Downstream Revenue Realized by Facilities Placing Inflatable Penile Prosthesis in Medicare Beneficiaries to Treat Erectile Dysfunction.

OBJECTIVE: To quantify the incremental downstream revenue generated from subsequent treatment of men who received an inflatable penile prosthesis (IPP) to treat erectile dysfunction (ED), compared to men without ED. METHODS: The 100% Medicare Standard Analytic Files were used to conduct a retrospective claims analysis of the 5-year revenue generated by patients receiving IPP to treat their ED, compared to a propensity-matched cohort of men without ED. Men aged 65 years or older with ED who underwent IPP implantation (Current Procedural Terminology 54405) in a hospital outpatient setting between January 1, 2016 and December 31, 2021, and who had continuous Medicare Parts A and B enrollment for 12 months pre-index IPP and 5 years post-index IPP discharge date were included in the study. Men without ED but with comparable characteristics were identified and used as a comparator group. Revenue received by hospitals from Medicare was defined as the sum of payments for patient services, other payor-paid amounts, patient deductibles, copayments, and coinsurance. Revenue was inflated to 2022 US dollars. The mean values and their corresponding standard deviations (SD) are reported. RESULTS: After matching, there were 2905 men with ED who received an IPP and 7462 men without ED. The IPP cohort showed a significantly higher 5-year cumulative revenue (mean=$34,571 [SD=$50,234]) compared to the men without ED (mean=$3189 [SD=$11,527]). When stratified by diagnosis type, the differences in revenue were $10,258 for circulatory disease, $2646 for diabetes, $2013 for urology, and $1043 for prostate cancer. Significantly more IPP patients had at least 1 health encounter for these conditions over the 5-year follow-up period than their matched controls (55.0% vs 7.8% for circulatory, 46.7% vs 16.8% for urology, 19.3% vs 3.6% for diabetes, and 19.0% vs 3.0% for prostate cancer). CONCLUSION: Men with ED who received IPP generated substantially higher revenue for the healthcare system over a 5-year period, nearly 10 times as much, compared to men without ED, excluding the initial cost of the IPP procedure. The presence of ED, coupled with IPP usage, is associated with significantly increased healthcare revenue across a range of medical conditions compared to men without ED. These findings emphasize the financial implications for advanced ED programs to improve access to necessary care for these patients. Healthcare facilities may leverage these insights to effectively allocate resources to deliver critical healthcare to men with ED.

Harnessing the mesenchymal stem cell secretome for regenerative urology.

The extensive arsenal of bioactive molecules secreted by mesenchymal stem cells (MSCs), known as the secretome, has demonstrated considerable therapeutic benefit in regenerative medicine. Investigation into the therapeutic potential of the secretome has enabled researchers to replicate the anti-inflammatory, pro-angiogenic and trophic effects of stem cells without the need for the cells themselves. Furthermore, treatment with the MSC secretome could circumvent hurdles associated with cellular therapy, including oncogenic transformation, immunoreactivity and cost. Thus, a clear rationale exists for investigating the therapeutic potential of the MSC secretome in regenerative urology. Indeed, preclinical studies have demonstrated the therapeutic benefits of the MSC secretome in models of stress urinary incontinence, renal disease, bladder dysfunction and erectile dysfunction. However, the specific mechanisms underpinning therapeutic activity are unclear and require further research before clinical translation. Improvements in current proteomic methods used to characterize the secretome will be necessary to provide further insight into stem cells and their secretome in regenerative urology.

Robotic cold ischemia achieves comparable functional outcomes to open cold ischemia during partial nephrectomy for complex kidney tumors.

OBJECTIVES: To compare the perioperative and functional outcomes after open and robotic partial nephrectomy performed with cold ischemia. METHODS: A retrospective chart review was completed of consecutive patients who underwent partial nephrectomy with renal hypothermia between January 2011 and September 2016. The study cohort included both open (Open Cold Ischemia, OCI; n=170) and robotic (Robotic Cold Ischemia, RCI; n=31) patients with complex renal masses (R.E.N.A.L. score >7) who did not meet exclusion criteria. A modified intracorporeal technique 1 was utilized for the introduction of ice slush at the time of hilar clamping in the RCI group. Statistical testing was performed to compare key perioperative and functional outcomes after ensuring equilibration of both groups by clinicodemographic criteria. RESULTS: Both groups were statistically equivalent with respect to baseline characteristics. Median GFR preservation postoperatively was 86.7% for the open group and 86.6% in the robotic group (p=0.49). Cold ischemia time (CIT) in the open group was 35 minutes compared to 28 minutes (p = 0.03) in the robotic group. LOS was significantly shorter by 2 days (p < 0.01) in the robotic group. Positive margins was noted to be 17 (10%) in the open group and 2 (6.5%) patients in the robotic group (p=0.48). CONCLUSIONS: We demonstrate an effective and simplified method of intracorporeal ice cooling during robotic partial nephrectomy. Our data suggests that results with this approach compare favorably to open cold ischemia technique. Intracorporeal ice cooling can be considered when performing complex partial nephrectomies with ischemia times expected to exceed 25 minutes.

