos/instrumentaçãoRESUMO
PURPOSE: We examined the incidence and predictors of complications due to urethral stricture in patients awaiting urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent urethroplasty from 2009 to 2013. The primary outcome was complications, defined as any unplanned interaction with the health care system due to urethral stricture during the period between the decision to perform surgery and urethroplasty. RESULTS: A total of 276 patients were identified for analysis. Median stricture length was 4.0 cm and 67.4% of strictures were in the bulbar urethra. The most common stricture etiologies were idiopathic in 47.8% of cases and traumatic in 15.9%. Overall 15.9% of patients presented with a complication with a median time to complication of 43 days. Median surgical wait time was 151 days. Complications included urinary tract infections in 56.8% of patients, acute urinary retention in 20.5%, genitourinary pain in 5.8% and catheter related issues in 15.9%. Univariate analysis suggested that catheter dependent status, number of prior endoscopic treatments, a hypospadias and/or trauma etiology, and prior urethroplasty were potential significant predictors of complications. Multivariate analysis yielded only catheter dependent status (HR 5.2, 95% CI 2.4-11.3, p <0.0001) and prior failed urethroplasty (HR 1.6, 95% CI 1.1-2.3, p = 0.03) as significantly associated with complications. CONCLUSIONS: To our knowledge our study is the first to examine and quantify the morbidity of urethroplasty wait time. Approximately 16% of patients experienced a complication while awaiting urethroplasty. The optimal wait time should be less than 43 days. Patients with prior urethroplasty and catheters at the time of the surgical decision should be prioritized as they may be more likely to experience complications.
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Procedimentos de Cirurgia Plástica/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Uretra/cirurgia , Estreitamento Uretral/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversos , Adulto , Alberta/epidemiologia , Endoscopia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Estreitamento Uretral/diagnósticoRESUMO
PURPOSE OF REVIEW: Functional complications after orthotopic neobladder urinary diversion (ONB), including urinary incontinence and urinary retention, present unique challenges. The purpose of this review is to outline contemporary treatment options for voiding dysfunction after ONB in females. RECENT FINDINGS: Meticulous surgical technique in the form of urethral nerve-sparing has been shown to play an important role in maintaining continence, as has sparing the uterus when possible. Data supporting the effectiveness of lifestyle measures, urethral bulking, pubovaginal slings, and transobturator slings in the treatment of urinary incontinence are widely variable and limited to case reports. Urinary retention is still most effectively managed with self-catheterization. Voiding dysfunction after ONB can be devastating. Recent advances focus on improving surgical techniques to decrease the risk of incontinence and retention, as post-operative management options are limited.
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Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/efeitos adversos , Transtornos Urinários/terapia , Cistectomia/efeitos adversos , Feminino , Humanos , Incontinência Urinária/etiologia , Incontinência Urinária/terapia , Retenção Urinária/etiologia , Retenção Urinária/terapia , Transtornos Urinários/etiologiaRESUMO
The adult mammalian cerebellum is histologically uniform. However, concealed beneath the simple laminar architecture, it is organized rostrocaudally and mediolaterally into complex arrays of transverse zones and parasagittal stripes that is both highly reproducible between individuals and generally conserved across mammals and birds. Beyond this conservation, the general architecture appears to be adapted to the animal's way of life. To test this hypothesis, we have examined cerebellar compartmentation in the talpid star-nosed mole Condylura cristata. The star-nosed mole leads a subterranean life. It is largely blind and instead uses an array of fleshy appendages (the "star") to navigate and locate its prey. The hypothesis suggests that cerebellar architecture would be modified to reduce regions receiving visual input and expand those that receive trigeminal afferents from the star. Zebrin II and phospholipase Cß4 (PLCß4) immunocytochemistry was used to map the zone-and-stripe architecture of the cerebellum of the adult star-nosed mole. The general zone-and-stripe architecture characteristic of all mammals is present in the star-nosed mole. In the vermis, the four typical transverse zones are present, two with alternating zebrin II/PLCß4 stripes, two wholly zebrin II+/PLCß4-. However, the central and nodular zones (prominent visual receiving areas) are proportionally reduced in size and conversely, the trigeminal-receiving areas (the posterior zone of the vermis and crus I/II of the hemispheres) are uncharacteristically large. We therefore conclude that cerebellar architecture is generally conserved across the Mammalia but adapted to the specific lifestyle of the species.
