Liposomal Bupivacaine Local Infiltration for Buccal Mucosal Graft Harvest Site Pain Control: A Single-blinded Randomized Controlled Trial.

OBJECTIVE: To assess efficacy and safety of liposomal bupivacaine (LB) infiltration of the buccal mucosal graft (BMG) harvest site in alleviating pain by evaluating the postoperative narcotic usage, pain score, and morbidities. PATIENTS AND METHODS: Single-blinded randomized controlled trial of 43 adult patients for BMG substitution urethroplasty between January 2015 to June 2017 (Clinicaltrials.gov: NCT03720223). A computer-generated allocation scheme randomized patients to control group (n = 22) no further local anesthetic infiltration aside from that of used in the hydrodissection for BMG harvest, and to intervention group with additional infiltration of LB to BMG harvest site (n = 21). We assessed postoperative cumulative narcotic use on post-op day 1 and 2 (24- and 48-hour total intravenous [IV] morphine equivalents in milligrams). A self-reported 10-point numeric rating scale survey was administered to assess postprocedural oral pain, oral conditions, and morbidity on days 1-3, and at 1-month follow-up. Fisher's exact test and independent T test were performed to assess differences between treatment groups. Linear regression was used to determine adjusted effect estimates of intervention. RESULTS: Compared to controls, a significantly lower narcotic use was noticed among the LB treatment group on post-op day 1 (IV morphine equivalent mean difference 8.58 mg; 95% confidence interval 1.59, 15.56, P =.017), while no significant difference was noticed on post-op day 2. There was no significant difference between treatment groups with regards to postprocedural oral pain score or oral morbidities. CONCLUSION: Our study showed that LB infiltration of the BMG harvest site is safe and associated with lower 24-hour narcotic use only at post-op day 1.

Placental membrane grafts for urethral replacement in a rabbit model: a pilot study.

PURPOSE: Several graft materials are available for use in the treatment of urethral stricture disease. Placental membrane is being used in a variety of settings as a graft in wound healing and tissue repair. We aim to evaluate the effect of implanting decellularized human placental membrane into rabbit urethras. METHODS: Dorsal onlay graft urethroplasty using prepared human placental membrane was performed in 10 New Zealand White rabbits (Oryctolagus cuniculus). After 3 months, the rabbits underwent cystourethroscopy to evaluate urethral patency. The rabbits were then euthanized and the urethras examined for pathological findings. RESULTS: All urethroplasties were performed without complication. There were no observed episodes of urinary retention, infection, or renal failure. Urethral patency was achieved in all rabbits 3 months postoperatively. Urothelial replacement of the placental membrane graft was observed in all rabbits without malignant transformation. CONCLUSION: Dorsal onlay urethroplasty using decellularized human placental membrane can safely be performed in a rabbit model. This pilot study demonstrated urothelial replacement of human placental membrane in the rabbit urethra without stricture formation. Placental membrane is a promising biomaterial for urethral reconstruction.

Male Slings for Post-prostatectomy Incontinence.

Stress urinary incontinence following radical prostatectomy can have a significant impact on a man's quality of life. Male slings offer a perceived minimally invasive treatment option and do not require the manual dexterity necessary to operate an artificial urinary sphincter. In this review, we outline the history of male slings and discuss the various fixed and adjustable slings that are available on the market. It is important for the general urologist to understand the technical differences, outcomes, and common complications of suburethral slings.

AdVance sling use decreasing relative to artificial urinary sphincters.

INTRODUCTION: To evaluate the percent of AdVance male sling usage relative to artificial urinary sphincters (AUS) over a 9 year period since its introduction in order to assess trends across the United States. MATERIALS AND METHODS: As a surrogate for procedures performed, we reviewed device utilization trends of the AdVance sling and AUS broken down by American Urological Association (AUA) section. ANOVA testing between years was used to determine purchasing trends with p values of < 0.05 considered statistically significant. RESULTS: Relative to AUS, AdVance sling percentage significantly increased from 36% in 2007 to 48% in 2008 (p = 0.032). Sling percentage then remained stable over the next 3 years from 2008-2011 with no significant percent change between years (p = NS). Compared with 2008-2011, AdVance usage decreased in 2012 to 29% (p = 0.002) and remained stable at this decreased relative level through 2015 (p = NS, difference between years 2012-2015). Comparing incontinence procedures across AUA sections, the Southeast section performed the highest percentage of male stress urinary incontinence procedures, including 27% of all AdVance slings and 25% of all artificial sphincters. CONCLUSION: Proportion of AdVance sling usage relative to AUS increased after its introduction through 2008. Usage remained stable at an increased level for the next3 years. More recent years have found decreased AdVance usage and a resurgence of the artificial urinary sphincter. Reasons for these trends remain speculative.

