Feasibility of same-day discharge of robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection.

PURPOSE: Prostate cancer is one of the most common oncologic diseases. Outpatient robotic-assisted laparoscopic radical prostatectomy (RALP) has gained popularity due to its ability to minimize patient costs while maintaining low complication rates. Few studies have analyzed the possibility of performing outpatient RALP specifically in patients undergoing concurrent pelvic lymph node dissections (PLND). METHODS: Using the National Surgical Quality Improvement Program Database (NSQIP), we identified total number of RALP, stratified into inpatient and outpatient groups including those with and without PLND from 2016 to 2021. Baseline characteristics, intraoperative and postoperative complications, and unplanned readmission rates were summarized. Proportions of outpatient procedures were calculated to assess adoption of outpatient protocol. RESULTS: Between 2016 and 2021, a total of 58,527 RALP were performed, 3.7% (2142) outpatient and 96.3% inpatient. Altogether, patients undergoing outpatient RALP without PLND were more likely to have hypertension (52.6% vs. 46.3%, p < 0.01). Patients undergoing outpatient RALP without PLND were more likely to have sepsis or urinary tract infections (3.4% vs. 1.9%, p = 0.04) when compared to outpatient RALP with PLND. Cardiopulmonary, renal, thromboembolic complications, and 30-day events such as unplanned readmission, reoperation rates, and mortality were similar in both groups. However, among multivariate analysis regarding 30-day readmission and complications, there were no significant differences between outpatient RALP with or without PLND. CONCLUSION: Patients undergoing outpatient RALP without PLND were more likely to have baseline hypertension and higher rates of postoperative infection, when compared to outpatient RALP with PLND. No significant differences were seen regarding 30-day readmission or complications on multivariate analysis.

Understanding Prescribing Differences Between Urologists and Medical Oncologists in the Management of Advanced Prostate Cancer.

INTRODUCTION: The availability of oral therapies for advanced prostate cancer allows urologists to continue to care for their patients who develop castration resistance. We compared the prescribing practices of urologists and medical oncologists in treating this patient population. METHODS: The Medicare Part D Prescribers data sets were utilized to identify urologists and medical oncologists who prescribed enzalutamide and/or abiraterone from 2013 to 2019. Each physician was assigned to one of 2 groups: enzalutamide prescriber (physicians that wrote more 30-day prescriptions for enzalutamide than abiraterone) or abiraterone prescriber (opposite). We ran a generalized linear regression to determine factors influencing prescribing preference. RESULTS: In 2019, 4,664 physicians met our inclusion criteria: 23.4% (1,090/4,664) urologists and 76.6% (3,574/4,664) medical oncologists. Urologists were more likely to be enzalutamide prescribers (OR 4.91, CI 4.22-5.74, P < .001) and this held in all regions. Urologists with greater than 60 prescriptions of either drug were not shown to be enzalutamide prescribers (OR 1.18, CI 0.83-1.66, P = .349); 37.9% (5,702/15,062) of abiraterone fills by urologists were for generic compared to 62.5% (57,949/92,741) of abiraterone fills by medical oncologists. CONCLUSIONS: There are dramatic prescribing differences between urologists and medical oncologists. A greater understanding of these differences is a health care imperative.

Narcotic Requirements before and after Implementation of Buccal Nerve Blocks for Buccal Mucosa Graft Harvest: Technique and Retrospective Review.

The reduction in opioid use has become a public health priority. We aimed to assess if performing buccal nerve blocks (BNB) at the time of buccal mucosa graft (BMG) harvest impacts post-operative narcotic usage in the inpatient setting. We retrospectively reviewed clinical characteristics and morphine milligram equivalents (MMEs) received for all patients that underwent a BMG urethroplasty at our institution. The primary outcome measure was post-operative MMEs for patients before and after implementing the BNB. We identified 74 patients that underwent BMG urethroplasty, 37 of which were before the implementation of the BNB and 37 of which were after. No other changes were made to the peri-operative pathway between these time points. The mean total MMEs per day, needed post-operatively, was lower in the BNB group (8.8 vs. 5.0, p = 0.12). A histogram distribution of the two groups, categorized by number of MMEs received, showed no significant differences between the two groups. In this retrospective analysis, we report our experience using BNBs at the time of buccal mucosa graft harvest. While there were no significant differences between the number of MMEs received before and after implementation, further research is needed to assess the blocks' impact on pain scores.

