Impact of Health Literacy on Satisfaction Following Male Prosthetic Surgery.

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

Are postoperative antibiotics necessary after artificial urinary sphincter insertion?

INTRODUCTION We sought to explore whether patients discharged without antibiotics after artificial urinary sphincter (AUS) insertion were more likely to require device explantation for infection or erosion compared to patients discharged with antibiotics at our institution and compared to patients in other large, contemporary series. MATERIALS AND METHODS: AUS insertions performed at our institution between 2013 and 2017 were retrospectively reviewed to determine demographics, comorbidities, and perioperative and medium-term outcomes. Patients were grouped based on 1) known risk factors for infectious complications or erosion and 2) postoperative antibiotic prescription status. Patients were placed in Group 1 if they did not demonstrate risk factors and did not receive postoperative antibiotics, Group 2 if they did possess risk factors but did not receive postoperative antibiotics, and Group 3 if they had risk factors and received postoperative antibiotics. RESULTS: Of the 155 men who met inclusion criteria, 44, 47, and 64 were categorized in Groups 1, 2, and 3, respectively. Median (IQR) follow up was similar across Groups 1, 2, and 3 (12.7 [4.6-25.1] versus 10.7 [4.5-31.3] versus 8.3 [4.4-26.4] months, p = 0.808). Rates of explantation due to device infection (0 versus 2 versus 6%, p = 0.172) or cuff erosion (2 versus 2 versus 8%, p = 0.253) did not vary significantly between Groups 1-3. CONCLUSIONS: Patients undergoing AUS insertion may be unlikely to benefit from the routine administration of postoperative antibiotics. In light of the known consequences of antibiotic overuse, a randomized controlled trial is warranted.

Minimal Inpatient Narcotic Requirement and Immediate Complication Profile Supports Same Day Discharge Following Artificial Urinary Sphincter Insertion.

INTRODUCTION: With more than 3,500 artificial urinary sphincters placed annually in the United States a significant cost burden is associated with overnight observation following surgery. We sought to determine whether inpatient management after artificial urinary sphincter insertion, our current local standard of care, is necessary with regards to inpatient narcotic requirements and immediate postoperative complications. METHODS: This was an institutional review board approved, retrospective review of artificial urinary sphincter insertions identified by CPT code 53445 between June 2013 and September 2017. Medical records were reviewed for patient demographics, postoperative narcotic use and immediate postoperative complications. RESULTS: We identified 163 men who underwent artificial urinary sphincter insertion for analysis. The cohort had a mean age of 69.8 ± 8.5 years, body mass index of 28.9 ± 5.1 kg/m2 and preoperative pad per day use of 5.8 ± 3.5. Of all patients identified 25 (15%) were using chronic narcotic pain medication preoperatively and 51 (31%) had a diagnosis of diabetes (mean A1c 7.0 ± 1.5%). All but 1 (99%) patients were discharged on the first postoperative day and 1 left on the second postoperative day. Two (1.2%) patients experienced immediate postoperative complication, and 8 (6%) patients failed a voiding trial on postoperative day 1. The 154 (94%) patients who required orally administrated narcotic pain medication after leaving the postanesthesia care unit used a median of 31.0 ± 22.9 morphine milligram equivalents. CONCLUSIONS: Immediate postoperative and peridischarge complication rates are around 1% after artificial urinary sphincter insertion, and narcotic requirements following postanesthesia care unit stay are minimal. Outpatient artificial urinary sphincter insertion is likely to be safe, effective and beneficial with regards to patient experience and total costs.

Penile Prosthesis Insertion in the Era of Antibiotic Stewardship-Are Postoperative Antibiotics Necessary?