An update on best practice in the diagnosis and management of post-prostatectomy anastomotic strictures.

Postprostatectomy vesicourethral anastomotic stenosis (VUAS) remains a challenging problem for both patient and urologist. Improved surgical techniques and perioperative identification and treatment of risk factors has led to a decline over the last several decades. High-level evidence to guide management is lacking, primarily relying on small retrospective studies and expert opinion. Endourologic therapies, including dilation and transurethral incision or resection with or without adjunct injection of scar modulators is considered first-line management. Recalcitrant VUAS requires surgical reconstruction of the vesicourethral anastomosis, and in poor surgical candidates, a chronic indwelling catheter or urinary diversion may be the only option. This review provides an update in the diagnosis and management of postprostatectomy VUAS.

Minimal Device Encrustation on Vesair Intravesical Balloons in the Treatment of Stress Urinary Incontinence: Analysis of Balloons Removed from Women in the SOLECT Trial.

INTRODUCTION: Encrustation of urinary biomaterials is common; however, the incidence of surface deposition on the Vesair® intravesical pressure-attenuation balloon has not been previously reported. The purpose of this analysis is to determine the incidence and potential risk factors for encrustation of the Vesair intravesical balloon. METHODS: The SOLECT trial is a prospective randomized controlled trial conducted at several European centers to evaluate the safety and efficacy of the Vesair balloon for the treatment of female stress urinary incontinence (SUI). Women included in the study demonstrated SUI symptoms for more than 12 months without complicating factors, such as history of recurrent urinary tract infections or nephrolithiasis. All balloons removed from women enrolled in the SOLECT trial were analyzed for surface characteristics and encrustation. Surface deposition severity was quantified and composition analyzed with infrared spectroscopy and scanning electron microscopy. Incidence of surface deposition was tabulated and risk factors analyzed. RESULTS: One hundred and five balloons removed from 75 women were included in this analysis. Measurable stone deposition of less than 1.5 mm was found on four balloons (3.8%), surface granules were noted on 42 (40.0%), surface film on 11 (10.5%), and both granules and film on two (1.9%). Analysis identified calcium oxalate both in measurable encrustation deposits as well as those with surface granulation. Pooled analysis found that dwell time was a risk factor for calcium deposition. CONCLUSION: The rate of encrustation on the Vesair intravesical balloon is low and does not appear to increase the rate of adverse outcomes or reduce clinical efficacy. FUNDING: Solace Therapeutics, Inc.

Robotic-assisted laparoscopic partial cystectomy for symptomatic urachal hamartoma.

We report a case of an urachal hamartoma in a 30-year-old African American woman. The urachal lesion was excised with a robotic-assisted laparoscopic partial cystectomy. Pathologic analysis revealed cysts, smooth muscle, and ciliated epithelium consistent with a hamartoma. The patient recovered without complication. This case highlights an unusual pathology that is infrequently reported following urachal remnant excision.

Penile Prosthesis Implantation in Patients with a History of Total Phallic Construction.

INTRODUCTION: Outcomes following penile prosthesis implantation in patients with a history of total phallic construction are not well described. AIM: The aim of this study was to evaluate outcomes following neophallus penile prosthesis placement. METHODS: Retrospective review penile prosthesis placement in patients with prior total phallic construction. GORE-TEX® (Gore Medical, Flagstaff, AZ) sleeve neotunica construction was utilized in all patients. MAIN OUTCOME MEASURE: Success defined as patient sexual activity with a functioning prosthesis. RESULTS: Thirty-one patients underwent neophallic prosthesis implantation at a mean 35.6 years of age. Prosthesis placement occurred at an average 56.3 months following phallic construction and follow-up was a mean of 59.7 months. Malleable prostheses were placed in 21 patients and inflatable in 10; implants were bilateral in 94%. Six percent experienced operative complications including a bladder injury (1) and phallic flap arterial injury (1). Postoperative complications occurred in 23% at a median 5.5 months following placement. Five prostheses were explanted secondary to infection or erosion and two additional required revisions. Of the explanted prosthesis two were later replaced without further complication. Eighty-one percent of patients were sexually active following prosthesis placement. CONCLUSIONS: Penile prosthesis placement is possible in patients with prior penile reconstruction/phallic construction. Although complications rates appear to be elevated in this population compared with historic controls of normal anatomic men, the majority of patients in this series were sexually active following prosthesis placement. This demonstrates the utility of prosthesis implantation in these difficult patients.

