The Management of Inflatable Penile Prosthesis Erosion and Infection following Iatrogenic Aspiration.

This case report presents a unique and previously unreported case of malfunction, infection, and erosion of an inflatable penile prosthesis (IPP) resulting from iatrogenic injury during a priapism aspiration procedure performed by an emergency medicine physician. The patient, a 75-year-old male with a history of IPP placement for erectile dysfunction, presented with urinary retention and priapism, leading to inadvertent deflation of the IPP during aspiration. Subsequent evaluation revealed a pinhole opening on the scrotum, indicating infection and erosion of the prosthesis tubing. The patient underwent emergent explantation of the infected IPP, washout, cystoscopy, and insertion of a suprapubic tube. Intraoperative cultures identified Escherichia cloacae as the causative pathogen. This case highlights the importance of thorough chart review to identify patients with IPPs before aspiration procedures and emphasizes the need for healthcare provider education regarding potential complications in this patient population. Early recognition and management of such complications are crucial for optimal patient outcomes. While IPP placement remains a highly satisfactory treatment for erectile dysfunction, this case highlights the importance of vigilance to ensure the best care for patients with penile prostheses. It is noteworthy that ultimately, a new IPP was not placed in this patient due to the patient's significant medical comorbidities.

A case report of melanosis of the bladder within a bladder diverticulum and associated Aerococcus urinary infection.

Background: Melanosis vesicae is a rare condition characterized by the deposition of melanin within the bladder urothelium. Case presentation: We present a case of a 72-year-old male with a history of recurrent urinary retention, bladder diverticula, and concurrent Aerococcus urinary tract infection who presented with left-sided abdominal pain. Cystoscopy revealed diffuse black splotch lesions throughout the bladder and two diverticula. Histopathological examination confirmed the diagnosis of melanosis vesicae. The patient ultimately underwent an open bladder diverticulectomy. Conclusion: The potential associations between melanosis vesicae, urinary tract malignancies and concurrent conditions such as bladder diverticula and urinary infections warrant further investigation.

Mature rectovesical fistula after salvage cryotherapy; A rare complication following treatment for locally advanced prostate cancer.

A rectovesical fistula is an abnormal connection between the bladder and rectum. A rectovesical fistula is a theoretical, but rarely documented phenomenon following locally advanced prostate cancer treatment (radiation therapy, cryotherapy, etc.). Here, we present a case report of a mature rectovesical fistula thirteen years after the patient was treated with radiation therapy and salvage cryotherapy for locally advanced prostate cancer and the various treatment options.

Appropriateness Criteria for Ureteral Stent Omission following Ureteroscopy for Urinary Stone Disease.

Objective: To bridge the gap between evidence and clinical judgement, we defined scenarios appropriate for ureteral stent omission after uncomplicated ureteroscopy (URS) using the RAND/UCLA Appropriateness Method (RAM). We retrospectively assessed rates of appropriate stent omission, with the goal to implement these criteria in clinical practice. Methods: A panel of 15 urologists from the Michigan Urological Surgery Improvement Collaborative (MUSIC) met to define uncomplicated URS and the variables that influence stent omission decision-making. Over two rounds, they scored clinical scenarios for Appropriateness Criteria (AC) for stent omission based on a combination of variables. AC were defined by median scores: 1 to 3 (inappropriate), 4 to 6 (uncertain), and 7 to 9 (appropriate). Multivariable analysis determined the association of each variable with AC scores. Uncomplicated URS cases in the MUSIC registry were assigned AC scores and stenting rates assessed. Results: Seven variables affecting stent decision-making were identified. Of the 144 scenarios, 26 (18%) were appropriate, 88 (61%) inappropriate, and 30 (21%) uncertain for stent omission. Most scenarios appropriate for omission were pre-stented (81%). Scenarios with ureteral access sheath or stones >10mm were only appropriate if pre-stented. Stenting rates of 5,181 URS cases correlated with AC scores. Stents were placed in 61% of cases appropriate for omission (practice range, 25% to 98%). Conclusion: We defined objective variables and AC for stent omission following uncomplicated URS. AC scores correlated with stenting rates but there was substantial practice variation. Our findings demonstrate that the appropriate use of stent omission is underutilized.

