The role of transcorporal cuff placement in high-risk and ultra-high-risk patients: are they actually helpful?

PURPOSE: To assess the incidence of artificial urinary sphincter (AUS) explant in high-risk patients and to evaluate the relationship between transcorporal cuff (TCC) placement and explant risk in this population. METHODS: We retrospectively reviewed all AUS insertions performed on high-risk patients by a single surgeon from 2010 to 2020. "High-risk" was defined as having ≥ 1 urethral risk factor: pelvic radiation, urethroplasty, recalcitrant urethral/bladder neck stenosis, urethral stenting, or previous AUS erosion/infection. Patients with ≥ 2 factors were "ultra-high-risk." Time-to-event analyses were used to assess all-cause-, infection/erosion-related-, and mechanical failure-related explant-free survival. Subgroup analyses were performed for patients with a history of radiation and urethral dissection. RESULTS: The final cohort included 68 men, mean age of 67 years (SD 11), and 77 AUS cuffs. Mean follow-up was 32 months (IQR 6-50). 29% of cuffs (n = 22) were transcorporal. 32 cuffs (42%) were explanted. All-cause explant-free survival was 64% at 1 year and 52% at 2 years. Classification as "ultra-high-risk" was not associated with explant risk (all p-values > 0.05). TCC placement was associated with an increased risk of explant for infection/erosion across all patients (HR 2.74, p = 0.03) and in radiated patients (n = 50; HR 4.1, p = 0.04), but not in patients with prior urethral dissection (n = 52; HR 1.98, p = 0.21). CONCLUSION: High-risk patients have a high rate of AUS explant and TCC placement may not be protective in this population. TCC placement was associated with an increased risk of infection/erosion in radiated patients, but not in those with a history of open urethral surgery.

Is colorectal mucosa a reasonable graft alternative to buccal grafts for urethroplasty?: A comparison of graft histology and stretch

ABSTRACT Objective: To compare the histological properties and stretch of colorectal mucosal grafts (CMG) and buccal mucosal grafts (BMG) and to evaluate the impact of age, medical comorbidity and tobacco use on these metrics. Materials and Methods: Samples of BMGs from patients undergoing augmentation urethroplasty were sent for pathologic review. CMGs were collected from patients undergoing elective colectomy. CMGs were harvested fresh, at full thickness from normal rectum/sigmoid. Patients with inflammatory bowel disease, prior radiation, or chemotherapy were excluded. Results: Seventy two BMGs and 53 CMGs were reviewed. While BMGs and CMGs were both histologically composed of mucosal (epithelium + lamina propria) and submucosal layers, the mucosal layer in CMG had crypts. The outer epithelial layers differed significantly in mean thickness (BMG 573μm vs. CMG 430μm, p=0.0001). Mean lamina propria thickness and submucosal layer thickness also differed significantly (BMG 135μm vs. CMG 400μm, p<0.0001; BMG 1090μm vs. CMG 808μm, p = 0.007, respectively). Mean delta stretch, as to length and width, was greater for CMG (118% x 72%) compared to BMGs (22% x 8%), both p<0.001. Conclusion: CMGs and BMGs significantly differ histologically in layer composition, width and architecture, as well as graft stretch. Given its elastic properties, CMG may be useful in covering large surface areas, but its thin epithelium, thick lamina propria and additional muscularis mucosal layer could impact graft take and contracture.

Is colorectal mucosa a reasonable graft alternative to buccal grafts for urethroplasty?: A comparison of graft histology and stretch.

OBJECTIVE: To compare the histological properties and stretch of colorectal mucosal grafts (CMG) and buccal mucosal grafts (BMG) and to evaluate the impact of age, medical comorbidity and tobacco use on these metrics. MATERIALS AND METHODS: Samples of BMGs from patients undergoing augmentation urethroplasty were sent for pathologic review. CMGs were collected from patients undergoing elective colectomy. CMGs were harvested fresh, at full thickness from normal rectum/sigmoid. Patients with inflammatory bowel disease, prior radiation, or chemotherapy were excluded. RESULTS: Seventy two BMGs and 53 CMGs were reviewed. While BMGs and CMGs were both histologically composed of mucosal (epithelium + lamina propria) and submucosal layers, the mucosal layer in CMG had crypts. The outer epithelial layers differed significantly in mean thickness (BMG 573µm vs. CMG 430µm, p=0.0001). Mean lamina propria thickness and submucosal layer thickness also differed significantly (BMG 135µm vs. CMG 400µm, p<0.0001; BMG 1090µm vs. CMG 808µm, p = 0.007, respectively). Mean delta stretch, as to length and width, was greater for CMG (118% x 72%) compared to BMGs (22% x 8%), both p<0.001. CONCLUSION: CMGs and BMGs significantly differ histologically in layer composition, width and architecture, as well as graft stretch. Given its elastic properties, CMG may be useful in covering large surface areas, but its thin epithelium, thick lamina propria and additional muscularis mucosal layer could impact graft take and contracture.

