Predictors of persistent opioid use in bladder cancer patients undergoing radical cystectomy: A SEER-Medicare analysis.

PURPOSE: To evaluate patient and provider characteristics that predict persistent opioid use following radical cystectomy for bladder cancer including non-opioid naïve patients. METHODS: Patients undergoing cystectomy between July 2007 and December 2015 were identified using the SEER-Medicare database. Opioid exposure was identified before and after cystectomy using Medicare Part D data. Multivariable analyses were used to identify predictors of the primary outcomes: persistent opioid use (prescription 3-6 months after surgery) and postoperative opioid prescriptions (within 30 days of surgery). Secondary outcomes included physician prescribing practices and rates of persistent opioid use in their patient cohorts. RESULTS: A total of 1,774 patients were included; 29% had prior opioid exposure. Compared to opioid-naïve patients, non-opioid naïve patients were more frequently younger, Black, and living in less educated communities. The percentage of persistent postoperative use was 10% overall and 24% in non-opioid naïve patients. Adjusting for patient factors, opioid naïve individuals were less likely to develop persistent use (OR 0.23) while a 50-unit increase in oral morphine equivalent per day prescribed following surgery nearly doubled the likelihood of persistent use (OR 1.98). Practice factors such as hospital size, teaching affiliation, and hospital ownership failed to predict persistent use. 29% of patients filled an opioid prescription postoperatively. Opioid naïve patients (OR 0.13) and those cared for at government hospitals (OR 0.59) were less likely to fill an opioid script along with those residing in the Northeast. Variability between physicians was seen in prescribing practices and rates of persistent use. CONCLUSIONS: Non-opioid naïve patients have higher rates of post-operative opioid prescription than opioid-naïve patients. Physician prescribing practices play a role in persistent use, as initial prescription amount predicts persistent use even in non-opioid naïve patients. Significant physician variation in both prescribing practices and rates of persistent use suggest a role for standardizing practices.

Prospective assessment of entrance skin dose and targets for radiation reduction during abdominal plain films in pediatric urology patients.

INTRODUCTION: Abdominal radiographs are frequently used for evaluation of bowel and bladder dysfunction in pediatric urology. However, the dose of radiation delivered with each study is estimated from machine settings as opposed to measurement of the true entrance skin dose. In addition, the correlation of radiographic constipation with patient symptoms has been questioned. OBJECTIVE: To evaluate the practices for obtaining abdominal radiographs and the true entrance skin dose of radiation for each examination in order to identify targets for radiation reduction. STUDY DESIGN: Pediatric urology patients were prospectively enrolled from June 2022 through June 2023. Dosimeters were attached to the navel to collect entrance skin doses from single view abdominal x-ray. Estimated doses were compared to measured entrance skin dose as well as patient characteristics. Exam parameters were evaluated to identify targets for radiation reduction. RESULTS: A total of 75 patients were recruited for this study with a median age of 10.0 years (IQR 6-14). Most evaluations were done to assess for bowel and bladder dysfunction (68 exams, 91%). The protocol for exams was not standardized resulting in 27% of patients undergoing a medium or high dose strength and 55% undergoing 1 or more image. The median estimated dose was 0.63 mGy (IQR 0.3-1.2 mGy). The median measured dose was 0.77 mGy (IQR 0.31-2.01 mGy) which was significantly different than the estimations (p < 0.001). The estimated dose, measured dose and estimate error were all found to be positively correlated with patient characteristics including age and body mass index (See Figure). Increasing age and body mass index also showed a higher likelihood of increased dose strength and image acquisition. DISCUSSION: The measured entrance skin dose of radiation is significantly higher than prior estimates. The measured dose but also the estimate error increased with patient age and size which is likely related to higher settings used for image acquisition as patients age. Standardized protocols using low dose settings and limiting image acquisition to the pelvis may reduce radiation exposure in children with bowel and bladder dysfunction while providing adequate diagnostic data. CONCLUSION: Radiation dose for abdominal radiographs is higher than previously estimated. Older and larger children received higher doses which may be mediated by increased dose strength and image acquisition. Standardization of protocols could lower radiation exposure.

Pelvic Neuroblastoma of the Pediatric Prostate.

Neuroblastoma accounts for a significant portion of childhood tumors and can present in a variety of ways. Pelvic neuroblastoma has been reported but few cases exist of neuroblastoma invading or originating from the bladder or prostate. We present a 4-year-old patient with pelvic neuroblastoma arising from the prostate and describe the medical and surgical management of this challenging case. While pelvic neuroblastoma may have an improved prognosis, this case demonstrates the challenging surgical decisions that accompany these patients to maintain quality of life while balancing oncologic efficacy of treatment.

