The Role of Suprapubic Superficial Fascial System Reconstruction During Repair of Adult-Acquired Buried Penis.

BACKGROUND: Adult-Acquired Buried Penis is a disorder associated with systemic obesity that confers increased risks of malignancy, sexual dysfunction, urinary abnormalities, and psychological distress. Surgical correction improves patient-reported functional and psychological outcomes and often requires collaboration between plastic and urologic surgeons. To improve postoperative cosmetic outcomes and decrease wound complications following adult-acquired buried penis repair, we performed an anatomic and histologic study of the superficial fascial layers providing support to the external male genitalia and describe our approach for fascial reconstruction. METHODS: We characterized the superficial fascial anatomy in three patients undergoing adult-acquired buried penis repair, including two patients with Wisconsin Type II disease and one patient with Wisconsin Type IV disease. Gross specimens were sent from two patients histologic analysis using H&E and elastin-specific stains to characterize the identity of the superficial fibrofatty tissue. RESULTS: In all three patients, the fundiform ligament overlying the suspensory ligament was identified, isolated, and transected for removal with the suprapubic specimen. We found that reapproximation of this ligament following transection at the time of escutcheonectomy provided significant lift to the penis and genitals via improved support of dartos fascia. Histologic analysis of the superficial fibrofatty tissue located beneath the dermis revealed histologic similarities with the superficial fascial system described previously in abdominal and breast tissue. CONCLUSIONS: Reapproximation of the fundiform ligament and superficial fascial tissue following suprapubic/lower abdominal fat pad removal during adult-acquired buried penis may improve postoperative cosmesis by reducing strain on the dermal closure. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

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.

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.

A Multipronged Intervention to Reduce Readmissions and Readmission Intensity After Radical Cystectomy.

OBJECTIVE: To develop a multipronged, evidence-based protocol to reduce readmission risk and readmission intensity, as represented by the duration of the index readmission, after radical cystectomy. MATERIALS AND METHODS: A per-protocol study was performed. The protocol included preoperative nutritional supplementation, early stent removal, and a follow-up phone call within 4-5days of discharge. The preprotocol period was from February 1, 2020 to July 31, 2021 and the postprotocol period was from December 1, 2020 to November 31, 2021. Using multivariate regression models, we compared outcomes among patients treated with radical cystectomy before and after protocol initiation. RESULTS: We identified 70 preprotocol patients and 126 postprotocol patients. After adjusting for age, sex, BMI, and frailty score, there was a significant reduction in 90-day readmission intensity (7 vs 5days; P = .048) among postprotocol patients. CONCLUSION: After implementation of an evidence-based protocol for patients undergoing radical 90-day readmission intensity decreased significantly. This protocol may move the needle forward on reducing readmissions, but a larger randomized trial is needed.

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.

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.

Neurobehavioral symptoms by gender and experience of nightmares after traumatic brain injury.

PURPOSE/OBJECTIVE: The purpose of this study is to assess how neurobehavioral symptoms following traumatic brain injury (TBI) may differ based on gender and the experience of nightmares. Research Method/Design: This cross-sectional study of community-dwelling adults ≥ 3 months post-TBI (n = 110) assessed differences in neurobehavioral symptoms between women (n = 41) and men (n = 69) by experience of nightmares. Outcome measures included the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Behavioral Assessment Screening Tool subscales for negative affect, substance abuse, executive functioning, fatigue, impulsivity, and maladaptive coping. RESULTS: N = 22 participants (n = 7 women, n = 15 men) experienced nightmares at least "sometimes" over the past 2 weeks. Nightmares were associated with more substance abuse, negative affect, fatigue, maladaptive coping, depressive symptoms, and anxiety symptoms (ps < .02). Women reported more negative affect, maladaptive coping, depressive symptoms, and anxiety symptoms (ps < .05) than men. Men experiencing nightmares reported more substance use than men without nightmares (p = .036), a difference not seen in women (p = .233). Women experiencing nightmares reported more impulsivity than women without nightmares (p = .028), a difference not seen in men (p = .559). CONCLUSIONS/IMPLICATIONS: Nightmares, post-TBI, are associated with more neurobehavioral symptoms. However, symptom patterns associated with nightmares may differ by gender. Nightmares may be a symptom of, or contribute to, sleep disruptions post-TBI or may indicate other conditions, like posttraumatic stress disorder. Future research should examine gender differences in neurobehavioral symptoms post-TBI in the context of nightmares and/or sleep disorders. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Decrease in Urologic Discharge Opioid Prescribing after Mandatory Query of Statewide Prescription Drug Monitoring Program.