PURPOSE: We sought to determine whether patients discharged from the hospital without antibiotics after inflatable penile prosthesis insertion were at increased risk for infectious complications compared to patients at our institution discharged with oral antibiotics and patients in other contemporary series. MATERIALS AND METHODS: We reviewed the medical records of patients who underwent inflatable penile prosthesis insertion from 2013 through 2017. Group 1 patients had no risk factors for infectious complications and did not receive postoperative antibiotics. Group 2 patients had risk factors for infectious complications but did not receive postoperative antibiotics. Group 3 patients had risk factors for infectious complications and received postoperative antibiotics. RESULTS: Of the 222 men who met study inclusion criteria 88 (40%) were in group 1, 48 (21%) were in group 2 and 86 (39%) were in group 3. The mean ± SD number of risk factors for infection was lower in group 2 than in group 3 (1.08 ± 0.28 vs 1.24 ± 0.46, p = 0.013). Median followup did not vary among groups 1, 2 and 3 (4.6 months, IQR 1.8-7.2; 3.5, IQR 1.4-6.9; and 4.5, IQR 1.4-7.4; p = 0.146, respectively). Rates of explantation due to device infection (0% vs 4% vs 5%, p = 0.130) and nonoperative infectious complications (1% vs 2% vs 2%, p = 0.829) did not vary among groups 1 to 3, respectively. CONCLUSIONS: Patients who undergo inflatable penile prosthesis insertion appeared unlikely to benefit from routine administration of postoperative antibiotics. In the current era of antibiotic stewardship these findings have the potential for substantial individual and population health benefits.

Impact of Radiation and Transcorporeal Artificial Sphincter Placement in Patients with Prior Urethral Cuff Erosion: Results from a Retrospective Multicenter Analysis.

PURPOSE: Many providers elect to use a transcorporeal approach for artificial urinary sphincter placement in an attempt to minimize risks, given the increased risk of complications in revision cases. We present outcomes in a multicenter retrospective analysis of artificial urinary sphincter cuff reimplantation in patients with prior cuff erosion with special consideration given to the transcorporeal approach. MATERIALS AND METHODS: We compiled a multi-institutional database of patients who underwent artificial urinary sphincter reimplantation after prior urethral erosion. Of the 34 identified patients 24 underwent transcorporeal cuff replacement. Patients with transcorporeal cuff replacement were further analyzed with specific stratification for radiation therapy. RESULTS: The rate of subsequent complications after eroded cuff reimplantation was 32.4% (11 of 34 patients). The most frequent complication was recurrent erosion, which developed in 9 of the 34 patients (26.4%). Repeat artificial urinary sphincter complications developed more frequently in patients with history of radiation compared to nonirradiated patients (8 of 16 or 50% vs 3 of 18 or 16.7%). However, this difference was not statistically significant (p = 0.066). The transcorporeal technique was applied in 24 of 33 patients (70.5%) and relative to the nontranscorporeal group there was no difference in the complication rate (p = 0.438). On subgroup analysis of the transcorporeal group there was a higher rate of repeat complications in irradiated patients (p = 0.006). CONCLUSIONS: These data suggest that transcorporeal cuff reimplantation may not decrease the incidence of repeat complications after prior cuff erosion. However, radiation therapy is associated with a worse outcome even when transcorporeal cuff placement is performed.

Prior Radiation Therapy Decreases Time to Idiopathic Erosion of Artificial Urinary Sphincter: A Multi-Institutional Analysis.

PURPOSE: Substantial controversy and conflicting data exist regarding the survival of the artificial urinary sphincter in patients with prior radiation therapy. We present data from a multi-institutional analysis examining the effect of prior radiation for prostate cancer on device survival. MATERIALS AND METHODS: A database was compiled of patients with artificial urinary sphincter cuff erosion, which included demographic and comorbid patient characteristics, functional analyses and interventions. We identified 80 patients with iatrogenic or idiopathic artificial urinary sphincter erosion. Idiopathic erosion cases were further analyzed to determine factors influencing device survival with specific stratification for radiation therapy. RESULTS: A total of 56 patients were identified with idiopathic artificial urinary sphincter erosion. Of those men 33 (58.9%) had not undergone radiation treatment while 23 (41.1%) had a history of brachytherapy or external beam radiotherapy. In patients without radiation erosion-free median device survival was 3.15 years (95% CI 1.95-5.80), in contrast to the median device survival of only 1.00 year (95% CI 0.36-3.00) in irradiated patients. The erosion-free survival experience of patients with vs without radiation differed significantly (Wilcoxon-Breslow test for equality of survivor functions p = 0.03). CONCLUSIONS: Radiation therapy in patients with known idiopathic cuff erosion in this contemporary analysis correlated with significantly increased time to erosion. Mean time to idiopathic cuff erosion was accelerated by approximately 2 years in irradiated cases. To our knowledge these data represent the first demonstration of substantial outcome differences associated with radiation in patients with an artificial urinary sphincter who present specifically with cuff erosion.