Evaluating Tools for Characterizing Anterior Urethral Stricture Disease: A Comparison of the LSE System and the Urethral Stricture Score.

PURPOSE: We evaluated if scores generated by the LSE classification system and the Urethral Stricture Score system are associated with intraoperative surgical complexity and stricture recurrence risk. MATERIALS AND METHODS: We retrospectively reviewed all consenting patients who underwent single-stage anterior urethroplasty by a single surgeon at 2 institutions. Urethral Stricture Score and a numerical LSE "score" was calculated for each patient. Pearson's correlation and linear regression analyses were used to assess for a relationship between increasing Urethral Stricture Score and LSE score and surgical complexity. Kaplan-Meier curves and Cox proportional hazard regression models were used to assess for an association between Urethral Stricture Score and LSE score and stricture recurrence risk. RESULTS: A total of 187 patients with a mean age of 48 years (SD 16) and mean stricture length of 4.2 cm (SD 3.3) were included. Mean follow-up was 21 months. Forty-six patients recurred over time. We found a strong positive linear correlation between Urethral Stricture Score and LSE score (P < .001). Both increasing Urethral Stricture Score and LSE score independently linearly correlated with increasing surgical complexity (both P < .0001). Univariable analysis demonstrated that increasing LSE score was significantly associated with an increased risk of stricture recurrence (HR 1.2, P = .02) but Urethral Stricture Score was not. Patients with a high LSE score (≥7) were nearly 3 times as likely to recur versus patients with a low LSE score (HR 2.7, P = .001). CONCLUSIONS: Increasing Urethral Stricture Score and LSE score are both associated with increasing surgical complexity, but only LSE score is associated with stricture recurrence risk. Conversion of the LSE classification system into a numeric score adds functionality to this novel system.

A Hard Day at Work: An Analysis of Occupational Genitourinary Injuries in the United States Workforce.

OBJECTIVE: To use national data to identify risk factors for occupational genitourinary (GU) injuries and to expose potential workplace safety issues requiring national regulation. MATERIALS AND METHODS: The National Trauma Data Bank was queried to identify all adults who suffered a work-related GU injury from 2007 to 2016. Injury was stratified by individual organ and by organ type: intra-abdominopelvic (IAP) vs external genitalia (EG). Distinct multivariable logistic regression models were used to examine associations between prespecified risk factors and GU injury (organ and type) and to identify predictors of intensive care unit and operating room (OR) transfer. RESULTS: Two thousand one hundred thirty-nine patients (total of 2681 GU injuries), were included. A mean of 1.3 GU organ injuries and 7.6 total injuries were suffered per patient. 72% suffered an IAP GU injury, 23% an EG injury, and 5% suffered both. Patients working in agriculture/forestry/fishing, (OR 2.3, P = .003), manufacturing (OR 1.9, P = .05), and natural resources/mining (OR 2.3, P = .012) were at significantly increased risk of EG injury. The penis and urethra were particularly at-risk in agriculture/forestry/fishing (OR 4.0, P = .005; OR 3.0, P = .002) and the urethra in natural resources/mining (OR 3.4, P = .004). IAP GU injury was a significant predictor of intensive care unit transfer (OR 1.8, P <.001), whereas EG injury was a significant predictor of OR transfer (OR 2.5, P <.001). CONCLUSION: Occupational GU injuries remain a major issue for blue-collar workers. External genitalia are particularly at-risk, and injuries often require emergent surgery. National occupational health agencies need to continue to enhance on-the-job safety for those at-risk.

Hospital Ownership, Geographic Region, Patient Age, Comorbidities, and Insurance Status Appear to Influence Patient Selection Robot-Assisted Ureteral Reimplantation for Benign Disease: A Population-Based Analysis.