Recent trends in the prescription of opioids in the emergency department in patients with urolithiasis.

PURPOSE: Pain management is central in the treatment of urolithiasis. We aimed to estimate the impact of the 2017 Department of Health and Human Services declaration of an opioid crisis on prescribing patterns of opioids and NSAIDs in emergency department visits for urolithiasis. METHODS: The National Health Ambulatory Medical Care Survey (NHAMCS) was queried for emergency department visits of adults with a diagnosis of urolithiasis. The association between urolithiasis and narcotic and NSAIDs prescription patterns was evaluated and compared at pre-declaration (2014-2016) to post-declaration (2017-2018) periods. RESULTS: Opioids were prescribed in about 211 million (41.1%) out of 513 million emergency department visits, over a 5-year period. Diagnosis of urolithiasis accounted for 1.9% of the visits (6.0 million). The use of opioids was higher in urolithiasis (82.7%) compared to non-urolithiasis diagnosis (40.3%), as well as the use of multiple opioids per visit (p < 0.01 for all). There was an overall decrease in opioid prescriptions in the post-declaration period, - 4.3% for urolithiasis (p = 0.254) and - 5.6% for non-urolithiasis visits (p < 0.05). A decrease in the use of hydromorphone (- 47.5%. p < 0.001), an increase in the use of morphine (+ 59.7% p = 0.006), and an increase of 'other' opioids (+ 98.8%, p < 0.041), were observed. Opioids combined with NSAIDs comprised 72.6% of the opioid prescriptions and 62.3% of all analgesic prescriptions in visits with urolithiasis diagnosis. CONCLUSIONS: The use of opioids when managing urolithiasis decreased 4.3% after the crisis declaration; however, statistically are not different from pre-declaration numbers. Most often, opioids were prescribed with NSAIDs in urolithiasis patients.

Moving away from mannitol infusion for partial nephrectomy: has this altered renal function?

In recent years, research has questioned the theorized renal-protective value of mannitol infusion during partial nephrectomy. This study considers whether the cessation of routine mannitol administration has shown any benefit or detriment to patients in the contemporary era. We retrospectively reviewed a multi-institution database for an association between mannitol administration and subsequent renal function during follow-up. These patients were assessed for de novo stage III chronic kidney disease (CKD III) and followed with estimated glomerular filtration rate (eGFR). Statistical analysis included Mann-Whitney-U and Chi-squared tests for comparing baseline and perioperative variables with postoperative outcomes. eGFR changes were evaluated with a mixed-effects linear regression model. Nine hundred and fifteen patients were identified whose operative reports or surgeons' treatment algorithms explicitly described whether or not mannitol was administered. 667 (73%) did not receive mannitol. There were no differences in demographics, age, Charlson comorbidity index, nephrometry score, tumor size, grading, or baseline eGFR from those who received mannitol. Ischemia time and operative time appeared slightly longer with mannitol use. Patients were followed for a median of 5 months (IQR 0.5-19 months), during which mannitol use was associated with an increase in de novo CKD III (14% v. 9%, p = 0.041) and minimally worsened median eGFR on final follow-up (72.82 v. 76.06, p = 0.039). Our analysis of partial nephrectomy patients indicates that mannitol administration likely confers no short- or long-term renal benefit. Mannitol may be used at the surgeon's discretion, but if it prolongs surgery time or ischemia time, it may in fact be detrimental to outcomes.

Bullseye Technique to Optimize S3 Foramen Access: Applying a Trusted Endourology Technique to Pelvic Medicine.

