Long-Term Surgical Management of Severe Pelvic Injury and Resulting Neurogenic Bladder From an Improvised Explosive Device.

Reconstructive surgery can help veterans improve their quality of life and live free of chronic indwelling catheters following injury from an improvised explosive device.

High Rates of Inadequate Urine Volume Cause Failure of Clinic Based Uroflowmetry in Men with Lower Urinary Tract Symptoms.

INTRODUCTION: Clinic based uroflowmetry is commonly used in the diagnosis and management of lower urinary tract symptoms. AUA (American Urological Association) guidelines recommend 2 separate uroflowmetry tests with a voided volume greater than 150 ml for accurate interpretation. We characterized the interpretability of a series of uroflowmetry tests done at our institution and hypothesized that a significant number were noninterpretable because of inadequate urine volume. METHODS: Uroflowmetry results were collected from male patients at the UH (University of Utah Hospital) and VAMC (George Wahlen Veterans Affairs Medical Center) urology clinics between August 31, 2014 and September 30, 2014. Average time to perform uroflowmetry was determined. Tests with a volume of 150 ml or less were classified as noninterpretable. Data were characterized using descriptive statistics. RESULTS: During the study period 169 tests were collected, including 104 at UH and 65 at VAMC, of which 107 (63%) were noninterpretable. An estimated total of 1,452 tests were performed at UH and VAMC within a 12-month period. Average time to perform uroflowmetry by health care workers was 2 minutes 18 seconds. The estimated time loss per year for medical personnel due to noninterpretable uroflow studies was 35 hours. CONCLUSIONS: More than 50% of clinic based uroflowmetry tests at our institution had a voided volume of 150 ml or less and were deemed noninterpretable per AUA guidelines. Current clinic based uroflowmetry testing strategies are inefficient and wasteful. Reliable, accurate alternatives to clinic based uroflowmetry for the diagnosis and management of lower urinary tract symptoms should be explored.

An antimicrobial prophylaxis protocol using rectal swab cultures for transrectal prostate biopsy.

PURPOSE: To evaluate the benefit of an antimicrobial prophylaxis protocol using rectal swab cultures in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy in our Veterans Affairs population. METHODS: Between June 1, 2013, and June 1, 2014, we implemented an antimicrobial prophylaxis protocol using rectal swab cultures on selective media containing ciprofloxacin for all men scheduled for TRUS-guided prostate biopsy. Data from 2759 patients from Jan 1, 2006 to May 31, 2013, before protocol implementation served as historical controls. Patients with fluoroquinolone (FQ)-susceptible organisms received FQ monotherapy, while those with FQ-resistant organisms received targeted prophylaxis. Our objective was to compare the rate of infectious complications 30 days after prostate biopsy before and after implementation of our antimicrobial protocol. RESULTS: One hundred and sixty-seven patients received rectal swab cultures using our protocol. Seventeen (14 %) patients had FQ-resistant positive cultures. Patients with positive FQ-resistant culture results were more likely to have had a history of previous prostate biopsy and a positive urine culture in the last 12 months (p = 0.032, p = 0.018, respectively). The average annual infectious complication rate within 30 days of biopsy was reduced from 2.8 to 0.6 % before and after implementation of our antimicrobial prophylaxis protocol using rectal swab cultures, although this difference was not statistically significant (p = 0.13). CONCLUSION: An antimicrobial prophylaxis protocol using rectal culture swabs is a viable option for prevention of TRUS-guided prostate biopsy infectious complications. After implementation of an antimicrobial prophylaxis protocol, we observed a nonsignificant decrease in the rate of post-biopsy infectious complications when compared to historical controls.

Use of a polytetrafluoroethylene (GORE-TEX) bolster to close the renal parenchymal defect during open partial nephrectomy.

INTRODUCTION: Numerous surgical techniques have been described to facilitate closure of the renal parenchymal defect. We sought to describe the operative technique and define the safety and efficacy of using an expanded polytetrafluoroethylene (GORE-TEX; WL Gore and Associates, Flagstaff, AZ) bolster to aid in closure of the renal parenchymal defect at the time of open partial nephrectomy (OPN). TECHNICAL CONSIDERATIONS: A retrospective review of 175 patients who underwent an OPN using an expanded polytetrafluoroethylene (ePTFE) bolster at the Huntsman Cancer Hospital, University of Utah and Salt Lake City Veterans Affairs Medical Center from March 2005 to February 2013 was conducted. Postoperative complications occurring within 90 days were graded using the Clavien grading system. CONCLUSION: Overall, 57 patients (32.6%) experienced a postoperative complication. Fifteen patients (8.5%) had a Clavien ≥ grade-III complication. Ten patients (5.7%) received blood transfusions. Urine leak requiring intervention occurred in 2 patients (1.1%). Delayed hemorrhage requiring nephrectomy and pseudoaneurysm formation were rare, occurring in 1 patient each (0.6%). Infection of the ePTFE material occurred in 2 patients (1.1%). In both cases, it was explanted without requiring nephrectomy. The use of an ePTFE bolster is an effective and safe method of closing the renal parenchymal defect after OPN with an acceptable 90-day postoperative complication rate and a low risk of infection.

Contemporary practice patterns of endoscopic surgical management for benign prostatic hyperplasia among urologists in the United States.