Erectile Dysfunction Following Pelvic Fracture Urethral Injury.

INTRODUCTION: Although pelvic fracture urethral injuries (PFUIs) are rare, approximately half these patients will report erectile dysfunction (ED) after their injuries. The anatomic relations of the cavernosal nerves and arteries to the bones of the pelvis and the urethra put these structures at significant risk at the time of PFUI. This review examines the epidemiology, evaluation, and management of ED in this patient population. AIM: To evaluate the epidemiology, pathophysiology, diagnosis, and management of patients with ED after PFUI. METHODS: A literature review was performed to identify articles on PubMed published before May 2017 addressing PFUI and ED. MAIN OUTCOME MEASURES: Incidence, mechanisms, risk factors, evaluation, and management strategies of ED after PFUI were analyzed. RESULTS: Patients with pelvic fractures are at risk of post-injury ED, whereas those with PFUI appear to be at even higher risk. Different potential mechanisms contributing to the pathophysiology of ED in this setting have been described in the literature, including damage to the nervous supply to the penis, arterial insufficiency, and veno-occlusive dysfunction. However, there is a lack of consensus on the predominant etiology. Appropriate diagnostic evaluation can help to elucidate the underlying pathophysiology on an individual basis and can help guide management. Oral therapies, intracavernosal injections, and inflatable penile prostheses have shown great success. Furthermore, unlike patients with ED from other causes, select patients with isolated arteriogenic ED are potentially eligible for penile revascularization procedures. CONCLUSION: Because most patients with pelvic trauma are younger than 40 years with a significant life expectancy, appropriate diagnosis and management of ED after PFUI can greatly improve quality of life and allow resumption of post-injury sexual function. Identification of the causative pathology can help tailor treatment on an individual basis. Johnsen NV, Kaufman MR, Dmochowski RR, Milam DF. Erectile Dysfunction Following Pelvic Fracture Urethral Injury. Sex Med Rev 2018;6;114-123.

Desmopressin acetate nasal spray for adults with nocturia.

INTRODUCTION: Nocturia impacts 70% of individuals over age 70 years. Nocturnal polyuria is present in up to 88% of adults with nocturia, however, treatment options for reducing nighttime urine production have historically been limited to behavioral modification and off label use of timed diuretics and desmopressin. NoctivaTM (desmopressin acetate nasal spray, DANS, Serenity Pharmaceuticals, LLC) is a novel formulation of desmopressin approved by the Food and Drug Administration for the treatment of nocturia due to nocturnal polyuria in March 2017. Areas covered: Incidence and etiology of nocturia, currently available therapies (approved and off label), and pharmacokinetic, efficacy, and safety data associated with DANS. Expert commentary: DANS has been studied for the treatment of nocturia in adults over age 50 without contraindications to the use of desmopressin. 49% receiving the higher clinical dose experienced ≥50% reduction in nocturnal voids in clinical trials vs. 30% with placebo. Although nadir serum sodium <135 mmol/L was not uncommon (14%), the incidence of sodium ≤125 mmol/L was rare (1%). DANS therefore appears to benefit a significant subset of patients with nocturia while maintaining an acceptable risk profile. Given the risks of hyponatremia, education of patients and prescribers in contraindications and the importance of monitoring are paramount.

Postoperative Complications of Patients With Spina Bifida Undergoing Urologic Laparotomy: A Multi-institutional Analysis.

OBJECTIVE: To characterize perioperative morbidity and mortality in adult patients with spina bifida undergoing laparotomy. PATIENTS AND METHODS: We retrospectively studied the postoperative complications of 59 operations of patients with spina bifida undergoing abdominal laparotomies for urologic indications at 3 institutions. We evaluated postoperative complications using the Clavien-Dindo classification scale. RESULTS: The overall complication rate was 91.5%. The most common complications were ileus, pressure ulcers, urinary tract infection, and wound infection. Over 40% of the patients developed a class 3 or 4 complication requiring subsequent surgery or intensive care unit admission. The hospital readmission rate was 42% and was correlated with higher-grade complications. On multivariable analysis, only older age was significantly associated with grade of complication. CONCLUSION: These data demonstrate that adult patients with spina bifida comprise a unique population that faces an extremely high surgical risk even in centers of excellence. As patients with spina bifida live longer lives, thanks to modern medicine, there is a timely opportunity for research on perioperative management in these patients to improve postsurgical outcomes.