Patient Interaction With the Health Care System Following a Nonopioid Discharge Strategy for Anterior Urethroplasty.

INTRODUCTION: Continued efforts have been made to minimize postoperative opioids following urologic interventions. Studies show that patient-reported pain outcomes are similar between those patients discharged with and without opioids following anterior urethroplasty, but we do not know what impact this has on health care utilization. We aim to show that a nonopioid discharge following anterior urethroplasty does not increase postoperative health care utilization. METHODS: Five hundred patients who underwent anterior urethroplasty from January 2016 to October 2022 were identified from retrospective chart review. Patient demographic information, surgical characteristics, and postoperative interactions with the health care system were extracted from the electronic medical record. We then compared these outcomes by discharge opioid prescription status. RESULTS: A total of 253 patients were discharged without an opioid prescription. Patients who received an opioid were more likely to have had a perineal incision (73% vs 64%, P = .02), more likely to have had an overnight hospital stay (30% vs 14%, P < .01), and were more likely to have been prescribed an opioid preoperatively (13% vs 7%, P = .03). There were overall low rates of interaction with the health system in both groups with no significant difference in 30-day unplanned office visits, emergency department visits, or office phone calls. Overall, by the end of our study period 97% were discharged without an opioid and 94% of patients were discharged the same day. CONCLUSIONS: Patients undergoing anterior urethroplasty can safely be discharged home without opioids following surgery without undue postoperative burden on the health care system.

Interdisciplinary planning improves radiologist obtained access for percutaneous nephrolithotomy.

INTRODUCTION: Proper antegrade access for percutaneous nephrolithotomy (PCNL) is essential for success but can be challenging. Previous work evaluating access obtained by interventional radiology (IR), largely in the emergent setting, has shown high rates of additional access at the time of PCNL. We hypothesize that efforts to improve pre-procedural communication between urology and IR can impact the utility of the access for subsequent PCNL. MATERIAL AND METHODS: We conducted a retrospective review of patients undergoing PCNL at a single hospital from January 2011 to December 2022. Adult patients undergoing PCNL with established preoperative access were included. RESULTS: A total of 141 cases were identified with preoperative access. A total of 111 patients had evidence of planning with IR prior to antegrade access. There were high rates of anatomic abnormality (50%) and staghorn calculus (53%). Patients with planned access had higher body mass index (BMI). While preoperative access was initially utilized in 97% of cases, 6% required additional access to be obtained intraoperatively; this included a low rate of new access in those that were previously discussed with IR (4% vs. 17%, p = 0.02). Overall stone free rates (91%), rates of second stage procedures (55%) and complications (14%) were similar between planned and unplanned groups. CONCLUSION: In this retrospective study of complex patients with large stone burden presenting for PCNL with preoperative antegrade access obtained by IR, the rate of new access was far lower than prior reports. This was likely influenced by urologist involvement in planning access.

Patient Reported Outcomes of Transperineal Prostate Biopsy With Tumescent Local Anesthesia.

OBJECTIVE: To report the outcomes of performing transperineal prostate biopsy in the office setting using the novel anesthetic technique of tumescent local anesthesia. We report anxiety, pain, and embarrassment of patients who underwent this procedure compared to patients who underwent a transrectal prostate biopsy using standard local anesthesia. MATERIALS AND METHODS: Consecutive patients undergoing either a transperineal prostate biopsy under tumescent local anesthesia or a transrectal prostate biopsy with standard local anesthetic technique were prospectively enrolled. The tumescent technique employed dilute lidocaine solution administered using a self-filling syringe. Patients were asked to rate their pain before, during, and after their procedure using a visual analog scale. Patient anxiety and embarrassment was assessed using the Testing Modalities Index Questionnaire. RESULTS: Between April 2021 and June 2022, 430 patients underwent a transperineal prostate biopsy using tumescent local anesthesia and 65 patients underwent a standard transrectal prostate biopsy. Patients who underwent a transperineal biopsy had acceptable but significantly higher pain scores than those who underwent a transrectal prostate biopsy (3.9 vs 1.6, P-value <.01). These scores fell to almost zero immediately following their procedure. Additionally, transperineal biopsy patients were more likely to experience anxiety (71% vs 45%, P < .01) and embarrassment (32% vs 15%, P < .01). CONCLUSION: Transperineal biopsy using local tumescent anesthesia is safe and well-tolerated. Despite the benefits, patients undergoing a transperineal prostate biopsy under tumescent anesthesia still experienced worse procedural pain, anxiety, and embarrassment. Additional studies examining other adjunctive interventions to improve patient experience during transperineal prostate biopsy are needed.

