Characterization of genital injuries secondary to foreign bodies from 2011 to 2020.

PURPOSE: To identify demographic trends of foreign object genital injuries presenting to emergency departments from 2011 to 2020. MATERIALS AND METHODS: The National Electronic Injury Surveillance System database reports consumer product-related injuries in United States ED visits. The database was queried to identify 375 cases of genital injuries from 2011 to 2020. Inclusion criteria consisted of cases reporting injuries involving the urethra, penis, or scrotum. Data was reported and analyzed using linear regression. RESULTS: Based on 375 cases, an estimated 13,170 (95% confidence interval, 10,817-15,522) patients in the US suffered genital injuries due to foreign bodies between 2011 and 2020. These injuries involved the penis (65.9%), urethra (30.7%) and scrotum (3.5%). Of all patients, 11.8% required hospital admission after treatment of which injuries to the urethra were most common (44.0%). Most of these patients were ages 19 to 64 (66.1%). Consumer products most implicated included rings (50.7%), zippers (17.1%), and pens and pencils (10.3%). Injuries due to zippers and swimming apparel occurred significantly more frequently in patients ages 0-18 (p<0.05). Injuries due to kitchen gadgets occurred significantly more in patients ages ≥65 (p<0.05). Pens, pencils, and massage devices were items that routinely resulted in urethral injuries, often requiring hospitalization. Linear regression showed genital injuries related to foreign objects significantly increased from 2011 to 2020 (p<0.001). CONCLUSIONS: Due to the nature of injury caused to genitalia by intentional and unintentional exposure to foreign bodies, educating individuals on this topic in sexual education classes is necessary for preventing future injuries.

A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury.

BACKGROUND: Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI. METHODS: Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction. RESULTS: There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784). CONCLUSION: In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The Outcomes of Pelvic Fracture Urethral Injuries Stratified by Urethral Injury Severity: A Prospective Multi-institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury. METHODS: Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score. RESULTS: There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (P < 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (P < 0.001). CONCLUSION: In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed.

Characterization of Pediatric Genital Injuries Due to Consumer Products From 2011 to 2020.

OBJECTIVE: To describe demographic trends of consumer product-related injuries in the pediatric cohort from 2011 - 2020. METHODS: The National Electronic Injury Surveillance System (NEISS) database surveying emergency department visits was retrospectively searched for all pediatric genitourinary injuries from 2011 to 2020. Data on demographics, diagnosis, products, disposition, and anatomy injured were collected on patients between the ages of 0-19 years. Statistical analysis was performed using linear regression. RESULTS: There were 12,953 reported pediatric cases involving injuries of the genital region from 2011 to 2020 with a national estimate of 324,636 (95% CI 241,527 - 407,746) pediatric genital injuries, comprising 0.76% of total pediatric injuries in the past decade. Of these patients, female (54.2%), white (39.7%) individuals sustained the most injuries, and items most commonly responsible included bicycles (9.4%), playground equipment (6.9%), toilets (4.6%), beds (4.5%), bathtubs and showers (4.4%), soaps (4.4%), chairs (4.1%), and razors and shavers (2.3%). Urethral injuries were due to chemical injuries from soaps (22%), furniture (17%), playground injuries (17%), insertion of foreign bodies into the urethra (13%), bicycles (10%), and swimming related injuries (4%). Genital injuries in children 0-5 years old were primarily caused by furniture (47.8%), while injuries in the 6-10, 11-15, and 16-19 age groups were attributed to sports and recreation (41.2%, 24.6%, 12.2% respectively). There was no significant change in the annual number of pediatric genital injuries from 2011 to 2020 (R2 = 0.38, P = 0.057). CONCLUSION: Identifying factors involved in pediatric genital trauma can allow for increased legislation, surveillance, and prevention of such injuries in targeted age groups.

Sexual Health Inventory for Men Questionnaire as a Screening Method for Erectile Dysfunction in a General Urology Clinic.

