Treatment of male stress urinary incontinence at time of inflatable penile prosthesis placement a review of contemporary literature.

Background and Objective: Male stress urinary incontinence (SUI) and erectile dysfunction (ED) are well established diagnoses within Men's Health, often more specifically within the prostate cancer survivorship cohort. Taken individually, well defined treatment algorithms exist with which many surgeons are comfortable; however, treatment of both in a single setting or staged fashion introduces complexity. Emerging treatment options also exist, and there is immature or minimal data when these are combined with inflatable penile prosthesis (IPP) insertion, radiation history, and/or variable degrees of incontinence. Our objective was to describe and summarize the currently available treatment options for SUI particularly at the time of IPP insertion. Methods: A literature review was performed to summarize contemporary treatment of SUI at time of IPP placement. Anecdotal experience was added from high volume, subspecialty trained Men's Health and Reconstructive Urologists. Key Content and Findings: Non-invasive approaches such as pelvic floor muscle training (PFMT), behavioral modification, and external compression devices play some limited role in treatment and/or management of SUI, particularly in the early post operative period, or for those unwilling or unable to undergo more definitive intervention. More invasive options such as artificial urinary sphincter (AUS) implantation, male sling, or other implantable devices are more appropriate for good surgical candidates with higher bother and/or more severe incontinence. These options can be concomitant or staged relative to IPP placement. Climacturia, particularly with mild or no bothersome SUI, can successfully be addressed at the time of penile prosthesis placement with the utilization of the Mini-Jupette suburethral sling. Conclusions: A variety of treatment options exist for concomitant treatment of SUI at time of IPP, and both safety and efficacy have been demonstrated for many in the same operative setting. As with treatment of ED or SUI in isolation, patient selection, careful counseling, and management of expectations can lead to high patient satisfaction.

Open retrieval management of inferior vena cava filter erosion resulting in symptomatic hydroureteronephrosis.

Inferior vena cava filters are effective for the management of thromboembolic disease but can erode into adjacent organ systems in rare instances. Endovascular retrieval of eroded filters has been the preferred management for this complication. We present a case for which endovascular retrieval was not appropriate because of filter orientation and erosion into the ureter and describe successful management using open retrieval of a permanent filter with erosion into the renal collecting system requiring reconstruction. Although minimally invasive retrieval is preferred over open repair, this approach should be considered when filter erosion is not amenable to endovascular retrieval.

Tips and tricks for the extravesical robotic-assisted laparoscopic ureteral reimplantation for pediatric vesicoureteral reflux.

Over the past few years, robotic-assisted laparoscopic ureteral reimplantation (RALUR) has gained popularity as an acceptable alternative for the traditional open approach if surgery is elected for children with vesicoureteral reflux (VUR). We present our technique including the tips and tricks for both male and female patients, including a stepwise approach for ureteral identification in female patients depending on the level of technical difficulty. Our series include 30 patients who represent a spectrum in which we presented the different tips and tricks included in this video.

Could the bulbar urethral end location on the cystourethrogram predict the outcome after posterior urethroplasty for pelvic fracture urethral injury?

Objectives: To identify cystourethrogram (CUG) findings that independently predict the outcome of posterior urethroplasty (PU) following pelvic fracture urethral injury (PFUI). Methods: Findings of CUG included the location of the proximal end of the bulbar urethra in zones A (superficial) or B (deep) according to its relationship with the pubic arch. Others included the presence of pelvic arch fracture, bladder neck, and posterior urethral appearance. The primary outcome was the need for reintervention either endoscopically or by redo urethroplasty. Independent predictors were modeled using a logistic regression model and a nomogram was constructed and internally validated using 100-bootstrap resampling. Time-to-event analysis was performed to validate the results. Results: A total of 196 procedures in 158 patients were analyzed. The success rate was 83.7% with 32 (16.3%) procedures requiring direct vision internal urethrotomy, urethroplasty, or both in 13 (6.6%), 12 (6.1%), and 7 (3.6%) patients, respectively. On multivariate analysis, bulbar urethral end located at zone B (odds ratio [OR]: 3.1; 95% confidence interval [CI]: 1.1-8.5; p = 0.02), pubic arch fracture (OR: 3.9; 95%CI: 1.5-9.7; p = 0.003), and previous urethroplasty (OR: 4.2; 95% CI: 1.8-10.1; p = 0.001) were independent predictors. The same predictors were significant in the time-to-event analysis. The nomogram discrimination was 77.3% and 75% in the current data and after validation. Conclusions: The location of the proximal end of the bulbar urethra and redo urethroplasty could predict the need for reintervention after PU for PFUI. The nomogram could be used preoperatively for patient counseling and procedure planning.