Accuracy of Radiology Reports for Obstructing Ureteral Stone Size in the Emergency Department.

OBJECTIVE: To evaluate the number of dimensions of obstructing ureteral stones in the emergency department (ED) described in present-day radiology computed tomography reports and assess for measurement discrepancies between radiologist and urologist review. METHODS: We conducted a single-center retrospective study of patients who presented to the ED with unilateral, solitary, obstructing ureteral stones from March 2018 to March 2021. Stone size in each reported dimension recorded by the radiologist was extracted from the chart and then compared to size independently measured by one of our urologists for all 3 stone dimensions. Our primary outcome was the number of stone dimensions included in the radiology report. RESULTS: In total, 181 patients were included for analysis. 82.3% of radiology reports described the stone in one dimension, 15% in two dimensions, and 2.7% in three dimensions. There was a significant difference in median maximal stone size between radiologist and urologist measurement (5.5 vs 6.5 mm, respectively, P < .001). One hundred fourteen stones (62%) had the maximal measurement recorded in the craniocaudal (CC) dimension by urologist review. Only 26% of radiology reports had the CC measurement included in the radiology report. CONCLUSION: Ureteral stone size in a present-day ED cohort is still frequently measured in only 1 or 2 dimensions. In many cases, this is associated with an absence of a reported CC measurement. Inadequate characterization of stone size may affect acute management. This study hopes to encourage reporting of all three dimensions of obstructing ureteral stones in the ED setting for improvements in patient management.

Surgical Outcomes and Prediction of Complications Following High-complexity Buried Penis Reconstruction.

PURPOSE: With uniform modern approaches to adult acquired buried penis reconstruction, this study provides updated results on surgical outcomes for complex cases while evaluating the relative influence of medical, surgical, and socioeconomic factors on these results. MATERIALS AND METHODS: Retrospective review was conducted of all patients undergoing initial buried penis reconstruction including escutcheonectomy and penile skin grafting at 1 tertiary center from 2015 through 2022. Summary scores for frailty and socioeconomic status were calculated with the Modified Frailty Index and Area Deprivation Index, respectively. RESULTS: The cohort included 103 patients. Median age was 51 years (IQR 44-65), and median BMI was 43 (IQR 38-49). Frail patients (≥2 Modified Frailty Index risk factors) accounted for 27% of the population while socioeconomic disadvantage (≥85th percentile on Area Deprivation Index) affected 33% of patients. Twenty-eight percent of repairs included a panniculectomy. Rate of revision for a poor outcome was 3.9% with median follow-up of 11 months. Complications were frequent (50%) with most being Clavien I or II (41%) and related to wound dehiscence (31%) or infection (30%). Frail patients had a higher rate of complication (71% vs 41%, P = .01) and were 6 times more likely to experience a complication on multivariable logistic regression (OR 6.41, 95% CI: 1.77-23.22, P = .005). CONCLUSIONS: The modern approach to complex buried penis reconstruction results in a low revision rate; however, low-grade complications are frequent. Patient frailty identifies those at highest risk for complication, offering an opportunity for counseling and preoperative preparation.

Catheter Free Day of Surgery Discharge vs Overnight Observation Following Artificial Urinary Sphincter Placement.

Introduction To confirm the safety and examine outcomes of a day of surgery discharge following artificial urinary sphincter implantation in a population discharged without a catheter. Methods We retrospectively identified 110 patients, 31 of whom were discharged on the day of surgery, from a single surgeon following artificial urinary sphincter implantation. After institutional board review approval, patient charts were reviewed capturing demographics as well as three, thirty, and ninety-day outcomes. Further outcomes specific to urinary retention were obtained. Results Patients who were discharged the same day were older (71 vs. 68), had shorter operative times (92 minutes vs 109 minutes), and were less likely to have been smokers (6% vs 31%). There were no differences in the proportion of patients who underwent prior radiation or prior implant surgery. There was no significant difference in the number of patients who had emergency department visits, urinary retention, office calls, office visits, or unplanned office visits at all time points following surgery. There was no significant difference in overall urinary retention (15% vs 5%), retention presenting after the initial surgical event (6% vs 5%), or need for a suprapubic tube (0% vs 5%). Conclusions Day of surgery discharge is a safe discharge strategy for patients who have undergone artificial urinary sphincter placement. Furthermore, catheter-free days of discharge surgery did not have a significantly greater risk of urinary retention, office calls, emergency department (ED) visits, or office visits compared to our overnight observation population. This approach should be considered for all patients undergoing artificial urinary sphincter (AUS) implantation.

Subcapsular hematoma in a solitary kidney: successful conservative management.