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Córtex Cerebelar/anatomia & histologia , Córtex Cerebelar/fisiologia , Toupeiras/anatomia & histologia , Toupeiras/fisiologia , Células de Purkinje/citologia , Células de Purkinje/fisiologia , Adaptação Fisiológica , Animais , Calbindinas/metabolismo , Meio Ambiente , Feminino , Imuno-Histoquímica , Masculino , Proteínas do Tecido Nervoso/metabolismo , Fosfolipase C beta/metabolismoRESUMO
OBJECTIVE: To determine which bacteria are associated with an increased risk of 90-day complications after urethroplasty. Preoperative bacteriuria is associated with an increased risk of complications after urethroplasty. However, it remains unclear which specific micro-organisms are the primary drivers of this morbidity. METHODS: A single-institution, 2-surgeon retrospective review was performed on patients undergoing urethroplasty from 08/2003 to 06/2021. Preoperative bacteriuria was considered significant when the patient had a mixed culture with ≥108 CFU/L or an identifiable micro-organism with ≥106 CFU/L. Descriptive statistics were used to summarize the results and chi-square was used to determine the association between 90-day complications (Clavien ≥2) and clinical characteristics/bacteria. RESULTS: Out of 1611 patients, 23.2% (373) had significant preoperative bacteriuria. The most common pathogens included coagulase-negative staphylococcus 18.5% (69), mixed growth 15.8% (59), Escherichia coli 10.7% (40), and Enterococcus 14.2% (53). 7.9% (128/1611) experienced a significant 90-day complication (Clavien-Dindo ≥2). Gram-negative bacilli including E coli, Pseudomonas sp, Klebsiella sp, Serratia sp, Citrobacter sp, Achromobacter sp, Stenotrophomonas sp, and Morganella sp were associated with higher rates of postoperative complications (14.2%; P = .01) as well as Enterococcus sp (15.1%; P = .03). However, gram-positive cocci (7.9%; P = .97), gram-positive bacilli (11.8%; P = .47), mixed growth (5.1%; P = .54) and Candida (16.7%; P = .27) were not. Neither escalating concentrations of bacteria (P = .44) or number of strains (P = .08) were associated with increased risk of complications. CONCLUSION: The main driver of bacteriuria-related complications after urethroplasty are gram-negative bacilli and Enterococcus sp. Patients with bacteriuria related to other micro-organisms can likely proceed with urethroplasty without increased risk of postoperative complications.
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Bacteriúria , Humanos , Bacteriúria/complicações , Bacteriúria/epidemiologia , Escherichia coli , Bactérias , Fatores de Risco , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , AntibacterianosRESUMO
BACKGROUND: Urinary incontinence (UI), erectile dysfunction and cardiometabolic conditions are common after prostatectomy for prostate cancer (PCa). Although physical activity could improve overall survival and quality of survivorship, fear of UI can restrict participation in exercise. Individuals with PCa could benefit from therapeutic exercise programming to support continence recovery and cardiometabolic health. AIM: The main objective of this study is to determine the feasibility and the effects of a combined pelvic health rehabilitation and exercise fitness program on UI after prostatectomy. The combined exercise program will be delivered both in-person and virtually. METHODS: This study follows a modified Zelen, two-arm parallel randomized controlled trial design. A total of 106 individuals with PCa will be recruited before prostatectomy surgery. Participants will be randomized between two groups: one receiving usual care and one receiving a combined exercise fitness and intensive pelvic floor muscle training program. Exercise programming will begin 6-8 weeks after prostatectomy and will last 12 weeks. Outcomes include: the 24-h pad test (primary outcome for UI); physical fitness, metabolic indicators, and patient-reported outcomes on erectile function, self-efficacy, severity of cancer symptoms and quality of life. Important timepoints for assessments include before surgery (T0), after surgery (T1), after intervention (T3) and at one-year after surgery (T4). CONCLUSION: This study will inform the feasibility of offering comprehensive exercise programming that has the potential to positively impact urinary continence, erectile function and cardiometabolic health of individuals undergoing prostatectomy for prostate cancer. CLINICALTRIALS REGISTRATION NUMBER: NCT06072911.