Cost-effective management of pelvic fracture urethral injuries.

PURPOSE: To compare the cost-effectiveness of various treatment strategies in the management of pelvic fracture urethral injuries using decision analysis. METHODS: Five strategies were modeled from the time of injury to resolution of obstructed voiding or progression to urethroplasty. Management consisted of immediate suprapubic tube (SPT) placement and delayed urethroplasty; primary endoscopic realignment (PER) followed by urethroplasty in failed patients; or PER followed by 1-3 direct vision internal urethrotomies (DVIU), followed by urethroplasty. Success rates were obtained from the literature. Total medical costs were estimated and incremental cost-effectiveness ratios (ICERs) were generated over a 2-year follow-up period. RESULTS: PER was preferred over SPT placement in all iterations of the model. PER followed by a single DVIU and urethroplasty in cases of failure was least costly and used as the referent approach with an average cost-effectiveness of $17,493 per unobstructed voider. The ICER of a second DVIU prior to urethroplasty was $86,280 per unobstructed voider, while the ICER of a third DVIU was $172,205. The model was sensitive to changes in the success rate of the first DVIU, where when the probability of DVIU success is expected to be less than 32% immediate urethroplasty after failed PER is favored. CONCLUSIONS: Management of pelvic fracture urethral injuries with PER is the preferred management strategy according to the current model. For those who fail PER, a single DVIU may be attempted if the presumed success rate is >32%. In all other cases, urethroplasty following PER is the preferred approach.

Urethral Stricture Outcomes After Artificial Urinary Sphincter Cuff Erosion: Results From a Multicenter Retrospective Analysis.

OBJECTIVE: To evaluate the influence of both repair type and degree of cuff erosion on postoperative urethral stricture rate. Sparse literature exists regarding patient outcomes after artificial urinary sphincter (AUS) cuff erosion. Surgeons from 6 high-volume male continence centers compiled a comprehensive database of post-erosion patients to examine outcomes. MATERIALS AND METHODS: This retrospective multi-institution study included 80 patients treated for AUS cuff erosions. Seventy-eight patients had specific information regarding post-cuff erosion urethral strictures. Erosion patients were categorized into 1 of 3 repair types at the time of explant surgery: catheter only, single-layer capsule-to-capsule repair (urethrorrhaphy), and formal urethroplasty. Operative notes and available medical records were extensively reviewed to collect study data. RESULTS: Twenty-five of 78 patients manifested a urethral stricture after AUS cuff erosion (32%). More strictures occurred among patients who underwent urethrorrhaphy (40% vs 29% for catheter only and 14% for urethroplasty). Stricture rates did not vary significantly by repair type (P = .2). Strictures occurred significantly more frequently in patients with complete cuff erosions (58%) as compared to partial erosions (25%, P = .037). A trend was detected regarding increased percentage of erosion correlating with increased stricture rate, but this did not reach statistical significance (P = .057). Partially eroded patients were more likely to undergo urethrorrhaphy repair (60%, P = .002). CONCLUSION: Urethral stricture was more likely to occur after complete cuff erosion as opposed to partial erosion in this multicenter retrospective population. Repair type, whether catheter only, urethrorrhaphy, or formal urethroplasty, did not appear to influence postoperative stricture rate.

Overactive bladder and autonomic dysfunction: Lower urinary tract symptoms in females with postural tachycardia syndrome.

