Cystectomy for Benign Indications.

PURPOSE OF REVIEW: This article evaluates the historical influences, current use, surgical techniques, and recent evidence on outcomes for cystectomy performed for benign indications. RECENT FINDINGS: At the population level, cystectomy for benign indications has similar perioperative morbidity to radical cystectomy for cancer. Postoperative patient satisfaction is high and functional outcomes appear good, including sexual function. Patient regret about diversion choice is low provided decisions are well informed. Cystectomy is important both as a primary procedure for benign disease and as an adjunct to primary urinary diversion. Early morbidity remains high but long-term results are encouraging. Further studies are needed to guide patient decision-making, to help inform diversion choice, and to understand the long-term impact of surgery and diversion choice on quality of life.

Incomplete bladder emptying and urinary tract infections after botulinum toxin injection for overactive bladder: Multi-institutional collaboration from the SUFU research network.

INTRODUCTION: Onabotulinumtoxin A (BTX-A) is an effective therapy for overactive bladder (OAB), however, adverse events may prevent patients from initiating therapy. The study objective was to report real-world rates of incomplete emptying and urinary tract infection (UTI) in men and women undergoing BTX-A for OAB. METHODS: Eleven clinical sites performed a retrospective study of adults undergoing first-time BTX-A injection (100 units) for idiopathic OAB in 2016. Exclusions included: postvoid residual (PVR) > 150 ml, prior BTX-A, pelvic radiation, or need for preprocedure catheterization. Primary outcomes at 6 months were incomplete emptying (clean intermittent catheterization [CIC] or PVR ≥ 300 ml without the need for CIC); and UTI (symptoms with either positive culture or urinalysis or empiric treatment). We compared rates of incomplete emptying and UTI within and between sexes, using univariate and multivariable models. RESULTS: 278 patients (48 men and 230 women) met inclusion criteria. Mean age was 65.5 years (range: 24-95). 35% of men and 17% of women had incomplete emptying. Men had 2.4 (95% CI: 1.04-5.49) higher odds of incomplete emptying than women. 17% of men and 23.5% of women had ≥1 UTI, the majority of which occurred within the first month following injection. The strongest predictor of UTI was a history of prior UTI (OR: 4.2 [95% CI: 1.7-10.3]). CONCLUSIONS: In this multicenter retrospective study, rates of incomplete emptying and UTI were higher than many previously published studies. Men were at particular risk for incomplete emptying. Prior UTI was the primary risk factor for postprocedure UTI.

Single Institutional Experience with Single Stage Sacral Neuromodulation: Cost Savings and Outcomes in a Contemporary Case Series.

PURPOSE: Sacral neuromodulation is traditionally performed in 2 stages. Studies have projected that 1-stage sacral neuromodulation is cost-effective if the conversion rate is 61.3% or greater. To our knowledge we present the first case series in the literature to evaluate the cost of 1-stage sacral neuromodulation. The objective of our study was to evaluate outcomes and analyze cost using our institutional experience with 1-stage sacral neuromodulation. MATERIALS AND METHODS: A total of 15 consecutive 1-stage sacral neuromodulation procedures were performed at a self-insured, integrated health care institution. Cost data were determined using 2019 Medicare reimbursement rates for CPT codes 64581, 64585, 64590 and 64595. Median operative time was derived from actual institutional data. RESULTS: One-stage sacral neuromodulation implantation was performed in 15 patients. Median followup was 14.6 months (IQR 6.9-22.5). Of the 15 cases 14 (93.3%) were successful, defined as a 50% or greater improvement from baseline. Total reimbursement for the 15 patients who underwent 1-stage implantation was $329,430. If these patients had undergone traditional 2-stage implantation with equivalent outcomes, the overall reimbursement was determined to be $414,796. Single-stage sacral neuromodulation implantation provided a calculated total cost savings of $85,366 (p <0.01). Moreover, a projected 233 minutes in operative time was saved by performing 1-stage sacral neuromodulation (p <0.01). CONCLUSIONS: This study demonstrates the potential health care savings of a 1-stage sacral neuromodulation procedure. Moreover, 1-stage sacral neuromodulation may have other added benefits, such as reduced infection rates, patient satisfaction and other indirect cost savings, including reduced time off from work.