Solitary Abdominal Wall Lymph Node Recurrence in Prostate Cancer Patient with Dramatic Prostate-Specific Antigen Decrease following Metastasectomy.

Prostate cancer patients routinely undergo surveillance for recurrence using prostate-specific antigen (PSA). While PSA's benefit in screening is controversial, its use for detecting recurrence in patients with history of prostate cancer is pivotal. Rising PSAs with the newly advanced prostate-specific membrane antigen positron emission tomography (PSMA PET) can help localize the location of recurrences for better excision and management. Here, we present a 55-year-old with prostate cancer, with initially undetectable postprostatectomy PSA levels, who later presented with a PSA of 3.47 ng/mL. PSMA PET showed isolated uptake in an abdominal wall mass. Pelvic lymphadenectomy and abdominal wall mass excision were performed, confirming a single metastasis in an abdominal wall lymph node. Metastasectomy led to a dramatic drop in PSA to 0.10 ng/mL both postoperatively and on long-term follow-up. Our case illustrates the potential benefit of metastasis-directed therapy in delayed oligometastasis following definitive management of prostate cancer.

Survival outcomes in node-positive non-metastatic bladder cancer: An analysis of the national cancer database.

Introduction: Clinically node-positive non-metastatic bladder cancer (cN+) has been the target of several studies aiming to establish a standard of care for this population. Limited studies have shown a survival benefit for various multimodal therapy approaches. The role of radiation therapy has not been well established. Our study aims to study the trends of the reported treatment options offered to patients with cN+ bladder cancer in a national database and to evaluate the effect of various treatments, including radiation, on survival. Methods: The National Cancer Database (NCDB) was used to identify cN+ bladder cancer patients who received chemotherapy alone or in combination with radical cystectomy (RC) or radiotherapy. 3,481 patients were included and divided into 4 groups: chemotherapy only, chemotherapy and RC, chemotherapy and radiation therapy, and chemotherapy, RC, and radiation therapy. Demographic data was compared using ANOVA for continuous variables, and Chi-square for categorical variables. Multivariable analysis was done to compare groups using a multinomial logistic regression model. Kaplan-Meier test was used for survival analysis and Cox-Regression was used for multivariable survival analysis. Results: Patients undergoing RC were significantly younger (P <0.001). There was a significant difference between the groups regarding racial distribution, facility-type and insurance status. There was no difference in gender, Charlson\Deyo score, financial or educational status. Patients who underwent combination therapy with chemotherapy and RC were found to have the longest median survival time at 27 months. Multivariable analysis showed that final treatment, age, sex, Charlson\Deyo comorbidity score, TNM edition and facility-type were significant survival predictors. Race, insurance and financial status failed to maintain significance. There was no survival difference between the chemotherapy group and chemo-radiotherapy group. Conclusions: The combination of surgery and chemotherapy achieves statistically significant superior survival in cN+ bladder cancer. Adding radiotherapy to chemotherapy did not improve survival in this group of patients. Abbreviations: (cN+): Clinically node-positive non-metastatic, (MIBC): Muscle invasive bladder cancer, (NCDB): National Cancer Database, (NAC): Neoadjuvant chemotherapy, (RC): Radical Cystectomy.