Infection-related hospitalization following ureteroscopic stone treatment: results from a surgical collaborative.

BACKGROUND: Unplanned hospitalization following ureteroscopy (URS) for urinary stone disease is associated with patient morbidity and increased healthcare costs. To this effect, AUA guidelines recommend at least a urinalysis in patients prior to URS. We examined risk factors for infection-related hospitalization following URS for urinary stones in a surgical collaborative. METHODS: Reducing Operative Complications from Kidney Stones (ROCKS) is a quality improvement (QI) initiative from the Michigan Urological Surgery Improvement Collaborative (MUSIC) consisting of academic and community practices in the State of Michigan. Trained abstractors prospectively record standardized data elements from the health record in a web-based registry including patient characteristics, surgical details and complications. Using the ROCKS registry, we identified all patients undergoing primary URS for urinary stones between June 2016 and October 2017, and determined the proportion hospitalized within 30 days with an infection-related complication. These patients underwent chart review to obtain clinical data related to the hospitalization. Multivariable logistic regression analysis was performed to determine risk factors for hospitalization. RESULTS: 1817 URS procedures from 11 practices were analyzed. 43 (2.4%) patients were hospitalized with an infection-related complication, and the mortality rate was 0.2%. Median time to admission and length of stay was 4 and 3 days, respectively. Nine (20.9%) patients did not have a pre-procedure urinalysis or urine culture, which was not different in the non-hospitalized cohort (20.5%). In hospitalized patients, pathogens included gram-negative (61.5%), gram-positive (19.2%), yeast (15.4%), and mixed (3.8%) organisms. Significant factors associated with infection-related hospitalization included higher Charlson comorbidity index, history of recurrent UTI, stone size, intra-operative complication, and procedures where fragments were left in-situ. CONCLUSIONS: One in 40 patients are hospitalized with an infection-related complication following URS. Awareness of risk factors may allow for individualized counselling and management to reduce these events. Approximately 20% of patients did not have a pre-operative urine analysis or culture, and these findings demonstrate the need for further study to improve urine testing and compliance.

Gross Hematuria in an Elderly Smoker Male Due to Eosinophilic Cystitis.

This is a case of a 71-year-old smoker man who presented with four days of gross hematuria, which turned to be caused by eosinophilic cystitis (EC) proven by bladder biopsy. EC is a rare clinical and pathological inflammatory condition of the bladder with an unknown exact cause. It can present with hematuria, urinary frequency, dysuria, and suprapubic pain. Sometimes, the presentation can mimic urinary tract infection (UTI) or malignancy, especially in older patients.

Shockwave Lithotripsy Use in the State of Michigan: American Urological Association Guideline Adherence and Clinical Implications.

OBJECTIVE: To understand how treatment of patients with urinary stones by shockwave lithotripsy (SWL) aligns with current published practice guidelines. METHODS: We used the Michigan Urologic Surgery Improvement Collaborative Reducing Operative Complications for Kidney Stones registry to understand SWL use in the state of Michigan. This prospectively maintained clinical registry includes data from community and academic urology practices and contains clinical and operative data for patients undergoing SWL and ureteroscopy (URS). We identified patients undergoing SWL from 2016 to 2019. In accordance with AUA guidelines, we evaluated practice patterns in relation to recommendations for treatment selection for SWL as well as clinical implications of guideline nonadherence. RESULTS: Four thousand, two hundred and nine SWL procedures performed across 34 practices were analyzed. Perioperative antibiotics were administered to 61.3% of patients undergoing SWL. A ureteral stent was placed at the time of SWL in 2.7% of patients. For lower pole renal stones >1 cm or large (>2 cm) renal stones in the registry, 32.2% and 58.9% of patients, respectively, underwent SWL, while the remainder were treated with URS. In these instances, SWL was associated with inferior stone-free rate (SFR) relative to URS. In patients with residual stones after SWL, 34.6% were treated with repeat SWL with lower SFR than those treated with subsequent URS. Postoperatively, 42.1% of patients were prescribed alpha-blockers with no benefit seen in terms of SFR. CONCLUSION: Substantial variation exists among urology practices with regard to SWL use. These data serve to inform quality improvement efforts regarding appropriateness criteria for SWL in Michigan.

