The urologist's role in bowel management of adult spina bifida: a narrative review.

Background and Objective: Urologists are central to the coordinated care of patients with spina bifida (SB), and efforts to optimize bladder management and protection of the upper tracts are well established. However, the urologist's role in treating this population often extends to the management of bowel dysfunction which may be less defined. The methods available to the urologist for bowel management range from lifestyle modifications to medical and surgical therapy, with many patients requiring combinations of multiple strategies to combat conflicting symptoms of constipation and fecal incontinence (FI). This narrative review aims to compile a detailed algorithm of management options, for the practicing urologist to more confidently address this important facet of care. Methods: A detailed review was conducted using PubMed and Google Scholar databases to assess the contemporary literature surrounding neurogenic bowel dysfunction in adult SB. Articles published in English between 1990 and 2023 were considered. Key Content and Findings: This review presents and investigates a schema of increasingly definitive and invasive treatments for bowel dysfunction including lifestyle adaptations, pharmacological treatment, transanal irrigation (TAI), sacral neuromodulation (SNM), antegrade continence procedures, and bowel diversion. TAI and medical bowel care are beneficial in postponing or avoiding more invasive surgical interventions. Should conservative measures prove ineffective, surgical management provides the most definitive bowel control. Conclusions: Symptoms of constipation and FI that result from neurogenic bowel are best managed with an individualized approach guided by the general treatment algorithm presented in this review. Educated on the numerous appropriate options, patients will often trial methods before proceeding with more invasive treatments. Additional work is required to further evaluate management options specific to the SB populations, especially in more contemporary and largely experimental treatment modalities such as SNM.

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

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

The Role of Alumni Networks and Career Advising in Early Career Stability of Urologists: Results of a Multi-institutional Study.

OBJECTIVE: To characterize training program and early career factors that impact decision-making and job retention following graduation in a diverse population of urologists. MATERIALS AND METHODS: We performed a computer-based survey distributed to residency graduates from 25 urology training programs. Five focus institutions were identified with a goal >30% response rate. The survey included questions about training program specifics and post-training employment characteristics. RESULTS: We obtained 180 responses from urology residency graduates of 25 programs. Overall, 72% (N = 129) remain in their initial post-training position at a median of 6years postgraduation (Interquartile Range (IQR) 3-10). On Cox-regression analysis stronger trainee-rated formal career advising was associated with lower risk of changing jobs (HR 0.77, 0.60-0.99, P = .048). Location/proximity to family was the most consistently cited as the top reason for selecting a job (41%). Sixty-three respondents (35%) joined practices employing graduates of the same residency program. Cox regression analysis showed that joining a practice with alumni of the same program was associated with lower risk of changing jobs from one's initial post-training position (HR 0.39, 95% CI 0.17-0.91, P = .03). CONCLUSION: In this multi-institutional study of urologists, we observed a high rate of job retention out to a median of 6years following completion of training, with formal career advising and joining alumni in practice being associated with job retention. Collectively, our data highlights that training programs should emphasize advising programs and alumni networking in guiding their graduates in the job search process.

A Disease-Specific Antibiogram to Evaluate Empiric Coverage Patterns in Fournier's Gangrene.

OBJECTIVE: To analyze our local antibiogram and antibiotic resistance patterns given concern for multidrug-resistant and fungal organisms in contemporary series detailing causative organisms in Fournier's Gangrene (FG). METHODS: All patients from 2018 to 2022 were identified from the institutional FG registry. Microorganisms and sensitivities were collected from operative tissue cultures. The primary outcome of this study was the adequacy of our empiric. Secondary outcomes included the rate of bacteremia, the concordance of blood cultures and tissue cultures, and the rate of fungal tissue infections. RESULTS: Escherichia coli and Streptococcus anginosus were most common, identified in 12 patients each (20.0%). Enterococcus faecalis (9, 15.0%), S agalactiae (8, 13.3%) and mixed cultures without a predominant organism (9, 15.0%) were also common. A fungal organism was identified in 9 (15.0%) patients. Patients who were started on Infectious Diseases Society of America guideline adherent antibiotic regimen were not significantly different in terms of bacteremia rate (P = .86), mortality (P = .25), length of stay (P = .27), or final antibiotic duration (P = .43) when compared to those on alternative regimens. Patients with a tissue culture positive for a fungal organism were not significantly different in terms of Fournier's Gangrene Severity Index (P = .25) or length of stay (P = .19). CONCLUSION: Local disease-specific antibiograms can be a powerful tool to guide empiric antibiotic therapy in FG. Although fungal infections are responsible for a majority of the gaps in empiric antimicrobial coverage at our institution they were present in only 15% of patients and their effect on outcomes does not justify addition of empiric antifungal agents.