Overview of surgical techniques in gender-affirming genital surgery.

Gender related genitourinary surgeries are vitally important in the management of gender dysphoria. Vaginoplasty, metoidioplasty, phalloplasty and their associated surgeries help patients achieve their main goal of aligning their body and mind. These surgeries warrant careful adherence to reconstructive surgical principles as many patients can require corrective surgeries from complications that arise. Peri-operative assessment, the surgical techniques employed for vaginoplasty, phalloplasty, metoidioplasty, and their associated procedures are described. The general reconstructive principles for managing complications including urethroplasty to correct urethral bulging, vaginl stenosis, clitoroplasty and labiaplasty after primary vaginoplasty, and urethroplasty for strictures and fistulas, neophallus and neoscrotal reconstruction after phalloplasty are outlined as well.

Anastomotic Urethroplasty for an Obstructing Calculus Within a Bulbar Urethral Diverticulum and Urethral Stricture.

A 61-year-old male with prior history of endoscopic urethral calculus removal presented to the emergency room with urinary retention and a palpable perineal mass. A CT showed a large calcification within the bulbar urethra. After multiple unsuccessful attempts at foley catheter insertion, the urology service was consulted. The patient was taken to the operating room where an obstructing urethral calculus with associated urethral stricture was visualized on cystoscopy. We present an exceedingly rare case of recurrent urethrolithiasis with associated urethral stricture managed with initial suprapubic tube and delayed primary end-to-end urethroplasty, excision of urethral stricture and urethral diverticulectomy.

Outcomes of Male Sling Mesh Kit Placement in Patients with Neuropathic Stress Urinary Incontinence: A Single Institution Experience.

BACKGROUND AND OBJECTIVES: The mainstay of therapy in patients with neuropathic stress urinary incontinence (nSUI) has been through the use of artificial urinary sphincter (AUS). AUS infection/erosion rates are higher in nSUI patients and these patients tend to be younger, increasing the likelihood of multiple AUS revisions in the future. We review our experience with mesh male slings for patients with nSUI. METHODS: A retrospective review of patients who had mesh sling placement. RESULTS: Twenty patients were identified between 2003 and 2011. 14/20 (70%) (5 = AdVance, 8 = InVance, 1 = Virtue) were available for long-term evaluation; in 6/20 (30%) the sling was removed for either infection or perineal wound breakdown. The mean time from injury to male sling was 148.2 (29-449) months. Pre-/post-op fluorourodynamic study was performed in 13 and 7 patients, respectively. There were no significant differences in ALPP (46.4 vs. 55.7 cm H2O, p = 0.106) and MCC (456.6 vs. 608 ml, p = 0.21) in the 7 patients who had a post-op study: five patients had new onset low bladder compliance and two had new onset detrusor overactivity post-sling. With a mean follow-up of 24.7 (1-66) months, 4/14 (28.6%) had no UI. CONCLUSIONS: With short-term follow-up, mesh male slings are a feasible option to treat nSUI. There appears to be a lower success rate for UI resolution, which may be attributable to new onset detrusor failure or wound infection requiring sling removal.

Total bladder and posterior urethral reconstruction: salvage technique for defunctionalized bladder with recalcitrant posterior urethral stenosis.