Incidence and Morbidity of Radiation-Induced Hemorrhagic Cystitis in Prostate Cancer.

OBJECTIVE: To determine if reported incidence rates of hemorrhagic cystitis after radiation therapy for prostate cancer are accurate, to investigate the effect of different radiation modalities on the development of hemorrhagic cystitis and to assess its morbidity and treatment. MATERIALS AND METHODS: A retrospective chart review was completed of 709 patients at 2 Detroit Medical Center hospitals who underwent radiation therapy for prostate cancer between January 2000 and September 2015. In patients who developed hemorrhagic cystitis, we analyzed the incidence, radiation modality, morbidity, treatment, and complications. RESULTS: The incidence rate of hemorrhagic cystitis after radiation for prostate cancer was 11.1%. There was no significant difference between external beam and intensity-modulated radiation therapy and the development of hemorrhagic cystitis (P = .18). Patients developed hemorrhagic cystitis an average of 79.1 months (4-230 months) after radiation. The average number of admissions was 2.5 (1-9) with an average length of stay of 7.6 days (1-42 days). Fifty-two percent of patients required blood transfusion with an average of 4.3 units transfused per patient (1-33U). The most common treatment was cystoscopy with fulguration/clot evacuation in 86% of patients. Complications included urinary tract infection, acute kidney injury, urosepsis, and even death. CONCLUSION: The incidence of hemorrhagic cystitis following radiation therapy for prostate cancer is under-reported in the literature. Hemorrhagic cystitis is associated with high morbidity and complications for patients, requiring multiple hospitalizations, blood transfusions, and procedures. Advances in radiation have not significantly reduced the risk of developing hemorrhagic cystitis.

Surgical cryoablation as an option for small renal masses in patients who are not ideal partial nephrectomy candidates: intermediate-term outcomes.

OBJECTIVE: There has been increasing interest in surveillance and ablative techniques for small renal masses (SRM), given the increasing number being diagnosed at smaller sizes. Of the currently available ablative techniques, radiofrequency ablation and cryoablation have been the popular ones. We describe our intermediate-term outcomes with using cryoablation for SRM in patients who were not ideal candidates for partial nephrectomy. MATERIALS AND METHODS: Nineteen patients treated with cryoablation were included. Patients with renal lesions <4 cm were considered for cryoablation, and all patients were treated between 2002 and 2007. Access was either laparoscopic (transperitoneal) or via open surgical techniques. From 2002 to 2004, the CryoCare System (Endocare, Inc., Irvine, CA) was used, with probe sizes ranging from 3 to 5 mm. Before 2004, the SeedNet system (Galil Medical, Arden Hills, MN) was used, with 17-gauge (1.47 mm) IceRod cryoneedles. Recurrence-free survival (RFS) and overall survival (OS) were calculated using Kaplan Meier methodology. RESULTS: The mean age was 56.7 years. The mean tumour size was 2.6 cm (range 1.2-4.0 cm). There were no intraoperative or postoperative complications in the 19 patients. One patient has been lost to follow-up; mean follow up was 41.6 months (range 7-84 months) in the cohort. Recurrence, defined as either increase in size of lesion or enhancement on follow-up imaging, was seen in 4 patients. There was 1 non-cancer specific death, and 1 cancer specific death. CONCLUSIONS: The 4-year RFS rate and OS rate were 83.6% and 94.1%, respectively, in patients with SRM who were unsuitable for partial nephrectomy.