Male Stress Urinary Incontinence.

Male stress urinary incontinence most commonly presents secondary to prostate treatment of prostate cancer or benign prostatic hyperplasia, although it can be seen following trauma or secondary to neurologic dysfunction. Patient selection is supremely important when choosing the appropriate nonoperative or surgical treatment. Although most patients prefer the passive mechanism of adjustable balloon devices or slings, the artificial urinary sphincter provides the most efficacious and durable results with regard to patient satisfaction and continence. Changes in prostate treatment modalities and anti-incontinence device development will offer more surgical options for patients in the future.

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

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

How a Large Academic Training Program Influences Early Career Decision-making and Employment Stability in Urology.

OBJECTIVE: To characterize training and practice factors that influence early career stability and satisfaction in urology residency and fellowship graduates. METHODS: A computer-based survey was distributed to residency and fellowship graduates from a single, large US training program from 1992 to 2015. Queries encompassed training program specifics, post-training practice characteristics, and a validated burnout assessment. RESULTS: Of 108 surveyed individuals there were 77 (71.3%) respondents. Fifty-one (67.1%) remained in their first position after residency. While 52 (67.5%) urologists reported that the program did not formally assist in finding their first post-residency position, no respondent reported difficulty securing a position. Proximity to family was a major factor in selecting a post-residency position in 40 (51.9%) of respondents. Twenty-nine (37.7%) participants joined practices with at least one other graduate of the same urology training program on staff and 24 remain in this position (82%). CONCLUSION: Urology graduates from a large US training program did not have difficulty finding employment after training and most remain in their first post-training position. While proximity to family was a strong consideration for graduates, the perceived importance of first-position characteristics varied widely. 37.7% of our cohort took initial positions at a practice already employing a graduate from the same training program with >80% staying in this position. Surveying a broader range of programs may help future graduates and training programs better tailor their mentorship curricula and alumni networks to trainee goals.

The Impact of Delayed-Phase Imaging at Admission on the Management of Urinary Extravasation in High-Grade Renal Trauma.

PURPOSE: American Urological Association Urotrauma guidelines recommend delayed-phase imaging on presentation for all renal injuries, although data to support it are anecdotal. Forgoing delays risks unrecognized collecting system injuries. We hypothesized that renal trauma patients without admission delays have more complications from urinary extravasation. MATERIALS AND METHODS: From 2005 through 2020, 1,751 renal trauma patients were identified from our institutional trauma registry. Included patients had an estimated American Association for the Surgery of Trauma renal injury grade of III-V and a perinephric fluid collection. Propensity scores for receipt of delayed-phase imaging were calculated based on Injury Severity Score, arrival condition, admission systolic blood pressure, sex and renal injury grade. Propensity score-adjusted logistic regression was used to compare clinical outcomes between those with and without admission delays. RESULTS: Ninety (28.6%) of 315 included patients had delays on presentation. Patients without delays had higher Injury Severity Scores (29 vs 23, p=0.002), fewer isolated renal injuries (27.6% vs 38.9%, p=0.05) and lower grade renal injuries (56.9% vs 41.1% grade 3, p=0.03). After propensity score adjustment, patients with delays were more likely to undergo immediate interventions (OR 11.75, 95% CI 2.99-78.10) and interval stent placement for urinary extravasation (OR 6.86, 95% CI 1.56-47.64) without a difference in urological complications (OR 5.07, 95% CI 0.25-766.16). CONCLUSIONS: Delayed-phase imaging was associated with an increased odds of undergoing immediate and asymptomatic interval urological interventions without a difference in the odds of a complication after high-grade renal trauma. Post-trauma urinary extravasation requires further research to determine which patients require imaging and intervention.

The Diagnosis and Management of Life-threatening Urologic Infections.

Genitourinary infections are commonly encountered and managed in inpatient, outpatient, and emergency settings. Fournier's gangrene, emphysematous pyelonephritis, and obstructive pyelonephritis represent the most serious urologic infections and have a high risk of mortality if not managed promptly. Due to the rarity of these infections, the evidence for specific treatment strategies is scattered. This review aims to provide comprehensive, evidence-based recommendations for the diagnosis and management of these life-threatening urologic infections.

High-Risk Nonmuscle Invasive Bladder Cancer: Selecting the Appropriate Patient for Timely Cystectomy.