PURPOSE: Recalcitrant posterior urethral stenosis is a challenging disease. When combined with a defunctionalized bladder, cutaneous urinary diversion is the most common surgical option. We present a novel technique of total lower urinary tract reconstruction, combining salvage cystectomy, ileal neobladder formation and urethral pull-through, as an orthotopic alternative in patients with a defunctionalized bladder and recalcitrant posterior urethral stenosis. MATERIALS AND METHODS: We completed a retrospective review of 8 patients who underwent salvage cystectomy, orthotopic ileal neobladder formation and urethral pull-through. Artificial urinary sphincter placement was performed in a staged fashion. Six patients received prostate cancer treatment including radiation therapy, 1 had urethral disruption after robotic radical prostatectomy, and 1 experienced bladder rupture and urethral distraction injury during a motorcycle accident. Patient demographics, operative variables and postoperative outcomes were examined. RESULTS: No high grade complications were observed after salvage cystectomy, orthotopic neobladder formation and urethral pull-through. After staged artificial urinary sphincter placement, a median of 2 revision surgeries (range 0 to 4) was required to establish social continence. All patients maintained functional urinary storage, urethral patency and social continence at a median followup of 58 months. No patient had complications related to orthotopic neobladder formation, including ureteroileal anastomotic stricture or pyelonephritis, and no patient required cutaneous diversion. CONCLUSIONS: Total lower urinary tract reconstruction with cystectomy, ileal neobladder formation and urethral pull-through offers an orthotopic alternative for patients with recalcitrant posterior urethral stenosis and defunctionalized bladders. Although it requires staged placement of an artificial urinary sphincter, this approach can offer functional urinary storage, durable urethral patency and avoidance of cutaneous urinary diversion.

Long-term efficacy of repeat incisions of bladder neck/external sphincter in patients with spinal cord injury.

OBJECTIVE: To evaluate the efficacy of repeat bladder neck incision (BNI), with or without external sphincterotomy (ES). BNI/ES has been commonly used for management of neurogenic bladder in spinal cord injury (SCI) patients. METHODS: This was a retrospective review of institutional review board-approved SCI database. RESULTS: A total of 97 patients underwent BNI/ES over a period of 40 years. During the period reviewed, a solitary redo BNI/ES was done in 46 patients, a second redo BNI/ES was done in 23 patients, and a third redo BNI/ES was done in 7 patients with success rates of 50%, 68.2%, and 85.7%, respectively. The most common indications for surgery failure and need for repeat surgery were elevated residual for the first repeat BNI/ES, recurrent urinary tract infections for the second, and elevated residual for the third repeat BNI/ES. All patients had a normal serum creatinine level at the end of the follow-up. Mean elapsed follow-up after the last redo BNI/ES was 119 months (range, 6-408 months) for all patients evaluated. Mean durability of successful redo BNI/ES was 109.1 months, which was significantly longer than mean durability of failed redo BNI/ES at 69.4 months (P <.05). CONCLUSION: SCI patients undergoing BNI/ES may require repeat BNI/ES to optimize lower urinary tract management. The success rate ranges from 50% to 85.7% after 3 repeat BNI/ES procedures with acceptable long-term durability and low perioperative complication rates.

Differences in urodynamic study variables in adult patients with neurogenic bladder and myelomeningocele before and after augmentation enterocystoplasty.

AIMS: To evaluate urodynamic parameters in myelomeningocele patients with native bladders and after augmentation, continence rates and check the longevity of these parameters after lower urinary tract (LUT) reconstruction. METHODS: A retrospective review of adult myelomeningocele patients with UDS. RESULTS: 118 adult patients with NGB secondary to myelomeningocele were identified. 58/118 (49.1%) had UDS performed in our clinic: 18/58 (31%) after prior reconstruction ("Augment" group) and 40/58 (69%) during annual urologic follow up ("NoSx" group). Urodyanmic findings after augmentation included: Pdet@MCC 31.1 (1-95) cmH(2)O, MCC 495.9 ml, NDO in 3/18 (16.7%), mean DLPP 54.0 (48-60) cmH(2)O and mean ALPP 39.6 (20-110) cmH(2)O in 5/18 with an incompetent sphincter. Patients in "NoSx" group had the following findings: Pdet@MCC of 39.6 (1-60) cmH(2)O, MCC 407.5 ml, 18/40 (45%) had NDO, mean DLPP of 48.1 (15-95) cmH(2)O and mean ALPP = 51 (17-78) cmH(2)O in 10/40 with incompetent sphincter. In the "NoSx" group, 19/40 (47.5%) had normal bladder compliance. Mean time from the surgery to UDS was 10.4 years. Continent patients in the "NoSx" group had a significantly higher MCC than incontinent patients in the same group (475 vs. 352 ml, P = 0.029). 8/17 (47.1%) continent patients in "NoSx" group had normal UDS. CONCLUSIONS: Most patients after augmentation maintain low bladder pressures for more than 10 years. Close long-term follow up should be maintained, especially in those patients that have not had prior augmentation. Urinary incontinence may be secondary to poor sphincteric function in patients with and without prior augmentation. Moreover, we should continue to follow patients after reconstruction as elevated detrusor pressures can still be seen. Strict follow up after LUT reconstruction still continues to be important.