BACKGROUND: Sacral neuromodulation (SNM) is an advanced therapy that stimulates sacral spinal nerves to modulate bladder or bowel dysfunction and is approved for the treatment of overactive bladder, fecal incontinence, and non-obstructive urinary retention. Prior to implantation, a successful trial period must be performed via percutaneous nerve evaluation (PNE) or a staged trial to assess treatment efficacy. Ideal lead placement in the S3 foramen is imperative to produce an adequate response and successful outcome. Traditional lead placement with fluoroscopic guidance utilizes the anteroposterior (AP) and lateral views. In this abstract we describe an additional modification which may aid lead placement. OBJECTIVE: This video demonstrates the bullseye technique to obtain S3 foramen access for optimal lead placement in SNM. METHODS/MATERIAL: Begin the procedure by placing the patient in the prone position. The medial edges of the S3 foramen are marked bilaterally in the AP view followed by a horizontal marking at the level of S3. The pelvis is imaged with live fluoroscopy starting at 0 degrees and then rotating the C-arm to 30 degrees. This rotation allows the "opening up" of the S3 foramen from an ellipsoid to an oval. The surgeon grasps the needle with a Kelly clamp, placing it at the level of the skin approximately 2 cm cephalad from the horizontal marking. Live fluoroscopy is performed to align the needle with the image intensifier to form the bullseye. Once the correct angle is identified, the needle is advanced. The procedure is repeated on the contralateral foramen. RESULTS: The bullseye technique allows quick and predictable access into S3. It can potentially decrease operating time, minimize needle entries in PNE, and allows the surgeon to access S3 while maintaining proper medial orientation. CONCLUSION: The bullseye technique can assist surgeons in obtaining optimal access in SNM and can quickly be integrated into current practices.

Ventral onlay glanuloplasty for treatment of fossa navicularis strictures

ABSTRACT Purpose: Management of fossa navicularis (FN) strictures balances restoring urethral patency with adequate cosmesis. Historically, FN strictures are managed via glans cap or glans wings, and in severe cases, multi-stage procedures. Ventral onlay glanuloplasty (VOG) is an easily reproducible technique that involves a single-stage augmentation with buccal mucosal graft. We have been applying this technique for several years and present early promising outcomes of this novel approach. Materials and Methods: We retrospectively reviewed all patients with FN strictures who underwent VOG at our institution. Treatment success was designated by the absence of extravasation on voiding cystourethrogram and no need for further urethral instrumentation on follow up. Glans cosmesis was assessed by patients providing binary (yes/no) response to the satisfaction in their appearance. We also noted stricture length, stricture etiology, demographic characteristics and any post-operative complications and reported median, interquartile range (IQR) and count, frequency (%), accordingly. Results: Ten patients underwent VOG and fit our inclusion criteria. Median stricture length was 2.0 cm (IQR 1.6 -2). Success rate was 90% (9/10) with a median follow up of 30 months (IQR 24.3 - 36.8). The one recurrence was treated by dilation combined with triamcinolone injection at 419 days post-op. Stricture etiology included primarily iatrogenic causes such as transurethral prostate resection (4/10), greenlight laser vaporization (2/10), cystolitholapaxy (1/10), and traumatic catheterization (3/10). All patients were satisfied with penile cosmesis. Conclusion: VOG is a simple technique for treating FN strictures. Based on our preliminary series, VOG provides sustained distal urethral patency and patients are pleased with the appearance.

Use of phosphodiesterase-5 inhibitors and the incidence of melanoma.

INTRODUCTION: Recent evidence of a causal link between Phosphodiesterase-5-inhibitor (PDE-5i) use and melanoma has caused concern in PDE-5i use and was even addressed in the 2018 American Urological Association guideline on erectile dysfunction (ED). Given that several studies have affirmed this low probability but statistically significant association, one might expect a shift in melanoma diagnoses since PDE-5is were introduced in 1998. We sought to determine if the introduction of PDE-5i drugs for ED treatment increased incidence of melanoma. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to compare the incidence of melanoma diagnosis in American men between 1973 and 2015, providing over a decade of data before and after PDE-5i introduction in 1998. Interrupted time-series and logistic regression were used to assess this relationship. RESULTS: Over 43 years, the SEER database has reported 292,166 cases of Melanoma, with males accounting for 53.7% of cases (Standard deviation [SD] 3%, Range 47.5-58.3%). After the introduction of PDE-5i, there was no proportional increase in melanoma diagnoses, in fact demonstrating a 2% lower incidence from prediction models (p < 0.05). CONCLUSION: Our analysis of the SEER database demonstrates that the trend in incidence of melanoma has fallen in the era of PDE-5i use for ED. These findings may be of value in counseling patients anxious about the potential association between PDE-5i use and skin cancer; however, continued research analyzing individual-level risk are needed.

