Long-term Renal Preservation and Complication Profile With Ileal Ureter Creation.

OBJECTIVE: To examine long-term ileal ureter replacement results at over 32 years at our institution. Long segment or proximal ureteral strictures pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, Boari flap, buccal ureteroplasty, and autotransplantation are common reconstructive techniques. We show that ileal ureter remains a lasting option. METHODS: We performed a retrospective review of patients undergoing open ileal ureter creation from 1989-2021. Patient demographics, operative history, and complications were examined. All patients were followed for changes in renal function. Demographic data were analyzed and Cox proportional hazard models were performed. RESULTS: One hundred and fifty-eight patients were identified with median follow-up time of 40 months. Eighty-one percent had a unilateral ileal ureter creation. Fifty percent were female, median age was 53.3. Twenty-seven percent of patients had radiation-induced strictures. Preoperatively, 56.3% of patients were chronic kidney disease stage 1-2 and 43.7% were stage 3-5. Post-operatively, 54% were stage 1-2 and 46% were stage 3-5. Cox proportional hazard models demonstrated no significant correlation between worsening renal function and stricture cause, bilateral repair, complications, or sex (biologically male or female). Seventy-seven percent had no 30-day complications. Clavien complications included grade 1 (18), grade 2 (4), grade 3 (9), and grade 4 (5). Long-term complications included worsening renal function (3%), incisional hernia (8.2%), and small bowel obstruction (6.9%). Five (3.1%) patients ultimately required dialysis and 5 (3.1%) patients developed metabolic acidosis. CONCLUSION: Ileal ureteral reconstruction is often a last resort for patients with complex ureteral injuries. Clinicians can be reassured by our long-term data that ileal ureteral creation is a safe treatment with good preservation of renal function and low risk of hemodialysis and metabolic acidosis.

Female Bladder Dysfunction Following Boari Bladder Flap Ureteral Reconstruction.

OBJECTIVE: To describe our institution's experience with Boari flap ureteral reconstruction, specifically focusing on the development of postoperative lower urinary tract symptoms (LUTS). METHODS: A retrospective review of all Boari flaps performed at our institution between 2013 and 2023 was performed, excluding patients with urothelial carcinoma and males, given the frequency of LUTS from benign prostatic hyperplasia. Primary outcome was the development of new onset LUTS and subsequent treatment. Secondary outcomes included postoperative infections and ureteral stricture. RESULTS: Twenty-nine total patients were identified. Mean age was 52.2 years (standard deviation (SD) 13.1). Mean follow-up was 22.3 months (SD 25.3). Primary reasons for ureteral reconstruction were radiation damage (37.9%) and iatrogenic surgical injury (37.9%). A concurrent psoas hitch was performed in 18/29 (62%) cases, nephropexy was utilized in 1/29 (3.4%) cases, and contralateral bladder pedicles were ligated in 10/29 (34.5%) for increased bladder mobilization. Postoperatively, 8 patients (27.6%) developed new-onset LUTS, effectively managed with oral anticholinergics. Recurrent urinary tract infections occurred in 5 patients (17.2%) and pyelonephritis in 1 (3.4%) patient. Two patients (6.9%) developed ureteral strictures, one treated with ileal ureter replacement and the other with ureteral balloon dilation. CONCLUSION: Boari bladder flap ureteral reconstruction leads to moderate rates of new onset LUTS postoperatively, which is important information when counseling women on reconstructive options. Boari flap ureteral reconstruction has a high success rate, and serious complications are rare. In the setting of ureteral injury, reconstruction using Boari flaps with or without psoas hitch should be considered for definitive management.

Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study.

OBJECTIVES: Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose. METHODS: Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0. RESULTS: A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05). CONCLUSIONS: There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

A review of the literature and proposed algorithm for penile fracture management.