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Doenças Cardiovasculares , Disfunção Erétil , Neoplasias da Próstata , Incontinência Urinária , Masculino , Humanos , Disfunção Erétil/etiologia , Disfunção Erétil/reabilitação , Qualidade de Vida , Estudos de Viabilidade , Diafragma da Pelve , Terapia por Exercício/métodos , Incontinência Urinária/etiologia , Incontinência Urinária/cirurgia , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Exercício Físico , Resultado do Tratamento , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
PURPOSE: Malone antegrade continence enema and cecostomy button improve quality of life in patients with neurogenic bowel. However, they have not been compared regarding fecal continence outcomes. We compared these 2 procedures with respect to continence, complications and conversions. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent Malone antegrade continence enema or cecostomy at the University of Alberta between January 2006 and January 2011. A total of 26 patients underwent Malone antegrade continence enema, of whom 20 underwent concomitant Monti procedure and bladder augmentation, 5 a laparoscopically assisted procedure and 1 concomitant ileovesicostomy. A total of 23 patients underwent cecostomy, of whom 1 underwent ileovesicostomy, 1 bladder augmentation, 1 a Monti procedure with bladder augmentation and 1 laparoscopic cecostomy. Continence was defined as ability to wear underwear with no accidents at most recent annual followup, which was a minimum of 1 year postoperatively. RESULTS: Fecal continence rates were 84.6% for Malone antegrade continence enema and 91.3% for cecostomy. There were no statistically significant differences in continence based on procedure (p = 0.48), age (p = 0.97) or gender (p = 0.54). Of patients who underwent cecostomy 8.7% switched to the Malone antegrade continence enema, while 11.5% with Malone antegrade continence enema switched to cecostomy. Mean length of hospital stay for patients undergoing cecostomy vs laparoscopically assisted Malone antegrade continence enema was 4.0 vs 5.2 days (p = 0.15). Complications included stomal pain (23.1% of patients) and difficulty with catheterizing (19.2%) following Malone antegrade continence enema, and difficulty flushing (26.1%) following cecostomy. CONCLUSIONS: There were no significant differences between Malone antegrade continence enema and cecostomy button with respect to fecal continence or complication rates. Each approach poses unique challenges, suggesting that patients and families need to understand the differences to make an individualized choice.
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Cecostomia/métodos , Enema/métodos , Incontinência Fecal/cirurgia , Intestino Neurogênico/cirurgia , Qualidade de Vida , Adolescente , Adulto , Fatores Etários , Idoso , Criança , Pré-Escolar , Estudos de Coortes , Intervalos de Confiança , Incontinência Fecal/etiologia , Incontinência Fecal/terapia , Feminino , Seguimentos , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Intestino Neurogênico/complicações , Intestino Neurogênico/diagnóstico , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Most centers have shifted to an extended day surgery (XDS ) model for urethroplasty. Our study characterizes outcomes and unplanned healthcare encounters of patients undergoing XDS urethroplasty compared to case-matched inpatient controls. METHODS: We conducted a retrospective, two-surgeon, single-center study of patients undergoing XDS urethroplasty (discharge <24 hrs) from November 2020 to November 2021. Patients were case-control matched based on age, stricture length, location, and etiology to patients who had previously undergone inpatient urethroplasty. Data was analyzed using descriptive and univariable statistics. Multivariable analysis by Cox proportional hazard regression was used to identify associations with postoperative complications. RESULTS: Ninety patients (mean age=53.8 years) underwent XDS urethroplasty during the study period. Mean stricture length was 4.4 cm (standard deviation [SD ] 2.4). Rates of postoperative complications were similar between XDS (17%, n=15) and admitted patients (21%, n=19), and XDS was not associated with increased risk on univariable analysis (odds ratio [OR ] 0.65, 95% confidence interval [CI] 0.31-1.3, p=0.36). When stratifying by location, penile stricture (OR 4.21, 95% CI 1.3-13.8, p=0.02) and lichen sclerosus (OR 2.91, 95% CI 0.79-9.9, p=0.08) were associated with increased risk of postoperative complication. On multivariable analysis, only penile stricture was identified as significant (OR 4.78, 95% CI 1.2-19.4, p=0.03). Forty-eight percent (n=43) of patients had unplanned healthcare encounters postoperatively, with similar numbers of phone calls (n=37) and emergency department visits (n=36) between groups. CONCLUSIONS: Our study shows that XDS urethroplasty is not associated with increased rates of complications relative to inpatient admission. This data supports using an XDS pathway for resource-efficient treatment of urethral strictures in a universal healthcare setting.