Background: Robot-assisted ureteral reimplantation (RAUR) is a relatively new minimally invasive procedure. As such, research is lacking, and the largest adult cohort studies include fewer than 30 patients. Our aim was to be the first population-based study to report on national utilization trends, factors associated with patient selection, inpatient outcomes, and the relative cost of RAUR for adults with benign ureteral disease (BUD). Materials and Methods: The National Inpatient Sample (2010-2015) was queried to identify all elective, nontransplant-related, open and robot-assisted reimplants for adult BUD. Survey-weighted logistic regression using Akaike Information Criterion identified patient-/hospital-level factors associated with robotic procedure. Survey-weighted regression models examined the association of robotic procedure with outcomes and charges. Results: A weighted total of 9088 cases were included: 1688 (18.6%) robot assisted and 7400 (81.4%) open. There were significantly increased odds of RAUR across consecutive years (odds ratio [OR] = 3.0, p < 0.001) and among patients operated on at private for-profit hospitals (OR: 2.1; p = 0.01), but significantly decreased odds among older patients (OR = 0.98, p < 0.001), those with Medicaid (OR = 0.5, p = 0.02), those with 2+ comorbidities (OR = 0.6, p = 0.009), and those operated on in western (OR = 0.5; p = 0.005) states. RAUR was significantly associated with a reduced length-of-stay (incidence rate ratio: 0.60; p < 0.001), decreased odds of blood transfusion (OR = 0.40; p < 0.001), and a lower mean ratio of total hospital charges (ratio: 0.71; p = 0.006). Conclusions: This is the first population-based study to report on the utilization and clinical benefits of RAUR for adult BUD. Open reimplantation remains the most common surgical technique utilized, despite the potential benefits of RAUR. Future research is needed to explore the mechanisms behind patient-/hospital-level factors and surgical selection. Work to investigate potential barriers in access to robotic procedure can help us provide equitable care across patient populations.

One-Year Results for the ROBUST III Randomized Controlled Trial Evaluating the Optilume® Drug-Coated Balloon for Anterior Urethral Strictures.

PURPOSE: The Optilume® drug-coated balloon (DCB) is a urethral dilation balloon with a paclitaxel coating that combines mechanical dilation for immediate symptomatic relief with local drug delivery to maintain urethral patency. The ROBUST III study is a randomized, single-blind trial evaluating the safety and efficacy of the Optilume DCB against endoscopic management of recurrent anterior urethral strictures. MATERIALS AND METHODS: Eligible patients were adult males with anterior strictures ≤12Fr in diameter and ≤3 cm in length, at least 2 prior endoscopic treatments, International Prostate Symptom Score ≥11 and maximum flow rate <15 ml per second. A total of 127 subjects were enrolled at 22 sites. The primary study end point was anatomical success (≥14Fr by cystoscopy or calibration) at 6 months. Key secondary end points included freedom from repeat treatment, International Prostatic Symptom Score and peak flow rate. The primary safety end point included freedom from serious device- or procedure-related complications. RESULTS: Baseline characteristics were similar between groups, with subjects having an average of 3.6 prior treatments and average length of 1.7 cm. Anatomical success for Optilume DCB was significantly higher than control at 6 months (75% vs 27%, p <0.001). Freedom from repeat intervention was significantly higher in the Optilume DCB arm. Immediate symptom and urinary flow rate improvement was significant in both groups, with the benefit being more durable in the Optilume DCB group. The most frequent adverse events included urinary tract infection, post-procedural hematuria and dysuria. CONCLUSIONS: The results of this randomized controlled trial support that Optilume is safe and superior to standard direct vision internal urethrotomy/dilation for the treatment of recurrent anterior urethral strictures <3 cm in length. The Optilume DCB may serve as an important alternative for men who have had an unsuccessful direct vision internal urethrotomy/dilation but want to avoid or delay urethroplasty.

Lower Urinary Tract Stenosis Following Surgery for Benign Prostatic Hyperplasia.

PURPOSE OF REVIEW: This article reviews the mechanisms, risk factors, evaluation and current management options for iatrogenic lower urinary tract stenosis, including urethral stricture and bladder neck contracture, caused by surgery for benign prostatic hyperplasia (BPH). RECENT FINDINGS: The incidence of iatrogenic stenosis following endoscopic BPH surgery ranges from 0 to 9.7%. New endoscopic techniques and technologies for treating BPH do not appear to substantially mitigate this risk. However, new advances in our understanding of urethral sphincter anatomy combined with both innovative open urethroplasty techniques and utilization of robotic surgery for bladder neck reconstruction, offer promise in improving treatment outcomes for this patient population. Treating patient with stenosis following BPH-related surgery can be challenging, especially in patients with recurrent disease. Optimizing outcomes and patient satisfaction relies on performing a thorough work-up and openly discussing treatment choices, risks and postoperative expectations with patients. Future research and emerging technology in both endoscopic BPH treatment surgical options and management of postoperative stenosis is critical to continuing to improve patient care.