INTRODUCTION: In the management of penile fractures, immediate surgical repair has resulted in better outcomes when compared with a conservative approach; however, there is currently no consensus on the treatment of patients presenting beyond the immediate period (>24 hours) following injury. OBJECTIVES: To examine the latest literature on management strategies in penile fracture and propose an optimal algorithm for the treatment of patients with delayed presentation. METHODS: A comprehensive search was conducted following the PRISMA-P 2020 guidelines. A search was performed in several databases with the following strategy: ("Penile fracture" OR "fracture of penis" OR "rupture of corpora cavernosa" OR "rupture of tunica albuginea") AND (management OR treatment OR surgery OR "surgical reconstruction" OR "surgical repair"). This resulted in 108 relevant articles. Two independent reviewers screened these articles according to the inclusion criteria. Full-text review of 56 articles was performed, and ultimately 20 studies were selected. Measures included the use of diagnostic imaging, timing of surgical repair (immediate, <24 hours after injury; delayed, >24 hours), surgical approach, and long-term complications (ie, erectile dysfunction and penile curvature). RESULTS: The review highlighted the benefits of immediate surgical repair in penile fractures, demonstrating improved patient outcomes. Furthermore, it found that surgical repair should be considered even in cases with delayed presentation (>24 hours after injury). To better evaluate the long-term impact of delayed surgical intervention on patient outcomes, we recommend standardized postoperative follow-up, with routine assessments of erectile function and penile curvature. CONCLUSION: Contemporary literature suggests that immediate and delayed surgical repair of penile fractures leads to adequate postoperative outcomes, and patients presenting >24 hours after injury should still be considered for surgery.

A contemporary review of the treatments and challenges associated with penile rehabilitation after radical prostatectomy including a proposed optimal approach.

Prostate cancer is one of the most prevalent malignancies affecting men worldwide. Despite advancements in understanding prostate anatomy and minimally invasive approaches to surgical treatment, surgery can have significant adverse effects on sexual function. Penile rehabilitation strategies have emerged as a promising approach to mitigate the impact of prostate cancer treatments on erectile function and improve quality of life. Several methods have been employed for penile rehabilitation, including pharmacotherapy, vacuum erection devices, intracavernous injections, and emerging novel techniques. Yet, there is no consensus on the exact programs or timing of initiation that should be utilized for optimal recovery after surgery. This review discusses various rehabilitation protocols and long-term outcomes and explores the cost-effectiveness of different interventions. Additionally, this review discusses the importance of a multidisciplinary approach to penile rehabilitation which includes patient education, counseling, and the selection of an appropriate rehabilitation strategy tailored to each individual's needs and preferences. Continued research and collaboration among healthcare professionals are essential to refine rehabilitation approaches and ensure optimal outcomes for patients with prostate cancer.

Ileal Ureter Utilization in Patients With Previous Urinary Diversions.

OBJECTIVE: To evaluate a subset of patients who develop strictures requiring Ileal Ureter (IU) in the setting of prior urinary diversion or augmentation (ileal conduits, neobladders, continent urinary diversions). To our knowledge, there are no prior studies on patients with IU substitution into established lower urinary tract reconstructions. METHODS: A retrospective review of patients (18 years) undergoing IU creation from 1989 to 2021 was performed. A total of 160 patients were identified. In total, 19 (12%) patients had IUs into diversions. We examined demographics, stricture cause, diversion type, renal function, and postoperative complications. RESULTS: Nineteen patients were identified. Sixteen were male. Mean age was 57.7(SD 17.0) years. Diversions included continent urinary reservoirs (4), neobladders (5), ileal conduits (7), and bladder augmentations with Monti channels (3). Fifteen had unilateral surgery, and 4 had bilateral "reverse 7" IU creation. Average length of stay was 7.6 days (SD 2.9). Average follow-up was 32.9 months (SD 27). Mean preoperative creatinine was 1.5 (SD 0.4); mean postoperative creatinine at most recent follow-up was 1.6 (SD 0.7). There was no significant difference between pre- and postoperative creatinine (P = .18). One patient had a ventriculoperitoneal Shunt infection resulting ventriculoperitoneal shunt externalization, 1 had Clostridium difficile infection potentially causing an entero-neobladder fistula, 2 with ileus, 1 urine leak, and 1 wound infection. None required renal replacement therapy. CONCLUSION: Patients with urinary diversions and prior bowel reconstructive surgeries with subsequent ureteral strictures are a challenging cohort of patients. In properly selected patients, ureteral reconstruction with ileum is feasible and preserves renal function with minimal long-term complications.