The heterogenous nature of high-risk nonmuscle invasive bladder cancer encompasses a wide range of tumor biologies with varying recurrence and progression risks. Radical cystectomy provides excellent oncologic outcomes but is often underutilized. Timing for these patients is critical, however, to its effectiveness. Certain unfavorable tumor characteristics predict worse outcomes and may help select the most appropriate patients for more aggressive initial therapy. This manuscript aims to outline factors that predict worse outcomes in high-risk nonmuscle invasive bladder cancer and proposes which patients may benefit most from a timely radical cystectomy.

Side Effects of Intravesical BCG and Chemotherapy for Bladder Cancer: What They Are and How to Manage Them.

Intravesical therapy for nonmuscle invasive bladder cancer decreases recurrence and progression but carries a high risk of side effects, which limit patient adherence. Appropriate management of the toxicities from intravesical therapy requires consideration of the agent used, the side effects experienced, and the timing of those side effects. Management strategies for intravesical toxicities ideally improve patient tolerance without sacrificing oncologic outcomes. This review aims to provide a comprehensive overview of the available evidence regarding the side effects of intravesical therapies for nonmuscle invasive bladder cancer and to propose practical strategies for toxicity management.

Transobturator sling for post-prostatectomy incontinence: radiation's effect on efficacy/satisfaction.

INTRODUCTION: We review our experience with the AdVance sling in patients with post- prostatectomy incontinence, comparing the role that adjuvant radiation therapy plays in sling success and patient satisfaction at short and long term follow ups. MATERIALS AND METHODS: Men who underwent AdVance sling placement for post-prostatectomy incontinence from 2007 to present were identified using Current Procedural Terminology (CPT) codes. Manual chart review was performed. Level of incontinence was assessed using Expanded Prostate Cancer Index Composite (EPIC) and pads per day (PPD) use. Satisfaction was assessed by willingness to recommend the procedure to a friend. Outcomes in men who received radiation were compared to radiation-naïve men. RESULTS: Fifty-two men underwent AdVance sling placement. Eighteen men received adjuvant radiation. Thirty-six men were available for short term (19.4 months) and 16 men for long term (61.5 months) follow up. Overall, significant improvement was seen in post-sling EPIC score (24.6, p < 0.001), EPIC incontinence score (39.1, p < .001), and pad use (3.2 PPD to 1.4 PPD, p < .001). Greater improvement in EPIC scores and PPD use was seen in radiation-free men. Irradiated men were less satisfied with the procedure at both short and long term follow up. Diminished efficacy and satisfaction occurred at extended follow up for both groups but was more pronounced with radiation. CONCLUSIONS: The majority of patients undergoing the AdVance sling procedure for post-prostatectomy urinary incontinence saw a significant reduction in pad use, and were overall satisfied in both radiated and non-radiated groups at short and long term follow up. However, improvements were greater in the non-radiated groups and diminished with time.

Novel pericatheter retrograde urethrogram technique is a viable method for postoperative urethroplasty imaging.

PURPOSE: The purpose of this study is to describe our technique for pericatheter retrograde urethrogram (pcRUG) and to evaluate the utility of a pcRUG to detect a clinically significant leak after urethral reconstruction. METHODS: We retrospectively reviewed our prospective IRB-approved database of patients undergoing urethral reconstruction. pcRUG was performed at 3-4 weeks after surgery, in standardized fashion. Patients were placed in oblique position, and with the penis stretched, diluted contrast was instilled via an angiocatheter alongside the indwelling urethral catheter under dynamic fluoroscopy. The image was then evaluated for the presence of any contrast extravasation. Patient with and without extravasation seen on initial pcRUG were compared. RESULTS: From September 2012 through February 2017, 144 pericatheter retrograde urethrograms were performed on 130 patients. 115 patients (88.5%) had no extravasation on pcRUG. Fifteen patients (11.5%) demonstrated extravasation, with 13 of those patients (10%) undergoing a repeat pcRUG. Patients with extravasation seen on initial pcRUG were more likely to have strictures that were panurethral (36 vs. 9%, p = 0.029) and ≥10 cm (43 vs. 11%, p = 0.016). One patient (0.8%) presented with urinary leak and scrotal abscess after a urethra was assessed as sufficiently healed at the initial pcRUG and the catheter removed. There were otherwise no infectious or procedural complications related to pericatheter retrograde urethrogram. CONCLUSIONS: Our pericatheter retrograde urethrogram technique is a safe and reproducible technique to effectively assess urethral healing after urethroplasty and determine timing of catheter removal. The pcRUG is minimally invasive and is comparable in accuracy and sensitivity to voiding cystourethrography and retrograde urethrography that have traditionally been used to assess healing after urethroplasty.