One-Stage Buccal Mucosal Graft Urethroplasty for Lichen Sclerosus-Related Urethral Stricture Disease: A Systematic Review and Pooled Proportional Meta-Analysis.

PURPOSE: Performing 1-stage urethroplasty in patients with urethral strictures caused by lichen sclerosus (LS) is hotly debated among reconstructive urologists due to conflicting reports of success. Therefore, the objective of this study was to determine the pooled incidence of stricture recurrence following 1-stage buccal mucosal graft (BMG) urethroplasty in patients with LS, to determine the impact of surgical technique on recurrence and to compare recurrence risk between patients with and without LS after 1-stage repairs. MATERIALS AND METHODS: A systematic review was conducted in accordance with PRISMA criteria. The primary outcome was pooled incidence of recurrence, which was calculated using a Der-Simonian-Laird binary random effects model with a Freeman-Tukey arcsine transformation. A total of 21 studies were included, of which 15 provided data for comparative analyses. RESULTS: Pooled data from 625 LS patients revealed a stricture recurrence rate of 10% (95% CI 6-14). Among studies with longer followup (≥24 months), this increased to 18%. Among patients with penile urethral involvement, studies utilizing a penile skin incision had significantly higher pooled recurrence rates than those utilizing penile invagination (p=0.004). Across all studies, there was no evidence to suggest a difference in pooled recurrence rate between patients with and without LS (p=0.36). However, across only long-term studies, recurrence risk was significantly higher for patients with LS (OR 1.83, p=0.05). CONCLUSIONS: One-stage BMG urethroplasty is likely a viable surgical option for patients with LS-related strictures; however, high-quality data are limited. Future multi-institutional, long-term prospective studies are needed to assess durability of 1-stage repair.

The Impact of Preoperative Oral Health on Buccal Mucosa Graft Histology.

PURPOSE: Previous studies have elucidated the unique macroscopic and histological properties of buccal mucosa that make it a viable and durable graft for urethral augmentation. However, no prior literature has directly investigated the impact of preoperative oral health on these features. MATERIALS AND METHODS: We analyzed all consenting patients who underwent buccal mucosal graft (BMG) urethroplasty at our institution from 2018 to 2020. Validated oral health surveys, the Oral Health Impact Profile (OHIP-14) and the Kayser-Jones Brief Oral Health Status Examination (BOHSE) were completed preoperatively. A staff pathologist analyzed BMG histology and quantified oral mucositis using a modified Oral Mucosa Rating Scale. RESULTS: We analyzed 51 patients with a median age of 40 years (IQR 31-58). Mean BOHSE score was 1.1 and OHIP-14 score was 1.4. Median epithelial thickness was 530 µm and lamina propria thickness was 150 µm. On age-adjusted analysis, increasing BOHSE and OHIP-14 were associated with decreasing epithelial thickness (p values <0.05). Higher BOHSE scores also correlated with thinner lamina proprias (p=0.05) and increased graft stretch (p=0.03). The 2 patients with postoperative urine leaks and available graft histology had lamina propria thicknesses well below the cohort median, at 50 µm and 60 µm. CONCLUSIONS: This is the first study to demonstrate that oral health conditions impact graft histology and stretch. Although much remains to be learned, our findings shed light on the potential importance of optimizing oral health prior to BMG urethroplasty, and raise the question of if preoperative mucosal biopsy could help inform surgical decision making and discussions regarding surgical success.

Long term outcomes of one-stage augmentation anterior urethroplasty: a systematic review and meta-analysis

ABSTRACT Objective: The objective is to summarize and characterize the long-term success of anterior augmentation urethroplasty in published series. The current literature on AU consists largely of retrospective series reporting intermediate follow-up and incompletely characterize the long term outcomes of AU. Materials and Methods: A systematic literature review was performed consistent with PRISMA guidelines to characterize long-term outcomes of AU with a minimum upper limit follow-up of 100 months. Penile/preputial skin flaps and graft and oral mucosal graft urethroplasties were included. The primary outcome was stricture-free survival for one-stage AU. Secondary analysis evaluated differences in outcomes based on two failure definitions: the need for intervention versus presence of recurrent stricture on cystoscopy or urethrography. Hazard rates were induced from the reported failure rates of one-stage AU and fixed and random effect models were fitted to the data. Additional subset analysis, removing potential confounders (lichen sclerosus, hypospadias and penile skin graft), was performed. Results: Ten studies met inclusion criteria, and two studies reported separate outcomes for grafts and flaps, and thus were included separately in the analysis. The mean hazard rate across all studies was 0.0044, the corresponding survival rates at 1 year 0.948, 5 years 0.766, 10 years 0.587, and 15 years 0.45. Subset analysis of the 4 select and homogeneous studies noted 1, 5, 10, and 15 years survival rates of 0.97, 0.96, 0.74, and 0.63, respectively. Conclusions: The long-term success rates of augmentation urethroplasty are appear to be worse than previously appreciated and patients should be counseled accordingly.