Ureteral frozen sections at the time of radical cystectomy: reliability and clinical implications.

BACKGROUND: We hypothesized that the incidence of ureteral abnormalities on frozen section analysis (FS) at the time of radical cystectomy is much lower than historical values and that FS has minimal impact on outcomes. We also sought to determine the accuracy of FS and the associated costs. METHODS: We reviewed the records of 301 patients who underwent a radical cystectomy for urothelial carcinoma of the bladder (UC) between March 2000 and January 2007. The ureteral margins were sent for FS and subsequent permanent hematoxyllin and eosin (H&E) sections and results were compared. Analyses were performed to determine the costs of FS and if any association was present with the pathological stage of the primary bladder tumour and regional lymph nodes, the presence of urothelial carcinoma in situ of the bladder (CIS) and survival outcomes with the FS. RESULTS: We identified 602 ureters for this study. The incidence of CIS or solid urothelial carcinoma in the ureter was 2.8%. The presence of CIS of the bladder and prostatic urethra was significantly associated with a positive FS (p = 0.02). The FS were not associated with survival outcomes. The cost to pick up 1 patient with any abnormality on FS was $2080. The cost to pick up 1 patient with CIS or solid urothelial carcinoma of the ureter on FS was $6471. CONCLUSION: The incidence of CIS and tumour on FS during radical cystectomy for UC is low. The costs associated with FS are substantial. Frozen section analysis should only be performed in select patients undergoing radical cystectomy.

Quality assurance and benchmarking for radical cystectomy: monitoring early complications and mortality using cumulative summation charts.

PURPOSE: Cumulative summation is one method for quality assurance that has recently been adapted to the medical field to monitor any binary surgical outcomes on an ongoing basis. In this study we used cumulative summation charts for quality assurance in radical cystectomies. MATERIALS AND METHODS: Cumulative summation charts were generated from prospectively collected data for the first 150 radical cystectomies performed by a single surgeon from 2001 to 2007. Overall and disease specific survival were estimated using the Kaplan-Meier actuarial methodology and stratified by pathological stage. Based on a literature review acceptable rates were identified as death 0.3% to 4%, ureterointestinal leak 0.3% to 1%, unplanned reoperation 2.3% to 17%, myocardial infarction 0.3% to 2% and pulmonary embolism 0.4% to 2%. RESULTS: Median followup was 16 months. There were 12, 12, 41, 26, 25 and 34 patients with pTis, pT1, pT2, pT3, pT4 and pN+ disease, respectively. The 5-year disease specific survival for less than pT2, pT2, pT3, pT4 and pN+ was 92%, 90%, 60%, 51% and 30%, respectively. The occurrence of postoperative death, rectal injury, ureterointestinal anastomotic leak, immediate reoperation, myocardial infarction and pulmonary embolus for the 150 patients was 1, 0, 3, 2, 2 and 3, respectively. Cumulative summation graphs allowed a visual guide to the key performance indicators. CONCLUSIONS: Using cumulative summation surgeons can continuously identify if their morbidity or mortality rates are approaching benchmark limits. This approach may provide more timely information when alterations in surgical technique, patient selection and perioperative care should be considered if benchmark limits are being approached for a variety of surgical outcomes.

Review of primary and salvage cryoablation for prostate cancer.