International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results.

OBJECTIVE: To present mid-term outcomes from an international, multi-institutional cohort of patients undergoing vessel-sparing excision and primary anastomosis urethroplasty for the reconstruction of the anterior urethra. MATERIALS AND METHODS: From June 2003 to December 2011, 68 patients underwent vessel-sparing anterior urethral reconstruction at five different international institutions using the vessel-sparing technique described by Jordan et al. (J Urol 177(5):1799-1802, 2007). RESULTS: Patients' age range was from 3 to 82 years (mean 51.2). Stricture length ranged from 1 to 3 cm (mean 1.78). After a mean follow-up of 17.6 months, 95.6 % of patients had a widely patent urethral lumen. Three patients failed the procedure, requiring either direct vision internal urethrotomy or urethral dilation, after which all were free of symptoms and did not require further instrumentation. Complications were minimal and as expected following open urethroplasty. CONCLUSION: Preservation of blood supply is a noble pursuit in surgery; however, it can be technically difficult and often requires more time and effort. This vessel-sparing technique for anterior urethral reconstruction is reproducible and appears to be reliable in this international cohort. Larger studies and longer follow-up are needed to support these encouraging results.

Evaluation of salvage male transobturator sling placement following recurrent stress urinary incontinence after failed transobturator sling.

OBJECTIVE: To evaluate the outcome of patients treated with a salvage AdVance male sling after a failed primary transobturator sling placement. METHODS: Retrospective review of patients treated at our center with a primary and subsequent salvage AdVance sling. Success was defined as a dry safety pad or no pads (cured), or >50% improvement in pads used per day and patient satisfaction (improved). Early primary sling failures (<6 months) were compared with late (≥6 months) failures with regard to continence outcomes. RESULTS: We identified 18 patients who underwent a salvage AdVance sling placement at our institution. Overall success was 72% at 6 months postoperatively and 56% at a mean follow-up of 17.5 months, including 50% and 39% of patients who were dry at those same time periods. Patients failing late after their primary sling (n = 8) enjoyed improved outcomes with salvage sling placement compared with patients who failed early (n = 10) after the primary sling. At 6 months, more patients in the late primary failure group were cured (75% vs. 30%; P = .031). These improved cure rates remained significant through final follow-up with cure rates of 63% and 20%, respectively (P = .041). CONCLUSION: Salvage AdVance male sling is a viable treatment option after a failed primary sling procedure, especially in patients who demonstrated a prolonged efficacy period before primary sling failure.

Role of allograft nephrectomy following kidney graft failure: preliminary experience with pre-operative angiographic kidney embolization.

INTRODUCTION: Allograft nephrectomy (AN) is not without morbidity following graft failure (GF) in kidney transplantation (KT). METHODS: Single center retrospective review of all adult patients undergoing AN following KT, including a subset of patients who underwent pre-operative angiographic kidney embolization (PAKE). RESULTS: Over a 104 month period, 853 adult patients underwent deceased donor KT. With a median follow-up of 3.5 years, 174 patients (20.4%) developed GF and 38/174 (21.8%) underwent AN. The rate of AN was higher in patients with delayed graft function [DGF, Odds Ratio (OR) 2.15, p = 0.023] and early GF (OR 1.7, p = 0.064). For patients undergoing PAKE (n = 13, mean timing of AN 27.5 months post-KT), the estimated intra-operative blood loss was reduced from a mean of 375 ± 530 to 100 ± 162 ml (p < 0.10), mean peri-operative transfusion requirements were reduced from 3.36 ± 4.8 to 0.23 ± 0.44 units (p < 0.05), and total mean operating time was reduced from 192 ± 114 to 141 ± 38 min (p = NS) compared to 13 control patients undergoing AN in the absence of vascular thrombosis or PAKE. Mean length of hospital stay was decreased from 8.5 ± 9 to 5.5 ± 3 days (p = NS) in patients with PAKE. Surgical complication and infection rates and hospital charges were comparable. CONCLUSIONS: Delayed graft function and early GF are associated with a higher rate of AN. PAKE may result in less blood loss, fewer transfusions, reduced operating time, and shorter length of stay, which may translate into reductions in morbidity.