OBJECTIVE: To examine the effectiveness of the introduction of the Pennsylvania Prescription Drug Monitoring Program (PDMP) on discharge postoperative opioid prescriptions in patients undergoing major urologic procedures within a large single tertiary care hospital. Opioids have historically been prescribed to control postoperative pain, but with growing concern regarding opioid overdose, misuse, and diversion, measures have been introduced to curb opioid prescribing. Numerous states have introduced PDMP programs as a method to search patients' prior opioid prescriptions. These programs have reduced opioid prescriptions in emergency department and outpatient settings, but their effectiveness, and the use of a prescriber query mandate, in reducing postoperative opioid prescribing has not been established. METHODS: We identified 582 patients who underwent major prostate or renal surgery between July 1st 2016 and June 30th 2017 at a single large academic hospital. We examined prescribing trends in both opioid naive and opioid tolerant patients measuring 5mg oxycodone equivalents before and after a PDMP query was mandated on January 1st 2017. RESULTS: There was no significant difference is the number of opioid prescriptions given after introduction of the required PDMP query, but there was an 18% decrease in the median number of 5mg oxycodone equivalents prescribed before and after the PDMP query (P < .001). This was consistent in both an opioid naive and opioid exposed population. CONCLUSION: This is the first study to establish that required PDMP queries may reduce the number of discharge opioid pills prescribed in a surgical setting. Required PDMP queries may help reduce the harm associated with opioid overprescribing.

The Safety and Short-term Outcomes of Leukocyte Depleted Autologous Transfusions During Radical Cystectomy.

OBJECTIVE: To examine long- and short-term outcomes using cell salvage with a commercially available leukocyte depletion filter following radical cystectomy in an oncologic population. MATERIALS AND METHODS: One hundred and fifty-seven patients, 87 of whom received a cell salvage transfusion, were retrospectively identified from chart review. Ninety-day outcomes as well as long-term mortality and cancer recurrence data were collected. Chi-square, Student's t, or Mann-Whitney U tests were used as appropriate. Multivariable regressions of survival were performed with a Cox proportional-hazards model. RESULTS: Those who received a cell salvage transfusion did not show any differences in rate of cancer recurrence (23%) vs those who did not receive a cell salvage transfusion (24%; P = .85). There were also no differences noted in mortality rates between the 2 populations (12% vs 17%; P = .36). Furthermore, no differences were noted in postoperative complication rates, length of hospital stay, 90-day culture positive infections or readmissions (P >.05). CONCLUSION: There are no significant differences in short-term or long-term patient outcomes between those who did and did not receive an intraoperative cell salvage transfusion. Cell salvage transfusions with a leukocyte depletion filter are safe and effective methods to reduce the need for allogeneic blood transfusions while controlling for the theoretical risk of metastatic spread.

Excessive Opioid Prescribing After Major Urologic Procedures.

OBJECTIVE: To examine the use of prescription opioids in patients undergoing major prostate and kidney operations. METHODS: This is a prospective observational study that includes opioid naïve patients who underwent a major prostate or kidney operation from January 2017-May 2017. A telephone survey was conducted 3-4 weeks postoperatively. The survey assessed the number of 5 mg oxycodone-equivalents prescribed, opioid use, and disposal. RESULTS: A total of 155 patients were included in our analysis. Most patients were male (86%), most were married (74%), the median was age 64 (interquartile range 59-70), and the majority were Caucasian (84%). Most patients reported social alcohol use (56%), but most denied current tobacco use (77%) or current and/or previous drug use (76%). Opioid prescribing exceeded use from 1.9- to 6.8-fold for all procedural categories. Overall, a total of 4065 oxycodone-equivalents were prescribed during this study and 60% of pills prescribed went unused. This resulted in 2622 excess pills in the community. CONCLUSION: Opioids are prescribed far in excess of need following major open and minimally invasive urologic procedures. Overall, 60% of prescribed opioids were unused. These data provide initial benchmarks for appropriate opioid prescribing after major prostate and kidney procedures. Future work to validate this initial guideline and improve patient counseling regarding appropriate perioperative opioid use and disposal is needed.

Cross-Lagged Panel Analysis of Depression and Behavioral Dysfunction in the First Year After Moderate-to-Severe Traumatic Brain Injury.

Timely treatment of depression and behavioral dysfunction after moderate-to-severe traumatic brain injury (TBI) could improve health, function, and quality of life. The authors hypothesized that 6-month depression would be the stronger contributor to later depression and behavioral dysfunction in a sample of 88 adults with moderate-to-severe TBI. A structural equation modeling cross-lagged panel analysis, adjusting for all 6-month predictors, revealed that 6-month depression had a stronger relationship to 12-month depression (ßstand=0.55, p=0.002) and behavioral dysfunction (ßstand=0.41, p=0.004) than did 6-month behavioral dysfunction (ßstand=0.17, p=0.270, ßstand=0.30, p=0.035). Depression may be in the developmental pathway to behavioral dysfunction, triggering a cycle of reciprocal causality.

COMT and ANKK1 Genetics Interact With Depression to Influence Behavior Following Severe TBI: An Initial Assessment.