Variations in Opioid Use Following Robotic Radical Prostatectomy in South Florida.

Introduction: Opioid dependency has been a persistent issue in the United States over the past two decades. Increased efforts have been made to reduce opioid prescribing. Our objective was to quantify at-home opioid requirements following radical prostatectomy. Methods: Written questionnaires were administered to patients 1 week following robot-assisted laparoscopic radical prostatectomy (RALP). Patients provided data on opioid use, pain levels, and demographic characteristics. Results: Sixty-five patients were included. Median age (interquartile range [IQR]) was 69 (62-72) years. The majority were white (85%) and hispanic (67%). Prescriptions ranged from 6 to 15 pills of 5-mg oxycodone equivalents. Twenty-two percent (145/663) of the prescribed pills in the study were consumed. Fifty-four percent (35/65) of patients did not take opioids. Of the 30 patients who took opioids, median use (IQR) was 4.5 (3-6) pills. Forty-six percent (30/65) reported catheter-related pain. Patients who took opioids reported higher levels of pain. On generalized linear regression, younger age, lower levels of education, and living with a family member were factors associated with increased risk for opioid use (all p < 0.05). Conclusions: Despite the Florida Department of Health's restriction on narcotic prescriptions to 3-day supplies, opioids are still overprescribed in our region. The majority of patients do not require opioids after RALP, and patients who do require an opioid analgesic can be adequately managed with less than 6 pills of 5-mg oxycodone equivalents.

Ventral onlay glanuloplasty for treatment of fossa navicularis strictures.

PURPOSE: Management of fossa navicularis (FN) strictures balances restoring urethral patency with adequate cosmesis. Historically, FN strictures are managed via glans cap or glans wings, and in severe cases, multi-stage procedures. Ventral onlay glanuloplasty (VOG) is an easily reproducible technique that involves a single-stage augmentation with buccal mucosal graft. We have been applying this technique for several years and present early promising outcomes of this novel approach. MATERIALS AND METHODS: We retrospectively reviewed all patients with FN strictures who underwent VOG at our institution. Treatment success was designated by the absence of extravasation on voiding cystourethrogram and no need for further urethral instrumentation on follow up. Glans cosmesis was assessed by patients providing binary (yes/no) response to the satisfaction in their appearance. We also noted stricture length, stricture etiology, demographic characteristics and any post-operative complications and reported median, interquartile range (IQR) and count, frequency (%), accordingly. RESULTS: Ten patients underwent VOG and fit our inclusion criteria. Median stricture length was 2.0 cm (IQR 1.6 -2). Success rate was 90% (9/10) with a median follow up of 30 months (IQR 24.3 - 36.8). The one recurrence was treated by dilation combined with triamcinolone injection at 419 days post-op. Stricture etiology included primarily iatrogenic causes such as transurethral prostate resection (4/10), greenlight laser vaporization (2/10), cystolitholapaxy (1/10), and traumatic catheterization (3/10). All patients were satisfied with penile cosmesis. CONCLUSION: VOG is a simple technique for treating FN strictures. Based on our preliminary series, VOG provides sustained distal urethral patency and patients are pleased with the appearance.

Overcoming Drug Resistance in Advanced Prostate Cancer by Drug Repurposing.

Prostate cancer (PCa) is the second most common cancer in men. Common treatments include active surveillance, surgery, or radiation. Androgen deprivation therapy and chemotherapy are usually reserved for advanced disease or biochemical recurrence, such as castration-resistant prostate cancer (CRPC), but they are not considered curative because PCa cells eventually develop drug resistance. The latter is achieved through various cellular mechanisms that ultimately circumvent the pharmaceutical's mode of action. The need for novel therapeutic approaches is necessary under these circumstances. An alternative way to treat PCa is by repurposing of existing drugs that were initially intended for other conditions. By extrapolating the effects of previously approved drugs to the intracellular processes of PCa, treatment options will expand. In addition, drug repurposing is cost-effective and efficient because it utilizes drugs that have already demonstrated safety and efficacy. This review catalogues the drugs that can be repurposed for PCa in preclinical studies as well as clinical trials.