BACKGROUND: Cryosurgery has gained popularity as a minimally invasive treatment option for primary and recurrent prostate cancer. Herein we present a review and summary reports on primary cryoablation for prostate cancer and salvage cryoablation following radiation failure. METHODS: We reviewed the current published literature in the English language on these topics, along with some historic articles dating back to the 1960s for background and development of the procedure. The material is supplemented by some commentary based on our own 13-year experience with cryoablation for prostate cancer. The review is divided into two sections: primary and salvage cryoablation. RESULTS: For primary cryoablation, success rates are proportional to the risk categories of the primary cancers. A pretreatment prostate-specific antigen (PSA) 10 ng/mL and post-cryoablation nadir PSA > 1 ng/mL for salvage procedures. Side effects are more prevalent and serious than with primary cryoablation but for carefully selected patients, the long-term results are favorable. CONCLUSIONS: Patient selection is the key to success with cryoablation, in both the primary and salvage setting. The modality can offer long-term cancer control in carefully selected patient with properly executed techniques.

Clinically significant prostate cancer found incidentally in radical cystoprostatectomy specimens.

OBJECTIVE: To review the incidence, histopathological features and clinical outcomes of patients with incidental prostate cancer found in radical cystoprostatectomy (RCP) specimens excised for bladder cancer, to determine if these cancers affected the follow-up strategy and if prostate-sparing cystectomy would be appropriate for these patients. PATIENTS AND METHODS: We retrospectively reviewed the charts of men who had a RCP for transitional cell carcinoma (TCC) of the bladder, at our institution between 1987 and 2003. Patients with a preoperative diagnosis or clinical suspicion of prostate cancer were excluded from further analysis. We identified those men with incidental prostate cancer in the RCP specimens. The patients' demographic, histopathological and clinical outcome data were collected. RESULTS: In all, 217 men had RCP for TCC between 1987 and 2003; 13 were excluded from the study due to a preoperative diagnosis or clinical suspicion of prostate cancer, and 58 (28%) were found to have incidental prostate cancer. The mean (range) follow-up was 47 (6-157) months. Of these prostate cancers, 20% were of Gleason score > or = 7 and two patients developed local and metastatic prostate cancer recurrences. CONCLUSION: Incidental prostate cancer is a relatively common finding in RCP specimens, with a significant proportion having the characteristics of clinically relevant prostate cancer. The follow-up for prostate cancer should be incorporated with that for TCC and adapted according to the grade and stage of the prostate cancer. Preserving the prostate in an attempt to decrease the morbidity after RCP carries a high risk of significant prostate cancer in the residual prostatic tissue, suggesting that prostate-sparing cystectomy should only be reserved for a highly selected group of patients.

Change of vanilloid receptor 1 following neuromodulation in rats with spinal cord injury.

BACKGROUND: Neuromodulation has been used to treat voiding dysfunction caused by spinal cord injury (SCI). However, the underlying mechanism of this technique is not well understood. Recently, vanilloid receptor 1 (VR1) has been recognized as a capsaicin receptor and an agent for noxious stimuli. The purposes of this study were to evaluate whether development of bladder hyperreflexia after SCI involves VR1 upregulation and whether VR1 is involved in the process of neuromodulation. MATERIALS AND METHODS: Sprague-Dawley rats (n = 20) were divided into five groups: sham control (n = 4); 3 days after SCI (n = 4); 7 days after SCI (n = 4); 14 days after SCI (n = 4), and 14 days after SCI with neurostimulation (n = 4). Bilateral electrode wires were implanted into S1 dorsal foramina and electrical stimulation was performed 8 h/day for 2 weeks. Spinal segments of L6, S1, and dorsal root ganglia were removed and cut into sections. The intensity of VR1 staining was evaluated by image analysis. RESULTS: VR1-positive staining was confined to the superficial dorsal horn of the spinal cord. The staining was weak in the sham group (1/luminosity: 0.0050 +/- 0.0006), but the staining intensity was significantly increased in three SCI groups (3 days, 7 days, and 14 days) when compared with that in the sham group (P < 0.05). After neuromodulation, the staining intensity was reduced. CONCLUSIONS: VR1 expression in the spinal cord is up-regulated after SCI. Sacral nerve root stimulation can down-regulate the VR1 expression.