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The mammalian cerebellar cortex is apparently uniform in composition, but a complex heterogeneous pattern can be revealed by using biochemical markers such as zebrin II/aldolase C, which is expressed by a subset of Purkinje cells that form a highly reproducible array of transverse zones and parasagittal stripes. The architecture revealed by zebrin II expression is conserved among many taxa of birds and mammals. In this report zebrin II immunohistochemistry has been used in both section and whole-mount preparations to analyze the cerebellar architecture of the Australian tammar wallaby (Macropus eugenii). The gross appearance of the wallaby cerebellum is remarkable, with unusually elaborate cerebellar lobules with multiple sublobules and fissures. However, despite the morphological complexity, the underlying zone and stripe architecture is conserved and the typical mammalian organization is present.
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Antígenos/análise , Padronização Corporal , Córtex Cerebelar/anatomia & histologia , Macropodidae/anatomia & histologia , Proteínas do Tecido Nervoso/análise , Animais , Córtex Cerebelar/química , Córtex Cerebelar/imunologia , Feminino , Macropodidae/imunologia , Masculino , Mamíferos/anatomia & histologia , Mamíferos/classificação , Camundongos/anatomia & histologia , Células de Purkinje/química , Especificidade da EspécieRESUMO
Despite the apparent uniformity in cellular composition of the adult mammalian cerebellar cortex, it is actually highly compartmentalized into transverse zones and within each zone further subdivided into a reproducible array of parasagittal stripes. This basic cerebellar architecture is highly conserved in birds and mammals. However, different species have very different cerebellar morphologies, and it is unclear if cerebellar architecture reflects taxonomic relations or ecological niches. To explore this, we have examined the cerebellum of the naked mole-rat Heterocephalus glaber, a burrowing rodent with adaptations to a subterranean life that include only a rudimentary visual system. The cerebellum of H. glaber resembles that of other rodents with the remarkable exception that cerebellar regions that are prominent in the handling of visual information (the central zone, nodular zone, and dorsal paraflocculus) are greatly reduced or absent. In addition, there is a notable increase in size in the posterior zone, consistent with an expanded role for the trigeminal somatosensory system. These data suggest that cerebellar architecture may be substantially modified to serve a particular ecological niche.