Selective angioembolization as a management strategy for angiomyolipoma causing urinary tract obstruction.

Angiomyolipoma (AML) is a benign renal tumor usually found incidentally. Rarely, AML can present with renal colic due to urinary tract obstruction. Prior cases of obstructing AML have been presented and managed successfully with surgical removal. Selective angioembolization has emerged as an alternative management strategy for AML, but no documented cases have been presented for this strategy in the setting of obstruction. Here, we present a case of obstructing AML treated with selective angioembolization with subsequent resolution of obstruction.

Management of a case of extensive penile condyloma acuminata with full thickness skin graft for penile skin reconstruction.

We present a case of extensive Condyloma acuminata lesions involving significant area of the penile and genital skin. He underwent a complete excision of the lesions. Reconstruction of the penile skin was performed using full-thickness skin graft. The patient recovered well with no graft contracture or disfigurement.

Trans-hepatic trans-portal selective angioembolization; a management option for severe acute variceal bleeding of ileal conduit stoma.

We present a case of severe acute variceal bleeding in an ileal conduit stoma successfully managed with trans-hepatic trans-portal selective angioembolization as a lifesaving measure. Despite repeated transfusions, the patient's hemoglobin continued to be unstable. The patient underwent transhepatic embolization of ileal stoma varicose veins. Angioembolization was followed up with excision of ileal conduit stoma and creation of cutaneous ureterostomy for definitive treatment management of hemorrhage. In conclusion, trans-hepatic trans-portal embolization is an effective option for management of severe acute variceal bleeding in an ileal conduit stoma as a lifesaving measure and can be followed by excision of the conduit.

Dysfunctional Voiding- Presentation of a Rare Case of Pediatric Non Muscle Invasive Urothelial Bladder Carcinoma.

Bladder cancer is rare in children, with 86.8% of pediatric patients diagnosed not carrying any of the common risk factors commonly seen in adults. Here, a 16-year-old female presented to the ED with in urinary retention. A renal bladder ultrasound revealed an echogenic focus in the bladder wall. On diagnostic cystoscopy a small papillary bladder lesion was appreciated and resected. Final pathology of the bladder mass resulted as non-invasive low grade papillary urothelial carcinoma (pTa). This report demonstrates bladder cancer in the pediatric age group, and should be considered as a possible differential diagnosis in patients with dysfunctional voiding.

The Impact of Targeted Education of American Urological Association Cryptorchidism Guidelines in a Rural State: Improvement Still Needed.

BACKGROUND: The American Urological Association published guidelines in 2014 regarding management of undescended testicles (UDT). Despite these guidelines, prior studies have indicated discordance between guidelines and actual practice, especially in rural states. This study aims to identify if educating referring providers improves management of UDT. METHODS: Patients with UDT referred to our institution were divided into two groups: those referred prior to (Group 1) and after (Group 2) targeted education. A retrospective review was performed to compare the groups in terms of age at time of referral and surgery, laterality, specialty, and practice setting of referring provider, and whether or not ultrasound (US) was performed prior to referral. RESULTS: A total of 100 patients were identified in Group 1 and 168 in Group 2. No significant differences were noted between groups regarding age, variability of referring provider, or those receiving US prior to referral. Median age at referral was 20.7 months (range=0-194) and 33 months (range=0-205.1) in Groups 1 and 2, respectively (p=0.26). Sixty-two (37%) patients underwent surgical evaluation within 18 months of age or younger in Group 1 compared to 39 (39%) in Group 2 (p=0.73). Private practice pediatricians comprised the majority of referring providers in both cohorts. US was performed prior to referral in 41% of patients in Group 1 compared to 35.8% in Group 2 (p=0.51). The number of US ordered prior to referral significantly decreased from 10 (50%) to six (19%) following education among academic providers (p=0.02). No significant difference was found following education for private practice physicians (p=0.27). CONCLUSION: Targeted education did not improve age at referral in the short-term, which may reflect suboptimal healthcare access. Additionally, more research is needed to evaluate whether more diverse targeted education provided on a regular basis to both physician and mid-level providers would have a meaningful impact.