Penile Prosthesis in Solid Organ Transplant Recipients-A Matched Cohort Study.

OBJECTIVE: To determine whether patients with solid organ transplant (SOT) are at higher risk of developing complications after inflatable penile prosthesis (IPP) implantation. METHODS: We retrospectively reviewed outcomes data for all patients with SOT who underwent IPP placement at our institution. A cohort of age-matched IPP recipients without SOT were used as controls. RESULTS: We identified 26 patients who underwent SOT and IPP between 1999 and 2015, and 26 controls. Transplants included heart (3), liver (2), kidney only (17), and kidney and pancreas (4). Mean follow-up time after IPP placement was 29.5 months (SOT group) and 13.5 months (controls). Age at IPP did not significantly differ between groups (53.7 + 8.1 vs 56.4 + 9.0, P = .26), nor did body mass index (30.3 + 5.5 vs 30.2 + 4.7, P = .92), history of prostatectomy (7.7% vs 15.4%, P = .39), rectal surgery (3.9% vs 3.9%, P = 1.00), hyperlipidemia (69.2% vs 69.2%, P = 1.00), hypertension (92.3% vs 76.9%, P = .25), or heart disease (57.7% vs 30.8%, P = .093). Peripheral vascular disease was more common in transplant patients (26.9% vs 3.9%, P = .021), as were stroke (19.2% vs 0.0%, P = .05) and diabetes (84.6% vs 53.6%, P = .016). No significant differences in IPP reoperation rates existed between patients with vs without SOT (11.5% vs 11.5%, P = 1.00), nor did they differ by organ transplanted (P = 1.00). No differences in IPP reoperation rate existed between 2-piece vs 3-piece IPP models (P = .47). CONCLUSION: Outcomes of IPP implantation in patients with SOT are similar to those of nontransplant patients. Patients with SOT should be considered suitable candidates for penile prosthesis.

Penile-sparing modalities in the management of low-stage penile cancer.

Penile-sparing modalities are gaining widespread adoption for the management of low-stage penile cancer due to an increasing demonstration of sound oncologic, cosmetic, sexual, psychosocial, and quality of life outcomes. This review aims to provide a comprehensive overview of the respective treatment options in the armamentarium of the practicing urologist in dealing with this rare but problematic condition.

Robot-assisted ureteral reconstruction - current status and future directions.

Robotic surgery in the treatment in certain urological diseases has become a mainstay. With the increasing use of the robotic platform, some surgeries which were historically performed open have transitioned to a minimally invasive technique. Recently, the robotic approach has become more utilized for ureteral reconstruction. In this article, the authors review the surgical techniques for a number of major ureteral reconstuctive surgeries and briefly discuss the outcomes reported in the literature.

Robotic Retrocaval Metastasectomy After an Ipsilateral Radical Nephrectomy.

OBJECTIVE: Robotic management of a retrocaval metastasis can be challenging because of prior surgery leading to scarring and obscure surgical planes around vital structures. We present our robotic approach and technique to manage a large retrocaval, biopsy-proven, metastatic mass after previous laparoscopic right radical nephrectomy with concomitant adrenalectomy 10 years ago. METHODS: We present a 62-year-old man who previously underwent a laparoscopic right radical nephrectomy for pT1bNxMx chromophobe renal cell carcinoma (RCC) in 2007. Surveillance imaging in November 2016 indicated a 5-cm retrocaval mass, and biopsy confirmed the metastasis. The patient was positioned in standard robotic positioning for right renal surgery. Meticulous dissection was required to free the duodenum and inferior vena cava from the mass, enabling the mass to be lifted anteriorly. Posteriorly, a labyrinth of vessels required hem-o-lok clips before excision, which allowed complete extraction of the mass. RESULTS: Operative time was 234 minutes and estimated blood loss was 40 cc. Final pathology revealed a right 5 cm × 3.1 cm metastatic RCC, chromophobe-type, lymph node. The surgical margins were negative for tumor. CONCLUSION: We present a successful surgical outcome of a robotic retrocaval metastasectomy for recurrent RCC, chromophobe type. At the time of publication, the patient continues to remain cancer free. Incorporating the da Vinci robotic platform allows for excellent visualization and access to difficult surgical locations while providing patients with the least invasive approach. A high degree of robotic experience is necessary before attempting this procedure, given the adherence of the mass to the inferior vena cava and duodenum.