AIMS: Postural Tachycardia Syndrome (POTS) represents an autonomic disorder predominantly affecting females between 15 and 50 years of age. POTS is a chronic disorder (>6 months) characterized by an excessive heart rate increment on standing (>30 beats/min) in the presence of characteristic symptoms of cerebral hypoperfusion or sympathetic activation. Patients have clinically been noted to describe lower urinary tract symptoms (LUTS), although urologic symptoms have not been methodically assessed in the POTS population. Herein, we present data from a pilot study designed to identify and quantitate overactive bladder (OAB) in patients diagnosed with POTS. METHODS: Patients admitted to the Vanderbilt Autonomic Dysfunction Center between June 2009 and October 2010 for evaluation for the potential diagnosis of POTS completed a validated, standardized questionnaire for OAB (OAB-q) at presentation. Symptom score and subscale analyses were conducted. Subscale health related quality of life (HRQL) scores were transformed into a 0-100 scale, with higher scores reflecting superior HRQL. Data are presented as mean ± SD. RESULTS: Thirty-two females presented for evaluation of symptoms consistent with POTS. Twenty-nine women were subsequently diagnosed with POTS with 19 of these patients completing the OAB-q questionnaire (65.5% response rate). Average age was 33.5 ± 8.3 years. Symptom severity transformed score was 26.0 ± 16.4, with 13 of 19 patients (68.4%) meeting clinical criteria for diagnosis of probable clinically significant OAB. Nocturia was the most bothersome symptom, followed by increased daytime frequency and urgency. CONCLUSIONS: This pilot study describes bothersome lower urinary tract dysfunction in patients presenting with POTS as assessed by patient-reported questionnaire data. Nocturia demonstrated the greatest negative impact on health-related quality of life (HRQL), while social interaction was the least affected HRQL domain. In patients with dysautonomia, this data provides a critical baseline for mechanistic insight into both disease-specific and global pathophysiology of nocturia and OAB. Neurourol. Urodynam. 36:610-613, 2017. © 2016 Wiley Periodicals, Inc.

Evaluation of the axonics modulation technologies sacral neuromodulation system for the treatment of urinary and fecal dysfunction.

INTRODUCTION: Sacral neuromodulation (SNM) remains one of the few effective treatments for refractory bladder and bowel dysfunction. However, SNM is associated with frequent need for surgical intervention, in many cases because of a failed battery. A rechargeable SNM system, with a manufacturer-reported battery life of 15 years or more, has entered post-market clinical testing in Europe but has not yet been approved for clinical testing in the United States. Areas covered: We review existing neuromodulation technologies for the treatment of lower urinary tract and bowel dysfunction and explore the limitations of available technology. In addition, we discuss implantation technique and device specifications and programming of the rechargeable SNM system in detail. Lastly, we present existing evidence for the use of SNM in bladder and bowel dysfunction and evaluate the anticipated trajectory of neuromodulation technologies over the next five years. Expert commentary: A rechargeable system for SNM is a welcome technological advance. However surgical revision not related to battery changes is not uncommon. Therefore, while a rechargeable system would be expected to reduce costs, it will not eliminate the ongoing maintenance associated with neuromodulation. No matter the apparent benefits, all new technologies require extensive post-market monitoring to ensure safety and efficacy.

An update on the use of transdermal oxybutynin in the management of overactive bladder disorder.

Antimuscarinic medications are used to treat nonneurogenic overactive bladder refractory to nonpharmacologic therapy. Side effects such as dry mouth, constipation, blurred vision, dizziness, and impaired cognition limit the tolerability of therapy and are largely responsible for high discontinuation rates. Oxybutynin is a potent muscarinic receptor antagonist whose primary metabolite after first-pass hepatic metabolism is considered largely responsible for its associated anticholinergic side effects. Transdermal administration of medications bypasses hepatic processing. Specifically with oxybutynin, whose low molecular weight permits transdermal administration, bioavailability of the parent drug with oral administration is less than 10%, whereas with transdermal delivery is a minimum of 80%. The result has been an improved side effect profile in multiple clinical trials with maintained efficacy relative to placebo; however, the drug may still be discontinued by patients due to anticholinergic side effects and application site reactions. Transdermal oxybutynin is available as a patch that is changed every 3-4 days, a gel available in individual sachets, or via a metered-dose pump that is applied daily. The transdermal patch was briefly available as an over-the-counter medication for adult women, although at this time all transdermal formulations are available by prescription only.

Evaluating the Role of Operative Repair of Extraperitoneal Bladder Rupture Following Blunt Pelvic Trauma.