Evaluation of Preoperative Tamsulosin Role in Facilitating Ureteral Orifice Navigation for School-Age Pediatric Ureteroscopy.

PURPOSE: To address whether preoperative tamsulosin increases the rate of successful ureteral orifice navigation for ureteroscopy (URS) without prestenting in school-age pediatric patients. METHODS: We retrospectively reviewed all pediatric patients who had undergone ureteroscopy (URS) at our institution from 2013 to 2020. Patients were divided into two groups: those who had received tamsulosin 0.4 mg daily ≥48 hours preoperatively and those who had not. Statistical analysis was done using independent-sample t-tests and Mann-Whitney U tests for continuous variables, and χ2 and Fisher's exact tests were used for categorical variables. Multivariate analysis was done using binary logistic regression test. RESULTS: Overall, successful ureteral orifice navigation occurred in 44 of 50 patients (88%) who had received tamsulosin and 17 of 26 (65.4%) who had not (p=0.019). On further subanalysis based on stone location and instrumentation used, successful ureteral orifice navigation had occurred in 21 of 24 patients (87.5%) in the tamsulosin group and one of five (20%) in the no-tamsulosin group for semirigid ureteroscopy for mid-distal ureterolithiasis (p=0.007). For proximal ureteral and renal stones, successful ureteral orifice navigation with a flexible ureteroscope or ureteral access sheath had occurred in 23 of 26 patients (88.5%) in the tamsulosin group and 16 of 21 (76.2%) in the no-tamsulosin group (p=0.437). Multivariate analysis showed no significant difference between success rates in the two groups after controlling for patient weight, height, BMI, and stone location. We did not observe any adverse effects from tamsulosin. CONCLUSION: This is the first study to evaluate preoperative tamsulosin on successful ureteral orifice navigation in school-age pediatric patients. Although not reaching statistical significance, further evaluation should be done on larger cohorts. Patient height was found to be an independent predictor of successful ureteral orifice navigation.

Measuring volumetric segmentation changes in the ipsilateral and contralateral kidney postpartial nephrectomy.

OBJECTIVE: To analyze the volumetric changes of the ipsilateral and contralateral kidneys and their effect on functional outcome post partial nephrectomy using segmentation analysis. PATIENTS AND METHODS: We have analyzed the data of 119 patients from a single surgeon series of partial nephrectomy patients. Median follow-up was 11.40 months. Patients with bilateral tumors, and solitary kidney were excluded from analysis. Volumetric measurements were performed using a semiautomated tissue segmentation tool. A simple linear regression model to assess the predictors for parenchymal volume loss (PVL). A multivariable linear regression model was used to evaluate the association between PVL and warm ischemia time (WIT), controlling for other factors. RESULTS: Mean WIT was 12.09 ± 4.40 minutes and the mean percentage decrease in the volume of the operated kidney was 16.99 ± 13.49%. WIT (ß = 1.24, P < 0.001) and tumor complexity (simple vs. intermediate, ß = 0.06, P = 0.984; simple vs. high, ß = 11.62,P = 0.007) were associated with PVL. A 1 minute increase in WIT was associated with an increase in the percentage volume loss in the operated kidney by 1.38% (ß = 1.20, P < 0.001). Patients with high tumor complexity (ß = 11.17, P = 0.009) had a significantly higher percentage volume loss compared to patients with simple tumor complexity. Ipsilateral PVL (ß = -0.35, P = 0.015) and male gender (ß = -9.89, P = 0.021) were associated with change in eGFR. After adjusting for confounders, % volume loss (ß = -0.32, P < 0.001) remained a significant predictor for contralateral hypertrophy. CONCLUSION: Tumor complexity results in higher WIT and increased PVL as measured by volumetric segmentation. PVL is a key factor associated with functional outcome, and is directly linked to WIT. Increased PVL is also associated with decreased contralateral hypertrophy. Prospective studies with larger samples sizes will be required to validate our findings.