Sarcoidosis: A rare cause of penile edema.

Reports of penile sarcoidosis are rare in the literature. We describe the case of a male who presented with several months of distal penile swelling and progressive inability to retract the foreskin. Firm, non-tender subcutaneous nodules were palpated near the base of the penis. The patient ultimately underwent penile skin resection, partial scrotal resection, and split thickness skin graft to the penis after failing multiple conservative treatments. Pathology revealed non-caseating granulomatous lesions which in addition to CT chest findings of bilateral hilar adenopathy suggested a diagnosis of penile sarcoidosis.

The role of urethral ligation after AUS failure and end stage urethra.

PURPOSE: To provide our single-center experience with an approach to refractory stress urinary incontinence (SUI) with permanent urethral ligation (PUL) and suprapubic tube (SPT) placement, in hopes of contributing to the limited body of research surrounding this surgical treatment option for patients with end-stage urethra (ESU). METHODS: All patients undergoing PUL with SPT placement from 01/01/2018 to 04/30/2022 were identified from an institutional database. Institutional Review Board exempt status was granted for the conduct of this study. Patients were seen postoperatively at 1 month and 1 year. If there were any concerns of incontinence, an antegrade urethrogram via the SPT was performed. Descriptive statistics were used to evaluate patients. RESULTS: Seven patients underwent PUL with SPT in our timeframe and were included in the study. All patients previously had an AUS placed, and two patients had a urethral sling previously placed. The median follow-up time was 21 months, ranging between 2 and 48 months. Complications included bladder spasms (43%) and continued leakage per urethra (14%). Of the 7 patients, 6 have reported continence through their urethra at their most recent follow-up. CONCLUSION: This initial data suggest that PUL with SPT placement may be a viable surgical approach to treating refractory SUI, especially for patients with ESU who wish to avoid the morbidity associated with more formal supravesical diversion. Further study of this technique and longer follow-up is required to determine its long-term efficacy and tolerability for patients.

Frailty in Surgical Patients: Is it Relevant to Sexual Medicine?

BACKGROUND: As the age of our surgical population continues to rise, there is an increased need for adequate preoperative evaluation and risk stratification to ensure the best possible surgical outcomes for patients. AIM: We sought to describe the 3 main models currently used to evaluate patient frailty and explore how they are being utilized in the field of surgery and sexual medicine. METHODS: We reviewed online resources including Pubmed with relevant search criteria centered around frailty, surgery, sexual medicine, and prosthetics. OUTCOMES/RESULTS: All relevant studies were reviewed and several models for patient frailty emerged; the Phenotype Model, the Frailty Index, the Clinical Frailty Scale, and the modified Frailty Index. Worse frailty indices were seen to be linked to higher rates of complications and mortalities postoperatively. CLINICAL IMPLICATIONS: Although the adoption of patient frailty in the field of sexual medicine has been sluggish, few studies have shown that its use could help predict which patients are at increased risk of complications and may require more support when it comes to postoperative care and teaching. STRENGTH & LIMITATIONS: Overall there is a paucity of literature as it relates to sexual medicine and patient frailty and this paper provides a limited look at the usage of patient frailty in sexual medicine. CONCLUSION: We implore all sexual health providers to begin to incorporate frailty metrics when caring for this population to help reduce postoperative complications and help better predict surgical success. Burns RT and Bernie HL, Frailty in Surgical Patients: Is it Relevant to Sexual Medicine?. J Sex Med 2022;19:401-403.