PURPOSE: Catheter drainage has become a standard management strategy for extraperitoneal bladder rupture from blunt trauma. However, data are lacking critically comparing outcomes between operative and nonoperative management. In this study we evaluate management strategies and identify risk factors for complications. MATERIALS AND METHODS: Patients with uncomplicated extraperitoneal bladder rupture due to blunt trauma from 2000 to 2014 were identified from our trauma registry. Initial management consisted of early cystorrhaphy or catheter drainage. Outcomes analyzed were incidence of inpatient complications, length of stay and time to negative cystography. Subgroup analysis was performed comparing outcomes between patients who did vs did not undergo cystorrhaphy during nonurological operative intervention. RESULTS: A total of 56 patients treated with catheter drainage and 24 who underwent early cystorrhaphy were identified. All early cystorrhaphies were performed as secondary procedures during nonurological interventions. There was no difference in demographics, complications, median intensive care unit or median hospital length of stay between the groups. Subgroup analysis comparing patients who did vs did not undergo cystorrhaphy during nonurological operative intervention showed that patients without cystorrhaphy experienced higher rates of urological complications (p <0.05), increased intensive care unit (9.0 vs 4.0 days, p=0.0219) and hospital (18.9 vs 10.6 days, p=0.0229) length of stay, as well as prolonged time to negative cystography (25.5 vs 20.0 days, p=0.0262). CONCLUSIONS: Conservative management of simple extraperitoneal bladder rupture with catheter drainage alone results in equivalent outcomes relative to operative repair in most patients. However, for those undergoing operations for other indications, cystorrhaphy decreases the risk of complications and is associated with decreased intensive care unit and hospital length of stay.

Lower HIV Risk Among Circumcised Men Who Have Sex With Men in China: Interaction With Anal Sex Role in a Cross-Sectional Study.

BACKGROUND: Voluntary medical male circumcision reduces the risk of HIV heterosexual transmission in men, but its effect on male-to-male sexual transmission is uncertain. METHODS: Circumcision status of men who have sex with men (MSM) in China was evaluated by genital examination and self-report; anal sexual role was assessed by questionnaire interview. Serostatus for HIV and syphilis was confirmed. RESULTS: Among 1155 participants (242 were seropositive and 913 with unknown HIV status at enrollment), the circumcision rate by self-report (10.4%) was higher than confirmed by genital examination (8.2%). Male circumcision (by examination) was associated with 47% lower odds of being HIV seropositive [adjusted odds ratio (aOR): 0.53; 95% confidence interval (CI): 0.27 to 1.02] after adjusting for demographic covariates, number of lifetime male sexual partners, and anal sex role. Among MSM who predominantly practiced insertive anal sex, circumcised men had 62% lower odds of HIV infection than those who were uncircumcised (aOR: 0.38; 95% CI: 0.09 to 1.64). Among those whose anal sex position was predominantly receptive or versatile, circumcised men have 46% lower odds of HIV infection than did men who were not circumcised (aOR: 0.54; 95% CI: 0.25 to 1.14). Compared to uncircumcised men reporting versatile or predominantly receptive anal sex positioning, those who were circumcised and reported practicing insertive sex had an 85% lower risk (aOR: 0.15; 95% CI: 0.04 to 0.65). Circumcision was not associated clearly with lower syphilis risk (aOR: 0.91; 95% CI: 0.51 to 1.61). CONCLUSIONS: Circumcised MSM were less likely to have acquired HIV, most pronounced among men predominantly practicing insertive anal intercourse. A clinical trial is needed.

The Impact of Urethral Risk Factors on Transcorporeal Artificial Urinary Sphincter Erosion Rates and Device Survival.

PURPOSE: We report the impact of urethral risk factors on erosion rates and device survival outcomes after transcorporeal artificial urinary sphincter placement. MATERIALS AND METHODS: We performed a retrospective analysis of all transcorporeal artificial urinary sphincters placed at a single institution between January 2000 and May 2014. We assessed patient demographic, comorbid diseases and surgical characteristics for risk factors considered poor for device survival. Risk factors were compared to postoperative complications requiring explantation, including cuff erosion, infection and device revision. RESULTS: A total of 37 transcorporeal artificial urinary sphincters were placed in 35 men. Placement was performed as a primary procedure in 21 of 37 cases (56.8%) and as salvage in the remainder. In this transcorporeal population there were 7 explantations (18.9%) due to erosion in 4 cases, cuff downsizing in 2 and infection in 1. Median followup from implantation to last followup was 8.5 months (range 0.9 to 63). Median time from artificial urinary sphincter placement to explantation was 17.3 months (range 0.9 to 63) and time specifically to transcorporeal erosion was 7.4 months (range 0.9 to 26). On univariate analysis no parameters were associated with sphincter cuff erosion but a history of an inflatable penile prosthesis was associated with a higher device explantation rate (60% vs 12.5%, p=0.04). No associations were revealed on multivariate logistic analysis. All 4 cuff erosion cases demonstrated greater than 2 urethral risk factors, including prior radiation therapy in all. The probability of cuff erosion in patients with 2 or more urethral risk factors was 1.65 times the probability of erosion in those with 0 or 1 urethral risk factor (95% CI 1.3, 2.2). The proportion of patients free of erosion at 35 months was 100% in those with 0 or 1 urethral risk factor and 64% in those with 2 or more risk factors (log rank test p=0.00). Similarly the proportion of patients free of explantation at 35 months was 100% in those with 0 or 1 urethral risk factor and 52% in those with 2 or more (log rank test p=0.02). CONCLUSIONS: Transcorporeal artificial urinary sphincter implantation is generally reserved for complex and high risk cases but favorable functional results were demonstrated. However, patients with multiple urethral risk factors face a higher risk of erosion and device loss.