Robotic partial nephrectomy for clinical T2a renal mass is associated with improved trifecta outcome compared to open partial nephrectomy: a single surgeon comparative analysis.

OBJECTIVE: Utilization of partial nephrectomy (PN) for T2 renal mass is controversial due to concerns regarding burden of morbidity, though most cited data are from open PN (OPN). We compared surgical quality and functional outcomes of RPN and OPN for clinical T2a renal masses (cT2aRM). METHODS: Retrospective analysis of 150 consecutive patients [RPN 59/OPN 91] who underwent PN from July 2008 to June 2016. Main outcome was achievement of Trifecta [negative surgical margin, no major urologic complications, and ≥90% preservation of estimated glomerular filtration rate (eGFR)]. Multivariable analysis was performed to identify factors of Trifecta attainment. RESULTS: Mean tumor size (RPN 7.9 vs. OPN 8.4 cm, p = 0.139) and median RENAL score (p = 0.361) were similar. No difference was noted for positive margins (RPN 3.4% vs. OPN 1.1%, p = 0.561), ΔeGFR (RPN - 6.2 vs. OPN - 7.8, p = 0.543), and ≥ 90% eGFR recovery (RPN 54.1% vs. OPN 47.2%, p = 0.504). RPN had lower blood loss (p = 0.015), hospital stay (p = 0.013), and Clavien ≥ 3 complications (RPN 5.1% vs. OPN 16.5%, p = 0.041). Trifecta rate was significantly higher in RPN (47.5% vs. 34.0%, p = 0.041). Multivariable analysis demonstrated decreasing RENAL score (OR 1.11, p < 0.001), RPN (OR 1.2, p = 0.013), and decreasing EBL (OR 1.02, p = 0.016) to be associated with Trifecta attainment. CONCLUSIONS: RPN provided similar functional and oncologic precision to OPN, while being associated with improvements in major complications, the latter of which was reflected in a higher rate of Trifecta achievement for RPN. RPN may be considered to be a first-line option for select patients with cT2aRM when feasible and safe.

Trends and outcomes in contemporary management renal cell carcinoma and vena cava thrombus.

INTRODUCTION: We sought to analyze the safety, efficacy, and national trends in the use of robotic radical nephrectomy (RN) and inferior vena cava thrombectomy in patients with renal cell carcinoma. PATIENTS AND METHODS: We analyzed 872 patients from the National Cancer Database dataset who underwent open (n = 838, 96.1%) or robotic (n = 34, 3.9%) radical nephrectomy with inferior vena cava thrombectomy for cT3b renal cell carcinoma between 2010 and 2014. Length of stay (LOS), 30-day readmissions and 30-day mortality were compared between the 2 groups. As internal validation, we performed a multi-institutional analysis of 20 patients (9 open [45%] vs. 11 robotic [55%]) undergoing RN with a level II thrombus. Patients were compared in terms of baseline characteristics, peri- and postoperative outcomes. Uni- and multivariable models were used adjusting for clinical and tumor characteristics. RESULTS: Baseline characteristics were similar between the 2 groups in both datasets. In the National Cancer Database, robotic approach was associated with 26% reduction in LOS (P < 0.001) but no difference in readmissions (odds ratio [OR] = 0.91; 95% confidence interval [CI] = 0.05, 4.50; P = 0.925) or 30-day mortality (OR = 2.72; 95% CI = 0.40, 10.86; P = 0.211). In multicenter database, open group had significantly greater blood loss (600 vs. 100.0 mL, P = 0.020). The rate of blood transfusion was higher in the open group, but was not significant (44.4% vs. 18.2%, P = 0.336). Robotic group had a shorter LOS (1 vs. 5 days; P = 0.026). No difference was seen between the open and robotic groups in terms of operative time (226 vs. 260 minutes, P = 0.922) and postoperative complications (P > 0.999). CONCLUSION: In select cases and experienced hands, robotic approach offers a reasonable alternative to open surgery without an increased complication rate.