Testicular seminoma: oncologic rationale and role of surgery in treatment.

Seminomas account for approximately 50% of all cases of testicular cancer. Testicular cancer is a highly curable disease that can be broadly classified as either seminomatous or nonseminomatous; the management and treatment of the 2 forms vary widely. Although surgery plays a large role in the management of nonseminoma, its role in the management of seminoma is much more limited. Most clinicians in the United States choose orchiectomy followed by surveillance for patients with stage I seminomatous disease, and chemotherapy or radiation-followed by surgery for the management of residual masses-for patients with disease that is stage II and higher. Recently, clinicians have proposed a larger role for surgery in stage II seminoma to avoid the long-term toxic effects of chemotherapy and radiation therapy. In this review, we discuss the oncologic rationale for the treatment of seminoma, the role of surgery, and the use of minimally invasive operative techniques for retroperitoneal lymph node dissection.

Current status of robotic single-port surgery.

Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.

Ex-vivo partial nephrectomy after living donor nephrectomy: Surgical technique for expanding kidney donor pool.

Renal transplantation has profound improvements in mortality, morbidity, and overall quality of life compared to renal replacement therapy. This report aims to illustrate the use of ex-vivo partial nephrectomy in a patient with a renal angiomyolipoma prior to living donor transplantation. The surgical outcomes of the donor nephrectomy and recipient transplantation are reported with 2 years of follow-up. Both the donor and recipient are healthy and without any significant comorbidities. In conclusion, urologic techniques such as partial nephrectomy can be used to expand the living donor pool in carefully selected and well informed transplant recipients. Our experience demonstrated a safe and positive outcome for both the recipient and donor, and is consistent with other reported outcomes in the literature.

Robotic-assisted Laparoscopic Bilateral Nerve Sparing and Apex Preserving Cystoprostatectomy in Young Men With Bladder Cancer.

OBJECTIVE: To describe our technique and outcomes of robotic-assisted nerve-sparing cystoprostatectomy with prostatic apex preservation and orthotopic ileal conduit urinary diversion in young men undergoing robotic-assisted radical cystectomy (RARC) for the management of urothelial carcinoma. MATERIALS AND METHODS: Young men (<40 years old) with the diagnosis of urothelial carcinoma undergoing RARC with orthotopic neobaldder formation were eligible for our technique of nerve-sparing cystoprostatectomy with prostatic apex preservation at the time of orthotopic ileal conduit urinary diversion. During the apical prostatic dissection step of the RARC, the plane of dissection is directed under the dorsal vein complex and through anterior prostatic fibromuscular stroma. This plane is further carried through the prostatic urethra, transecting the most caudal aspect of prostatic peripheral zone posteriorly, to create a long urethra and a posterior urethral plate formed by peripheral zone of the prostate, which serves as a robust, long stump for the subsequent vesicourethral anastomosis. RESULTS: From January 2013 to January 2014, 3 men were treated with RARC and intracorporeal neobladder urinary diversion based on the described technique. There were no intraoperative complications. Two patients experienced grade II complications postoperatively. Pathologic assessment demonstrated negative surgical margins in all 3 cases. With mean follow-up time of 28.2 months, 2 out of 3 patients are free from disease recurrence. All patients report daytime urinary continence with no pad usage and potency without the need for phosphodiesterase-5 inhibitors. CONCLUSION: RARC with bilateral nerve and apical preservation can be performed safely in appropriately selected young patients with excellent functional and acceptable short-term oncologic results.

The Digital Footprint of Academic Urologists: Where Do we Stand?