Primary Endoscopic Realignment of Urethral Disruption Injuries--A Double-Edged Sword?

PURPOSE: Controversy remains regarding initial management of traumatic urethral disruption injuries. We evaluated the outcomes of primary endoscopic realignment vs suprapubic tube placement in this patient population. MATERIALS AND METHODS: We reviewed our urological trauma database for patients with blunt trauma related posterior urethral injuries from 2000 to 2014. Patients underwent primary endoscopic realignment or suprapubic tube placement alone. The primary outcome was the success of primary realignment, defined as no further need for urological intervention. Secondary outcomes were the need for endoscopic interventions and/or urethroplasty, time to urethroplasty, urethroplasty success and long-term functional outcomes. RESULTS: A total of 27 patients underwent primary realignment and 14 underwent suprapubic tube placement. Mean followup was 40 months (median 24, range 1 to 152). Realignment was successful in 10 patients (37%) at a mean followup of 67.3 weeks (median 27.3, range 4 to 284). In the 17 cases (63%) that failed mean time to failure was 9.7 weeks (median 8.5, range 1 to 26). Seven patients (26%) treated with realignment and 11 (79%) with a suprapubic tube proceeded to urethroplasty. Mean ± SD time to urethroplasty was significantly shorter in the suprapubic tube group (14.6 ± 7.6 vs 5.8 ± 1.6 months, p = 0.003). There was no difference in operative time, complications, success or functional outcomes. CONCLUSIONS: Management of traumatic urethral disruption injuries by primary endoscopic realignment serves as definitive therapy in more than a third of treated patients. It prevents the need for formal urethroplasty in more than half of failed cases.

Urinary diversions after radiation for prostate cancer: indications and treatment.

OBJECTIVE: To characterize the presentation and symptom progression culminating in urinary diversion after radiotherapy for prostate cancer at a tertiary care reconstructive urology practice. MATERIALS AND METHODS: Retrospective review of electronic medical records was performed for all patients between 2005 and 2011 who underwent urinary diversion for urologic complications of radiation therapy for treatment of prostate cancer. We analyzed demographics, type of radiation, presenting symptoms, diagnostic evaluation, and surgical interventions. RESULTS: Of the 30 patients identified, 20% underwent external beam radiotherapy, 37% underwent brachytherapy, and 43% underwent combination therapy. Average time from radiation treatment until presentation to our institution was 4.6 years. Overall indications for urinary diversion included fistula (37%), end-stage bladder (20%), devastated outlet (27%), and a combination of end-stage bladder and devastated outlet (17%). Types of urinary diversion included cystectomy with conduit diversion, conduit diversion alone, and chronic indwelling suprapubic catheter. Eight patients additionally required bowel diversion for intractable gastrointestinal symptoms. Patients underwent an average of 4.4 procedures attempting to salvage native voiding function before urinary diversion. CONCLUSION: The reported need for urinary diversion after radiation therapy for prostate cancer is rare and thus indications have not been well characterized. We found that all of our patients with rectourethral fistula had prior placement of brachytherapy seeds. External beam radiotherapy resulted in a higher incidence of end-stage bladder dysfunction, whereas brachytherapy seed placement was more commonly associated with a devastated outlet. Surgical management for end-stage disease included cystectomy with conduit diversion, conduit diversion alone, and indwelling suprapubic catheter.