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Córtex Cerebelar/anatomia & histologia , Ratos-Toupeira/anatomia & histologia , Animais , Córtex Cerebelar/metabolismo , Feminino , Masculino , Proteínas do Tecido Nervoso/metabolismo , Fosfolipase C beta/metabolismo , Células de Purkinje/metabolismoRESUMO
INTRODUCTION: The artificial urinary sphincter (AUS) is the most effective treatment option for incontinence after prostate cancer treatment. However, patients with a "fragile urethra" (defined as prior radiotherapy, previous failed AUS, or previous urethroplasty) are at increased risk of AUS failure. The aim of this study was to evaluate outcomes using standard and transcorporal cuff placement in this group of patients. METHODS: A retrospective review was performed on patients with a fragile urethra who underwent AUS insertion between 2004 and 2017. The primary outcome was the need for AUS revision. Secondary outcome measures included change in pad use, patient satisfaction, continence (≤1 pad/day), improvement (≥50% change in pad use), and cuff erosion rates. RESULTS: Seventy-six patients met the criteria for inclusion, with a mean age of 71.6 years and a mean followup of 37.9 months. A total of 42.1% had prior radiotherapy, 56.6% had a history of failed AUS, and 19.7% had previous urethroplasty. Transcorporal cuff placement was performed in 31.6% (n=24). These patients had lower revision (20.8% vs. 36.5%; p=0.05) and erosion rates (8.3% vs. 17.3%; p=0.09). There was no significant difference in functional outcomes such as continence (66.7% vs. 73.1%; p=0.57), improvement (100% vs. 90.4%;p=0.17), or satisfaction (82.6% vs. 69.4%; p=0.26), nor for 90-day complications (4.2% vs. 9.6%; p=0.41). CONCLUSIONS: AUS insertion is an effective treatment option for post-prostatectomy incontinence in the setting of a fragile urethra. Transcorporal cuff placement in this subset of patients may be recommended, as it is associated with lower revision and erosion rates compared to standard cuff placement.
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INTRODUCTION: Our objective was to determine which clinical factors are associated with failure to achieve continence after nonadjustable trans-obturator sling in otherwise well-selected men undergoing treatment for post-prostatectomy incontinence (PPI). METHODS: A retrospective review of AdVance/AdVance™ XP male sling procedures was performed from December 2006 to May 2017. Patients with known risk factors for sling failure, including severe incontinence (>5 pads), radiation therapy, or detrusor dysfunction, were excluded. The primary outcome was failure to achieve continence, defined as ≤1 pad per day when pad use was ≥2 preoperatively (or 0 pads if preoperative pad use was 1). Covariates included patient age, Charlson comorbidity index (CCI), diabetes, obesity (body mass index [BMI] ≥35), type of prostatectomy, and number of preoperative pads. Descriptive statistics and Cox regression analysis was performed. RESULTS: Of 158 patients, continence was achieved in 82.3% (n=130) with a mean followup of 42.7 months. Patient-reported satisfaction was 86.7% (n=137) and the 90-day complication rate was 12% (n=19). On univariate Cox regression analysis, increasing age (p=0.02), CCI (p=0.02), and preoperative pad use (p<0.0001) were associated with sling failure, whereas obesity (p=0.95), diabetes (p=0.49), and type of prostatectomy (p=0.88) were not. On multivariate analysis, only increasing preoperative pad use remained associated with sling failure (hazard ratio [HR] 1.3; 95% confidence interval [CI] 1.1-16; p=0.008). Patients wearing >3 pads per day were more likely to experience failure (35.5% vs. 13.4%; p=0.007). CONCLUSIONS: Increasing preoperative pad use is independently associated with an increased risk of failure after non-adjustable sling for post-prostatectomy incontinence in otherwise well-selected patients.
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INTRODUCTION: We aimed to compare single-stage and two-stage urethroplasty techniques for the treatment of penile urethral strictures. METHODS: We performed a retrospective review of all penile urethroplasties performed at a single centre between 2003 and 2017. The primary outcome was urethral patency, defined as the ability to easily pass a 16 Fr flexible cystoscope at six and 18 months of followup, and development of 90-day complications. RESULTS: Overall, 101 single-stage procedures (48 buccal mucosal graft [BMG] and 53 penile fasciocutaneous flap [PFF]) and 53 two-stage procedures were performed. There was no difference in median stricture length between groups (p=0.25). Cox regression analysis did not identify stricture etiology, length, age, obesity, prior reconstruction, or urethroplasty technique to be associated with failure. Log-rank testing did not demonstrate a difference in success rates between surgical techniques (91% [48/53] PFF vs. 83% [40/48] BMG vs. 87% two-stage [46/53]). Thirty-nine percent (60/154) of patients experienced a complication (51% [27/53] PFF vs. 29% [14/48] BMG vs. 36% [19/53] two-stage). Multivariate analysis found urethroplasty technique to be the only factor associated with development of complication (p=0.02); odds ratio relative to BMG was 3.1 (p=0.009) for PFF and 1.4 (p=0.43) for two-stage. CONCLUSIONS: There appears to be little difference in success between penile urethroplasty techniques. The shift in technique to a single-stage BMG, when appropriate, appears to be founded on the basis of fewer operations for the patient, relative to a two-stage repair, and a lower complication profile, relative to single-stage PFF, without compromising success rates.