PURPOSE: We describe contemporary trends in endoscopic surgical management for benign prostatic hyperplasia. We examined case logs submitted by urologists for American Board of Urology certification or recertification. We compared electrosurgical transurethral resection of the prostate vs laser vaporization or laser enucleation and determined the impact of surgeon age on practice patterns. MATERIALS AND METHODS: We analyzed case logs from 2004 to 2010 for trends and used logistic regression models to assess the impact of surgeon age on endoscopic surgery use. RESULTS: A total of 3,955 urologists included at least 1 endoscopic surgical management in the case logs, while 2,334 (59%) exclusively performed electrosurgical transurethral resection of the prostate and 309 (8%) exclusively performed laser vaporization or laser enucleation. We observed a large increase in the number and proportion of laser procedures from 11% in 2004 to 44% in 2010. Although there was no difference in median age between urologists who performed exclusively electrosurgical transurethral resection and those who performed laser procedures, the latter had a substantially higher case volume. Older urologists were significantly less likely to perform laser vaporization or enucleation when undergoing the second recertification (OR 0.56/10 years of age, 95% CI 0.36-0.87, p = 0.009), but not the initial certification. CONCLUSIONS: There was a substantial increase in laser vaporization or laser enucleation procedures performed by urologists who underwent board certification or recertification in 2004 to 2010. However, of those undergoing the second recertification older age was significantly associated with a lower likelihood of performing laser procedures. These data provide estimates of current practice patterns and further our understanding of evolving surgical treatment for benign prostatic hyperplasia.

York-Mason procedure for repair of recto-urinary fistulae: a 40-year experience.

OBJECTIVE: To review the use of the York-Mason transanal, transrectal procedure, used in properly selected patients over a 40-year period, for repairing recto-urinary fistulae. PATIENTS AND METHODS: We retrospectively reviewed the medical records of all patients who underwent acquired recto-urethral or rectovesical fistula repair at our institution. A total of 51 patients have undergone York-Mason recto-urinary fistula repair at our institution during this time. RESULTS: Since our last report in 2003, we have performed this procedure an additional 27 times. We continue to have good results, with 25 of these patients having resolution of their fistulae after one procedure. Failures in the updated cohort were radiation-induced fistulae. We continue to find no evidence of faecal incontinence or stenosis after this procedure. CONCLUSIONS: Over a period of 40 years, the York-Mason posterior, transanal, transrectal correction of iatrogenic recto-urinary fistula has been highly successful, reliable and safe, when used for fistulae occurring after prostate surgery. Preliminary faecal diversion can often be avoided in selected patients.

Overprescription of postoperative narcotics: a look at postoperative pain medication delivery, consumption and disposal in urological practice.

PURPOSE: Prescription narcotic abuse is a significant social problem. Surplus medication following surgery is 1 source of prescription diversion. We assessed prescribing practices, consumption and disposal of prescribed narcotics after urological surgery. MATERIALS AND METHODS: Surveys were administered to a 3-month consecutive sample of adult patients who underwent surgery performed by full and adjunct University of Utah Urology faculty. Surveys were performed 2 to 4 weeks postoperatively. With the exception of the investigators, prescribing physicians had no prior knowledge of the study. Data collected included perception of pain control, type and quantity of medication prescribed, quantity of leftover medication, refills needed, disposal instructions and surplus medication disposition. RESULTS: Overall 47% of 586 patients participated in the study. Hydrocodone was prescribed most commonly (63%), followed by oxycodone (35%), and 86% of the patients were satisfied with pain control. Of the dispensed narcotics 58% was consumed and 12% of patients requested refills. A total of 67% of patients had surplus medication from the initial prescription and 92% received no disposal instructions for surplus medication. Of those patients with leftover medication 91% kept the medication at home while 6% threw it in the trash, 2% flushed it down the toilet and less than 1% returned it to a pharmacy. CONCLUSIONS: Overprescription of narcotics is common and retained surplus medication presents a readily available source of opioid diversion. It appears that no entity on the prescribing or dispensing ends of prescription opioid delivery is fulfilling the responsibility to accurately educate patients on proper surplus medication disposal. Surgeons should analyze prescribing practices and consider decreasing the quantity of postoperative narcotics prescribed.

CT-guided biopsy for the diagnosis of renal tumors before treatment with percutaneous ablation.

OBJECTIVE: Percutaneous thermal ablation is an emerging technique in the management of renal cell carcinoma (RCC), with greatest efficacy in tumors < or = 3 cm. The purpose of this retrospective study was to evaluate the role and utility of pretreatment CT-guided biopsy in patients referred for percutaneous thermal ablation of renal tumors. CONCLUSION: Less than 5% of samples in our study were benign, and 11.8% were nondiagnostic. Biopsy in smaller lesions was less accurate; therefore biopsy is less useful for these renal lesions. Because fine-needle aspiration (FNA) has higher sensitivity than core biopsy, an appropriate algorithm may be to begin with FNA and reserve core biopsy for cases in which an onsite cytotechnologist is unavailable or deems the sample of inadequate cellularity.

Laparoscopic nephroureterectomy complicated by rupture of adrenal artery pseudoaneurysm.

We present a case of ruptured adrenal artery pseudoaneurysm as a complication of laparoscopic nephroureterectomy. An 87-year-old woman with hematuria and transitional cell carcinoma on imaging underwent laparoscopic nephroureterectomy. Her postoperative recovery was uneventful until day 17, when she presented with severe abdominal pain, syncope, and significant anemia. An aneurysm was suspected on computed tomography and Doppler ultrasonography. Selective angiography showed a pseudoaneurysm of the adrenal artery that could not be successfully embolized. Exploratory laparotomy obtained hemostasis, and the pseudoaneurysm was identified as involving an adrenal artery next to a surgical clip, which is speculated to be the cause.