OBJECTIVE: To characterize the digital footprint of academic urologists by examining their web search results and identifying patterns within them. MATERIALS AND METHODS: Faculty lists were obtained from the top 10 ranked Urology residency program websites. A standardized Google search for "First Name Last Name Degree" was then completed for each staff physician. The total number of results and type of sites returned were recorded and patterns contained within identified. RESULTS: A total of 247 staff physicians were identified, with 13-36 per institution. A median of 11 (interquartile range: 10-12) search results returned for each person. Most (number = 231) staff had at least 1 rating site returned, with a mean of 3.50 (standard deviation: 1.45) noted. Overall, 3.44 (1.39) pages related to the practice were listed. Social media use was poorly visible, with a median 0 [0-1] results listed and only 7 Twitter accounts observed. More than half of sites, 6.34 (1.87) on average, were physician-controllable content. Having certain types of results was significantly associated with fewer ratings sites. Having an additional degree was also associated with significantly fewer ratings sites and more sites with physician-controllable content. CONCLUSION: The digital footprint of academic urologists contains more physician-controllable content than noncontrollable information; however, social media visibility in this group is poor. Optimization of the digital identity of academic urologists may be possible by exploiting the patterns observed in this study.

Comparative Cost-Effectiveness Analysis of Modified 1-Layer versus Formal 2-Layer Vasovasostomy Technique.

PURPOSE: Approximately 2% to 6% of men undergoing vasectomy will ultimately have it reversed. Cost is a major consideration for patients and providers with regard to vasovasostomy. Opportunities for cost savings for vasectomy reversal lie in the reduction of variable costs, namely operative time and materials used. In this study we determine the cost benefits of a modified 1-layer vasovasostomy compared to a formal 2-layer vasovasostomy. MATERIALS AND METHODS: A retrospective analysis was performed of a single surgeon experience of vasectomy reversals performed from 2010 to 2015. The cohort consisted of men who underwent bilateral vasovasostomy using a formal 2-layer or modified 1-layer technique. The primary end points of the analysis were total operative time; number, cost and type of suture used; and patency/postoperative semen analysis. Bivariate analysis was performed for these continuous variables using the Wilcoxon rank test and the chi-square test was used for categorical variables. RESULTS: Of the 106 men who underwent bilateral vasovasostomy 81.1% (86) had a formal and 18.9% (20) had a modified 1-layer repair. The modified 1-layer closure resulted in a significantly shorter operative time, lower microsuture cost and lower overall operative cost compared to formal repair (all p <0.05). There were no statistically significant differences in semen parameters between the 2 techniques at the first postoperative visit. CONCLUSIONS: The modified 1-layer vasovasostomy resulted in shorter operative times and lower costs compared to formal repair without compromising postoperative patency. In this era of cost containment the modified repair provides the opportunity to perform vasectomy reversal at a lower cost to patients and providers.

Bilateral primary adrenal non-Hodgkin's lymphoma without adrenal insufficiency.

We are presenting a rare case of bilateral adrenal non-Hodgkin's lymphoma (NHL) that presented as a primary malignancy. An 83-year-old man presented with newly discovered bilateral adrenal incidentalomas, fatigue, and 30 pound weight loss. Of the 116 cases of primary adrenal NHL reported, over half have presented bilaterally and occur with adrenal insufficiency. Therefore, the finding of bilateral adrenal masses requires an urgent work-up of the functional status of the adrenal gland as well as a thorough analysis of the imaging characteristics seen on noncontrast computed tomography (CT) in order to maximize patient survival. Adrenal function testing was normal. Repeat CT imaging revealed rapidly growing lesions with high attenuations; both masses >10 HU. Histological examination of core biopsies discovered malignant lymphoma with no known past history of lymphoma. Our case coincides with the literature, which states that a mass with attenuation >10 HU in the adrenal glands has a high risk of malignancy.

Primary bladder lymphoma, diffuse large B-cell type: Case report and literature review of 26 cases.