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INTRODUCTION: We aimed to determine if there is a correlation between International Prostate Symptom scores (IPSS) and 24-hour urine collection volumes, as patients experiencing lower urinary tract symptoms (LUTS) may have impaired ability to increase fluid intake for stone prevention. METHODS: We conducted a single-centre, retrospective review was performed of stone-formers presenting from 2014-2016. Inclusion criteria were completion of an IPSS questionnaire and a 24-hour urine collection. Exclusion criteria included symptomatic stone or urinary tract infection at time of IPSS completion, inadequate 24-hour collection, or incomplete IPSS questionnaire. RESULTS: A total of 131 patients met inclusion criteria. Stratification by IPSS severity into mild (0-7), moderate (8-19), and severe (20-35) yielded groups of n=96, 28, and 7, respectively. Linear regression modelling did not reveal a correlation between IPSS score and volume (p=0.10). When compared to those with adequate urine volumes (>2 L/day, n=65), low-volume patients (<1 L/day, n=10) had a significantly higher total IPSS (11.7 vs. 6.1; p=0.036). These groups showed significant differences in their responses to questions about incomplete emptying (p=0.031), intermittency (p=0.011), and stranguria (p=0.0020), with higher scores noted in the low urine output group. CONCLUSIONS: This study is the first to examine the correlation between IPSS and 24-hour urine volume. Though our data does not show a linear relationship between urine output and IPSS, those with lower urine volumes appear to have worse self-reported voiding symptoms when compared to those with adequate volumes (>2 L/day) for stone prevention. The overall number of patients in our study is relatively small, which may account for the lack of a relationship between IPSS and 24-hour urine volumes.
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OBJECTIVE: To describe the spectrum of adult presentations with hypospadias-related complications and examine the effect of childhood surgical repair on these adult presentations. METHODS: A retrospective chart review over a 10-year period, from August 2004 to December 2014, demonstrated 93 adult patients who presented to a reconstructive urologist with complications related to hypospadias. Patients were divided into 2 groups: those with no prior hypospadias surgery (Group 1, N = 19) and those who underwent surgical correction as a child (Group 2, N = 74). Charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required. RESULTS: The mean age at presentation was 34.6 ± 0.6 years. Overall, lower urinary tract symptoms (LUTS) (49%) was the most common presenting complaint, followed by spraying (24%), urethrocutaneous fistula (18%), recurrent urinary tract infections (UTIs) (15%), and chordee (14%). Comparison demonstrated that Group 2 patients were more likely to present with LUTS (55% vs 26%; P = .038) and recurrent UTIs (19% vs 0%; P = .050). There was a trend toward Group 1 patients presenting more commonly with cosmetic dissatisfaction (16% vs 4%; P = .06). Urethral stricture was demonstrated more commonly in Group 2 (47% vs 11%; P = .0043). Of these, strictures were significantly longer in the previous surgery group (5.5 ± 0.6 cm vs 3.0 ± 0.6 cm, P = .019). CONCLUSION: Correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent UTIs, and subsequent LUTS, with a trend toward improving patient satisfaction with cosmesis compared to nonsurgical management. Follow-up of hypospadias repair patients should extend into adulthood, as a significant portion of adult presentations ultimately require surgical intervention.