Female Sexual Dysfunction After Pelvic Fracture: A Comprehensive Review of the Literature.

BACKGROUND: Female sexual dysfunction (FSD) after pelvic fracture (PFx) has garnered little attention in the urology literature. AIM: To review and summarize the current evidence regarding female PFx-related sexual function. METHODS: We performed a systematic review in accordance with PRISMA guidelines, including PubMed, EMBASE, and MEDLINE. We included only English-language manuscripts and abstracts with sufficient data for inclusion. We used the search terms "female sexual dysfunction AND pelvic fracture," "sexual dysfunction AND pelvic fracture," and "female pelvic fracture AND sexual dysfunction." A total of 177 articles were identified; 41 abstracts were reviewed; of which, 19 manuscripts were reviewed. Fifteen met inclusion criteria for analysis. OUTCOMES: The main outcome measures of this study are rates and types of female sexual dysfunction after pelvic fracture. RESULTS: FSD is prevalent after PFx, with reported rates between 25% and 62%. Three studies used the validated Female Sexual Function Index. The other 12 used non-validated questionnaires or adapted quality-of-life questionnaires with specific questions regarding FSD. The most common complaints include difficulty with intercourse, dyspareunia, orgasmic dysfunction, genitourinary pain, decreased interest in intercourse, decreased satisfaction with intercourse, and pelvic floor dysfunction. Only 1 study addressed resolution of dysfunction (30 of 98 patients [30.4%]). CLINICAL IMPLICATIONS: FSD is prevalent and an under-recognized sequela of pelvic fracture. This requires future prospective study to better characterize sexual dysfunction and identify effective treatments in trauma survivors. STRENGTH AND LIMITATIONS: To Increase awareness of FSD after pelvic trauma and the impact on the quality of life in trauma survivors. The current literature is limited by a lack of standardized assessment of FSD, limited follow-up, and minimal discussion of treatment options, in addition to the inherent bias of retrospective studies. CONCLUSIONS: FSD after traumatic PFx is not uncommon, occurs mostly in young women, and can be morbid. FSD after PFx is underreported in the urology literature. Thus, all female PFx patients should be screened for FSD by validated questionnaires. The published literature offers little knowledge as to the epidemiology, evaluation, definition, and potential treatments of FSD after PFx. Prospective studies are needed to better understand female sexual function in trauma survivors and the potential methods for prevention and rehabilitation, all within the context of a multidisciplinary approach. Walton AB, Leinwand GZ, Raheem O, et al. Female Sexual Dysfunction After Pelvic Fracture: A Comprehensive Review of the Literature. J Sex Med 2021;18:467-473.

The Rising Incidence of Penile Prosthesis Surgery as the First Line Surgical Treatment for Peyronie's Disease.

INTRODUCTION: Peyronie's disease is a potentially debilitating connective tissue disorder of the penis that at times requires surgical intervention. There is a dearth of multi-center or community-level data regarding management trends. The aim of this study was to perform the first population-based assessment of surgical practice patterns in the treatment of Peyronie's disease among New York State urologists. METHODS: We used the New York Statewide Planning and Research Cooperative System (SPARCS) database to identify all patients who underwent surgical treatment for Peyronie's disease between 2003 and 2016. We used descriptive statistics and multinomial regression modeling to assess predictors of treatment choice. RESULTS: Among 1,733 patients who underwent surgical treatment for Peyronie's disease, 30% underwent insertion of a penile prosthesis alone and 40% underwent insertion of a penile prosthesis with concurrent auxiliary procedures. Penile prosthesis (alone or in combination) was the first line surgical treatment in 21% of patients without documented erectile dysfunction. Relative rates of performing tunical plication and penile grafting decreased over time (both p <0.05), while insertion of a penile prosthesis/insertion of penile prosthesis with concurrent auxiliary procedures rates correspondingly increased (p=0.012). CONCLUSIONS: Insertion of penile prosthesis is by far the most commonly performed primary procedure for Peyronie's disease in New York State, with 1 in 5 patients without erectile dysfunction receiving an implant. While this trend cannot be explained by an administrative data set alone, it does warrant further exploration, as the declining utilization of alternate surgical treatments could compromise surgeon comfort in performing penile grafting and/or tunical plication in the future and may exacerbate disparities in treatment over time.