Subcapsular renal hematoma (SRH) is an infrequent complication of urologic interventions but can lead to serious consequences in patients with a solitary kidney. We present our experience with conservative management of a patient with a solitary kidney and multiple medical comorbidities who developed a SRH and subsequent renal failure after nephroureteral catheter placement. Literature on the management of this unique clinical scenario is limited. Herein, we share our experience with supportive care and temporary dialysis in a medically complex patient whose outcome is complete renal recovery.

Prior Placement of Male Urethral Slings Can Increase the Need for Revision of Artificial Urinary Sphincters.

BACKGROUND: Recurrent stress urinary incontinence (SUI) following male sling can be managed surgically with artificial urinary sphincter (AUS) insertion. Prior small, single-center retrospective studies have not demonstrated an association between having failed a sling procedure and worse AUS outcomes. The aim of this study was to compare outcomes of primary AUS placement in men who had or had not undergone a previous sling procedure. METHODS: A retrospective review of all AUS devices implanted at a single academic center during 2000-2018 was performed. After excluding secondary AUS placements, revision and explant procedures, 135 patients were included in this study, of which 19 (14.1%) patients had undergone prior sling procedures. RESULTS: There was no significant difference in demographic characteristics between patients undergoing AUS placement with or without a prior sling procedure. Average follow up time was 28.0 months. Prior sling was associated with shorter overall device survival, with an increased likelihood of requiring revision or replacement of the device (OR 4.2 (1.3-13.2), p = 0.015) as well as reoperation for any reason (OR 3.5 (1.2-9.9), p = 0.019). While not statistically significant, patients with a prior sling were more likely to note persistent incontinence at most recent follow up (68.8% vs. 42.7%, p = 0.10). CONCLUSIONS: Having undergone a prior sling procedure is associated with shorter device survival and need for revision or replacement surgery. When considering patients for sling procedures, patients should be counseled regarding the potential for worse AUS outcomes should they require additional anti-incontinence procedures following a failed sling.

The concealed morbidity of buried penis: a narrative review of our progress in understanding adult-acquired buried penis as a surgical condition.

Adult acquired buried penis (AABP) is a condition of entrapment of the phallus resulting most commonly from morbid obesity and formation of cicatrix with other etiologies including genital lymphedema, hidradenitis and trauma. The incidence of this syndrome is invariably connected to the increasing prevalence of obesity. The purpose of this review is to examine the current literature in AABP with a focus on the morbidity of AABP and perioperative management. The discussion and literature surrounding buried penis reconstruction started with the goal of correcting a cosmetic problem and has recently become fairly successful in this aim with an over 85% rate of successful reconstruction in many series with a more uniform surgical approach. The most recent trends have examined the significant burden of morbidity and even mortality that AABP can place on patients as it contributes to risk of penile cancer, urethral strictures and mood disorders. Studies in this space have shown that surgical repair can be successful in improving quality of life for patients with AABP and the removal of the offending pathophysiology suggests its success in correcting the physical morbidities. New directions for research and management of this condition should include a focus on educating providers and patients to make reconstruction more accessible to patients in need as AABP continues to journey toward mainstream acceptance as a surgical condition.

Revisiting the penoscrotal approach to artificial urinary sphincter surgery: how does it compare to a perineal incision for initial implantation?

PURPOSE: Artificial urinary sphincters (AUS) remain the gold standard to treat male stress urinary incontinence. AUS implantation can be performed through a penoscrotal or perineal incision depending on surgeon preference. METHODS: The present study compares initial AUS implantation through two surgical approaches focusing on outcomes of continence and revision. All AUS implanted at an academic medical center between 2000 and 2018 were retrospectively reviewed. RESULTS: A total of 225 AUS implantations were identified, of which, 114 patients who underwent virgin AUS placement were included in the study with a mean follow-up of 28.5 months. A total of 68 patients (59.6%) had AUS placement through penoscrotal incision; while, 46 (40.4%) had a perineal incision. While operative time was significantly shorter for penoscrotal placement (98.6 min vs. 136.3 min, p = 0.001), there were no significant differences in continence rates between either surgical approach with 76.5% socially continent defined as using zero to less than 1 pad per day (safety pad). The overall rate of device erosion or infection was not significantly different between groups. However, the rate of revision or replacement was significantly higher in the perineal group (26.1% v. 8.8%; p = 0.01). On multivariate analysis, the penoscrotal incision predicted a lower rate of device revision (p = 0.01). CONCLUSIONS: The penoscrotal approach of AUS placement is associated with shorter operative time. While we observed a lower revision rate compared to the perineal approach, there were equivalent continence outcomes.