OBJECTIVE: Genetic variations in the dopamine (DA) system are associated with cortical-striatal behavior in multiple populations. This study assessed associations of functional polymorphisms in the ankyrin repeat and kinase domain (ANKK1; Taq1a) and catechol-O-methyltransferase (COMT; Val158Met) genes with behavioral dysfunction following traumatic brain injury (TBI). PARTICIPANTS: This was a prospective study of 90 survivors of severe TBI recruited from a level 1 trauma center. MAIN MEASURES: The Frontal Systems Behavior Scale, a self- or family report questionnaire evaluating behavior associated with frontal lobe dysfunction, was completed 6 and 12 months postinjury. Depression was measured concurrently with the Patient Health Questionnaire-9. Study participants were genotyped for Val158Met and Taq1a polymorphisms. RESULTS: No statistically significant behavioral differences were observed by Taq1a or Val158Met genotype alone. At 12 months, among those with depression, Met homozygotes (Val158Met) self-reported worse behavior than Val carriers (P = .015), and A2 homozygotes (Taq1a) self-reported worse behavior than A1 carriers (P = .028) in bivariable analysis. Multivariable models suggest an interaction between depression and genetic variation with behavior at 12 months post-TBI, and descriptive analysis suggests that carriage of both risk alleles may contribute to worse behavioral performance than carriage of either risk allele alone. CONCLUSION: In the context of depression, Val158Met and Taq1a polymorphisms are individually associated with behavioral dysfunction 12 months following severe TBI, with preliminary evidence suggesting cumulative, or perhaps epistatic, effects of COMT and ANKK1 on behavioral dysfunction.

A Dopamine Pathway Gene Risk Score for Cognitive Recovery Following Traumatic Brain Injury: Methodological Considerations, Preliminary Findings, and Interactions With Sex.

OBJECTIVES: With evidence of sexual dimorphism involving the dopamine (DA)-pathway, and the importance of DA pathways in traumatic brain injury (TBI) recovery, we hypothesized that sex × DA-gene interactions may influence cognition post-TBI. PARTICIPANTS: Adult survivors of severe TBI (n = 193) consecutively recruited from a level 1 trauma center. DESIGN: Risk allele assignments were made for multiple DA pathway genes using a sex-specific stratified approach. Genetic risk alleles, and their impacts on cognition, were assessed at 6 and 12 months postinjury using unweighted, semiweighted, and weighted gene risk score (GRS) approaches. MAIN MEASURES: A cognitive composite score generated from 8 standardized neuropsychological tests targeting multiple cognitive domains. RESULTS: A significant sex × gene interaction was observed at 6 and 12 months for ANKK1 rs1800497 (6M: P = .002, 12M: P = .001) and COMT rs4680 (6M: P = .048; 12M: P = .004); DRD2 rs6279 (P = .001) and VMAT rs363226 (P = .043) genotypes were independently associated with cognition at 6 months, with trends for a sex × gene interaction at 12 months. All GRS methods were significant predictors of cognitive performance in multivariable models. Weighted GRS multivariate models captured the greatest variance in cognition: R = 0.344 (6 months); R = 0.441 (12 months), significantly increasing the variance captured from the base prediction models. CONCLUSIONS: A sex-specific DA-pathway GRS may be a valuable tool when predicting cognitive recovery post-TBI. Future work should validate these findings and explore how DA-pathway genetics may guide therapeutic intervention.

Posttraumatic Brain Injury Cognitive Performance Is Moderated by Variation Within ANKK1 and DRD2 Genes.

OBJECTIVE: As dopamine neurotransmission impacts cognition, we hypothesized that variants in the linked dopamine D2 receptor (DRD2) and ankyrin repeat and kinase domain (ANKK1) genes might account for some individual variability in cognitive recovery following traumatic brain injury (TBI). PARTICIPANTS: Prospective cohort of 108 survivors of severe TBI, recruited consecutively from a level 1 trauma center. DESIGN: We examined relationships between DRD2 genetic variation and functional recovery at 6 and 12 months post-TBI. MAIN MEASURES: Cognitive performance was evaluated using 8 neuropsychological tests targeting different cognitive domains. An overall cognitive composite was developed using normative data. We also assessed functional cognition, depression status, and global outcome. Subjects were genotyped for 6 DRD2 tagging single-nucleotide polymorphisms and Taq1A within ANKK1. RESULTS: ANKK1 Taq1A heterozygotes performed better than homozygotes across several cognitive domains at both time points postinjury. When adjusting for age, Glasgow Coma Scale score, and education, the Taq1A (ANKK1) and rs6279 (DRD2) variants were associated with overall composite scores at 6 months post-TBI (P = .0453 and P = .0452, respectively). At 12 months, only Taq1A remained a significant genetic predictor of cognition (P = .0128). Following multiple-comparisons correction, there were no significant associations between examined genetic variants and functional cognition, depression status, and global outcome. CONCLUSION: These data suggest that genetic variation within DRD2 influences cognitive recovery post-TBI. Understanding genetic influences on dopaminergic systems post-TBI may impact current treatment paradigms.