Primary lymphoma of the urinary bladder is exceedingly rare, representing 0.2% of all extranodal non-Hodgkin's lymphoma. Although Matsuno et al. and others state the most common type is mucosa-associated lymphoid tissue (MALT) lymphoma, 20% of all the primary lymphomas of the urinary bladder are considered to be high grade neoplasms; the majority being diffuse large B-cell lymphoma (DLBCL). This is a case report of a 48-year-old man that presented with hematuria, frequency, nocturia, and flank pain that was found to have high grade DLBCL. Twenty-six other cases of both low and high grade primary bladder lymphomas were selected in order to provide a thorough comparison of different treatment modalities. Of the cases reviewed, bladder lymphoma was more common in females (2:1). The average age at diagnosis was 63.9 years old (low grade: 68.7 years old, high grade: 58.8 years old). The most common low-grade neoplasm was MALT lymphoma (85.7%). For the low-grade malignancies, the most successful treatments were simple therapies (2 transurethral resection of a bladder tumour [TURBT], 1 antibiotics), solitary chemotherapy, and combination TURBT/chemo; all 3 of which achieved 100% clinical remission (CR) in the cases reviewed. The most common high grade neoplasm was DLBCL (76.9%). The most successful therapies used to treat high grade lesions were solitary chemotherapy (cyclophosphamide, duanorubacin, vincristine, prednisolone [CHOP] or ritoximab, CHOP [R-CHOP]) and combination therapies (2 radiation/CHOP, 2 surgery/CHOP). In the agreement with the current literature, this review has shown that simple therapies (TURBT) are equally as effective as aggressive treatments (chemotherapy, radiation) and should therefore be used as first line treatment in low grade tumors. For high grade malignancies, chemotherapy (R-CHOP or CHOP) alone or combination therapy (CHOP/surgery or CHOP/radiation) is recommended.

Regeneration and bioengineering of transplantable abdominal organs: current status and future challenges.

INTRODUCTION: The most critical issue to organ transplantation is the identification of new sources of organs. The present manuscript illustrates the state-of-the-art regenerative medicine (RM) investigations aiming to manufacturing abdominal organs for transplant purposes. AREAS COVERED: This manuscript focuses on research in the bioengineering and regeneration of kidneys, insulin-producing cells, livers and small bowel. The main technology currently under development exploits the seeding of cells on supporting scaffolding material. Despite favorable preliminary results obtained with relatively simple, hollow organs, when more complex organs are considered, the scenario changes dramatically. Investigations are still in early stages, and clinical translation is not yet foreseeable based on current knowledge and information. Obstacles are numerous but we believe the critical factor hampering success is lack of in-depth understanding of the extracellular matrix (ECM) and cell-ECM interactions, as well as the mechanisms with which organs develop in utero. EXPERT OPINION: The success of RM to generate transplantable abdominal organs relies heavily on progress in (stem) cell therapies, developmental and ECM biology, and in the thorough understanding of the intricate relationship and interplay between cells and the ECM. This will require enormous investments in financial and medical resources, which ideally should be embarked upon by governments, the private sector and academia.

Immunoisolation: where regenerative medicine meets solid organ transplantation.

Immunoisolation refers to an immunological strategy in which nonself antigens present on an allograft or xenograft are not allowed to come in contact with the host immune system, and it is implemented to prevent allorecognition and avoid immunosuppression. In this setting, the two most promising technologies, encapsulation of pancreatic islets (EPI) and immunocloaking (IC), are used. In the case of EPI, islets are inserted in capsules that, allow exchange of oxygen, nutrients and other molecules. In the case of IC, a natural nanofilm is injected prior to renal transplantation within the vasculature of the graft with the intent to pave the inner surface of the vascular lumen and camouflage the antigens located on the membrane of endothelia cells. Significant progress achieved in experimental models is leading EPI and IC to clinical translation.

Robot-assisted partial nephrectomy: current status, techniques, and future directions.

Open partial nephrectomy for the treatment of small renal masses (SRMs) concerning for renal cell carcinoma has been increasingly utilized with the increased incidental detection of SRMs and the growing recognition of the benefits of renal preservation. Laparoscopic partial nephrectomy (LPN) is a minimally invasive technique that achieves comparable oncologic and improved morbidity outcomes when compared to the open procedure. However, LPN is a technically demanding procedure resulting in a long learning curve and a lack of widespread adoption. Robot-assisted partial nephrectomy (RAPN) overcomes many of the technical hurdles of the LPN and is now coming to the forefront for the minimally invasive surgical management of SRMs. To date, the short-term oncologic outcomes of RAPN have been comparable to the open operation while providing the improved morbidity outcomes of LPN. Although encouraging, we await the long-term oncologic results of this new and promising procedure. The current bottleneck is an issue of cost and reliance on a patient-side surgeon. Future developments in instrumentation, newer robots, cost reduction, more streamlined training, increased robotic experience, and adoption by more centers will lead to greater benefit for patients with SRMs requiring nephron-sparing surgery. This review will discuss techniques for RAPN and then delve into the current status of RAPN using parameters such as warm ischemia time, blood loss, hospital stay, oncological outcomes, complications, learning curve, and quality of life. There will be an exploration of potential disadvantages associated with RAPN followed by a look at evolving techniques in regard to this groundbreaking procedure.