Augmentation enterocystoplasty in overactive bladder: is there still a role?

Overactive bladder (OAB) is a highly prevalent syndrome defined as "urinary urgency, usually accompanied by frequency and nocturia with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology." It is known to generate a large degree of bother and can lead to significant morbidity. Augmentation cystoplasty (AC) historically has been reserved for patients refractory to conservative management. Over time, the treatment options for OAB have grown. We now have multiple pharmacological agents approved by the US Food and Drug Administration to treat OAB. In addition, neuromodulation and botulinum toxin now are viable options for patients who have suboptimal outcomes after treatment with anticholinergics and/or pelvic floor behavioral therapy. This may suggest that AC no longer is utilized as a mainstay therapy for OAB. However, despite these many possible treatment options, AC remains an important, time-tested tool in the armamentarium of the urologist to combat the patient with refractory OAB.

Comparison of extraperitoneal and intraperitoneal augmentation enterocystoplasty for neurogenic bladder in spinal cord injury patients.

OBJECTIVES: Augmentation enterocystoplasty is the standard treatment for patients with neurogenic bladder who have failed medical management. Our "extraperitoneal" approach involves a small peritoneotomy to obtain the segment of bowel for augmentation, and a standard "clam" enterocystoplasty. We compared operative and postoperative parameters and clinical outcomes of this technique with the standard intraperitoneal technique. METHODS: We retrospectively reviewed charts of 73 patients with neurogenic voiding dysfunction refractory to medical management who underwent augmentation enterocystoplasty alone or in conjunction with additional procedures. A total of 49 patients underwent extraperitoneal augmentation and 24 patients underwent intraperitoneal augmentation. Operative and postoperative parameters including time of surgery, estimated blood loss, need for blood transfusion, time for return of bowel function, and length of hospital stay were examined. Clinical outcomes including early and late postoperative complications, and continence status were also analyzed. RESULTS: Median follow-up was 2.5 years. Patients in the extraperitoneal group had significantly shorter operative time (3.9 vs. 5.6 h, P < 0.0001); shorter hospital stay (8.0 vs. 10.5 days, P = 0.009); and shorter time to return of bowel function (3.5 vs. 4.9 days, P = 0.0005). There was no significant difference in complication rates. Postoperative continence was equally improved in both groups. When only patients with no prior abdominal surgery were compared, the findings were analogous: shorter operative time, shorter length of stay, sooner return of bowel function, and no difference in complication rate. CONCLUSIONS: The extraperitoneal technique provides an equally effective method of bladder augmentation to the standard technique with easier early postoperative recovery.

Augmentation cystoplasty: what are the indications?

Augmentation cystoplasty has been studied and performed by urologists for more than 100 years. Although specific indications, techniques, and materials used have undergone major changes and revisions during this period, the general concepts have remained the same. Bladder augmentation increases the bladder's storage capacity. Specific indications include structurally diminished bladder capacity, neurogenically incapacitated bladder, special circumstances of overactive bladder, and interstitial cystitis. This article briefly reviews techniques including laparoscopic and extraperitoneal approaches. Most common long-term consequences of bladder augmentation including chronic infections, bladder stones, perforation, and malignancy are described. Overall, we demonstrate that in appropriately selected patients, bladder augmentation presents an excellent treatment option to improve bladder capacity, achieve socially acceptable continence, and stabilize renal function.