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Previsões , Hipospadia/cirurgia , Procedimentos de Cirurgia Plástica/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Uretra/cirurgia , Adulto , Alberta/epidemiologia , Criança , Fístula Cutânea/epidemiologia , Fístula Cutânea/etiologia , Humanos , Incidência , Sintomas do Trato Urinário Inferior/epidemiologia , Sintomas do Trato Urinário Inferior/etiologia , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Retalhos Cirúrgicos , Resultado do Tratamento , Estreitamento Uretral/epidemiologia , Estreitamento Uretral/etiologia , Fístula Urinária/epidemiologia , Fístula Urinária/etiologia , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversosRESUMO
INTRODUCTION AND OBJECTIVE: The manufacturer for the Storz Modulith SLX-F2 lithotripter recommends treatment head exchange after 1.65 million shocks. However, there is no documentation describing longevity of the treatment head with continued usage. The objective of this study is to determine whether there is a difference in stone fragmentation effectiveness with the treatment head at the beginning versus the end of its treatment life. METHODS: We conducted a retrospective chart review of 200 patients-50 consecutive patients treated immediately preceding, and following, two separate treatment head exchanges. Primary outcome measures were stone-free rate (no stone), total stone fragmentation (any decrease in size), and fragmentation rate ≤4 mm (decrease in size with largest residual fragment ≤4 mm), based on most recent follow-up imaging post shockwave. RESULTS: There were no baseline characteristic differences between the pre-exchange and postexchange groups with respect to first time lithotripsy for the stone (85% vs. 77%), stone location, preoperative stenting (3% vs. 4%), mean stone density (912 hounsfield units [HU] vs. 840 HU), mean stone size (9.0 mm vs. 8.1 mm), stone location, and mean number of shocks delivered (3105 vs. 3089). Mean time to follow-up was 2.7 weeks in both groups, with most follow-up imaging consisting of a kidney ureter bladder X-ray (87% pre-exchange vs. 85% postexchange). Stone free (34% vs. 27%), total stone fragmentation (76% vs. 76%), fragmentation ≤4 mm (48% vs. 42%), re-treatment rates (38% vs. 51%), and complication rates (6% vs. 7%), were not statistically different between the pre and postexchange groups, respectively. CONCLUSIONS: Exchanging the Storz Modulith F2 lithotripter head at the manufacturer recommended 1.65 million shocks does not affect the stone-free or fragmentation rate. If the manufacturer's recommendation for treatment head longevity is based on clinical outcomes, then there is likely room to extend this number without affecting treatment efficacy.
Assuntos
Cálculos Renais/terapia , Litotripsia/instrumentação , Cálculos Ureterais/terapia , Adulto , Idoso , Intervalo Livre de Doença , Análise de Falha de Equipamento , Feminino , Humanos , Cálculos Renais/patologia , Litotripsia/normas , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Cálculos Ureterais/patologiaRESUMO
OBJECTIVE: To assess artificial urinary sphincter (AUS) outcomes in challenging post-prostatectomy patients with a "fragile urethra" at risk for urethral erosion. METHODS: An institutional retrospective review of all AUS placements between August 2004 and March 2014 was performed. A "fragile urethra" was defined as a history of pelvic radiation, previous failed AUS, previous urethroplasty, or cystoscopic and/or clinical findings of urethral atrophy. The primary outcome was continence, defined as requiring ≤1 pad per day. Secondary outcomes included 90-day complications, need for further treatment, change in continence pads, and patient-reported satisfaction. RESULTS: Thirty patients were identified as having a "fragile urethra." Thirteen of these patients underwent a transcorporal AUS (TCAUS) and 17 had a standard AUS cuff placement. Seventeen patients had radiation, 8 had a previous eroded AUS, and 10 had a prior urethroplasty. Five patients had multiple risk factors for urethral erosion. Continence was achieved in 77% (23/30), 97% (29/30) were improved, and the mean change in pads was 6.0 ± 2.8. Only 7% (2/30) required explantation, both for erosion. When the TCAUS and standard AUS groups were compared, no differences were noted in continence rates (P = .43), improvement (P = 1.00), explantation rates (P = .18), or erosion rates (P = .18), despite TCAUS having a higher proportion of previous urethroplasties. CONCLUSION: AUS is a viable treatment option for post-prostatectomy incontinence, even in the fragile urethra. TCAUS may be utilized in patients with a very high risk for atrophy with similar continence and complication rates compared with standard AUS.