Management of high complexity renal masses in partial nephrectomy: A multicenter analysis.

OBJECTIVE: To determine the safety and efficacy of performing partial nephrectomy (PN) on patients with high nephrometry score tumors. PATIENTS AND METHODS: We used a prospectively maintained multi-institutional kidney cancer database to identify 144 patients with R.E.N.A.L. nephrometry score ≥10 who underwent PN for a cT1-cT2 renal mass. Baseline demographics and clinical characteristics, tumor characteristics, perioperative, and pathological outcomes were analyzed and reported. Trifecta achievement, defined by warm ischemia time <25 minutes, no perioperative complications, and negative surgical margins, was the primary outcome. We assessed the relationship of baseline clinical and tumor characteristics data to trifecta achievement and perioperative complications. RESULTS: Baseline median eGFR was 84.57 ml/min/1.73 m2, with 119 (84.39%) patients having normal baseline kidney function. The median clinical tumor size was 4.95 cm, with 74 (51.75%) being completely endophytic and 58 (41.73%) located on the hilum. The median ischemia time was 20 minutes. Median estimated blood loss was 150 ml. Twelve patients (8.33%) had intraoperative complications. No patient had a conversion to open surgery. Postoperative, perioperative, and major complication rate were 10.42%, 17.3%, and 2.34% respectively. Thirty-six patients (37.89%) developed postoperative acute kidney injury and 28 (20.90%) developed new-onset CKD at a median follow-up of 6 months. Eight patients (5.56%) had a positive surgical margin. Trifecta was achieved in 89 (61.81%) patients. There was no significant difference in baseline, clinical, and tumor characteristics between those that achieved trifecta and in those where trifecta was not. Pathologic tumor stage was the only factor significantly associated with trifecta achievement (P = 0.025). CONCLUSION: In treating complex renal tumors, PN should be performed when possible. Although this remains a challenging procedure, with experience and appropriate case selection, the trifecta outcome can be achieved in a significant number of patients with high renal score lesions.

Is there a way to predict failure after direct vision internal urethrotomy for single and short bulbar urethral strictures?

OBJECTIVE: To identify patient and stricture characteristics predicting failure after direct vision internal urethrotomy (DVIU) for single and short (<2 cm) bulbar urethral strictures. PATIENTS AND METHODS: We retrospectively analysed the records of adult patients who underwent DVIU between January 2002 and 2013. The patients' demographics and stricture characteristics were analysed. The primary outcome was procedure failure, defined as the need for regular self-dilatation (RSD), redo DVIU or substitution urethroplasty. Predictors of failure were analysed. RESULTS: In all, 430 adult patients with a mean (SD) age of 50 (15) years were included. The main causes of stricture were idiopathic followed by iatrogenic in 51.6% and 26.3% of patients, respectively. Most patients presented with obstructive lower urinary tract symptoms (68.9%) and strictures were proximal bulbar, i.e. just close to the external urethral sphincter, in 35.3%. The median (range) follow-up duration was 29 (3-132) months. In all, 250 (58.1%) patients did not require any further instrumentation, while RSD was maintained in 116 (27%) patients, including 28 (6.5%) who required a redo DVIU or urethroplasty. In 64 (6.5%) patients, a redo DVIU or urethroplasty was performed. On multivariate analysis, older age at presentation [odds ratio (OR) 1.017; P = 0.03], obesity (OR 1.664; P = 0.015), and idiopathic strictures (OR 3.107; P = 0.035) were independent predictors of failure after DVIU. CONCLUSION: The failure rate after DVIU accounted for 41.8% of our present cohort with older age at presentation, obesity, and idiopathic strictures independent predictors of failure after DVIU. This information is important in counselling patients before surgery.