INTRODUCTION: Sexual Health Inventory for Men (SHIM) is a validated questionnaire that is widely used in urology clinics to evaluate and assess treatment efficacy for erectile dysfunction (ED). AIM: In this study, we evaluated the benefit of using the SHIM questionnaire as a screening tool for ED in a general urology clinic MATERIAL AND METHODS: We retrospectively reviewed records of patients presenting to our general urology clinic from October 2018 to June 2019. During this period, all new male urology patients who are 40 years of age or older visiting the general urology clinic for any urologic condition received the SHIM questionnaire. We excluded all patients whose chief complaint was ED, Peyronie's disease, and hypogonadism. Patients were then asked if they want treatment for ED, and those patients who did, received a full ED evaluation and treatment. Factors associated with desire for ED treatment were analyzed using logistic regression. MAIN OUTCOME MEASURES: SHIM score, desire for ED treatment, and factors influencing desire for treatment. RESULTS: Three hundred seventy-nine patients received the SHIM questionnaire. Of which, 48 patients (12.7%) declined to fill the questionnaire. We excluded all patients presenting for sexual health issues (67 patients, 17.7%). We included the remaining 264 patients (69.6%). The mean age was 61.7 years (range 40 to 85). Older patients were more likely to want ED treatment and had lower SHIM scores. However, older than the age of 70 years, there was a decline in the number of patients wanting treatment. In a multivariate regression analysis, age between 61 and 70 years and having diabetes mellitus were associated with the desire for ED treatment. CONCLUSIONS: The SHIM questionnaire is a useful tool in the general urology clinic. It can serve as an efficient tool to screen for and quantify ED in patients presenting for other urologic issues. Maximum benefit is seen in patients between the age of 51 and 70 years and in patients with diabetes. Alwaal A, Awad M, Boggs N, et al. Sexual Health Inventory for Men Questionnaire as a Screening Method for Erectile Dysfunction in a General Urology Clinic. Sex Med 2020;8:660-663.

Total involvement of penis, scrotum and pubis by giant melanocytic nevus: A unique presentation.

Giant melanocytic nevus is a rare dermatological condition. However, total involvement of male genitalia and pubic area has never been reported in the literature and this presentation is considered the first reported case of such condition. The choice of reconstructive intervention should be tailored to the patient's expectations, body habitus and previous surgical procedures.

Complex anal fistula involving male genital tract: a new diagnostic entity.

We present three male patients who had a rare presentation of anal fistula reaching the genital tract. Patient 1: a 44-year-old diabetic man presented initially to urology clinic complaining of penile and scrotal masses increasing in size for 6 months. Patient 2: a 67-year-old diabetic man presented with chronic sinus discharge from the scrotum. Patient 3: a 37-year-old diabetic man who presented with chronic sinus draining pus-like material from the scrotum for 1 year. Patients 1 and 2: following diagnosis of perianal fistula by MRI fistulography, complete excision of the fistula was done. This required tracking the fistula surgically, a perineal midline incision to release the fistula and excision of the fistula opening in the anal canal. The patients were doing well postoperative and no recurrence of fistula at 1-year follow-up. Patient 3: he refused surgical intervention. Penile mass or scrotal discharge has not been reported to be caused by fistula-in-ano.

The extra-tunical grafting procedure for Peyronie's disease hourglass and indent deformities.

BACKGROUND: To describe a novel, tunica-sparing surgical technique-extra-tunical grafting (ETG)-for the treatment of penile indent and hourglass (HG) deformities and to describe patient-reported outcomes after the ETG procedure. METHODS: An IRB-approved, retrospective chart review of ETG patients was performed to collect data including pre-operative deformity, operation performed, and post-operative patient-reported perception of deformity, erectile function, penile sensation, and overall satisfaction with the ETG operation. The indications for surgery were difficulty with sexual intercourse due to deformity and/or poor cosmesis of the penis. Pre-operatively all patients had erections adequate for intercourse with or without medications. The ETG procedure is performed through a ventral longitudinal penile skin incision. The dissection is continued to the level between Dartos and Bucks fascia, circumferentially for HG deformity and focally for indent deformity. The neurovascular bundle (NVB) is left undisturbed. A cadaveric fascia graft is applied, singly or in multiple layers, to fill the exposed tunical depressions. Our preferred graft material is Tutoplast Suspend® (Coloplast, Minneapolis, MN, USA). The graft is sutured into position with multiple interrupted, long-lasting absorbable sutures to achieve the desired penile shaft contour. The urethra is excluded from the graft. RESULTS: From October 2013 to June 2017, 36 patients had the ETG procedure for HG and/or indent with or without penile curvature. Results with a minimum of 6 months of follow-up could be extracted for 18 of the patients. One was excluded as he required concurrent excision of a large calcified tunical plaque, which necessitated incision into the tunica albuginea (TA). Follow-up was between 6 and 44 months (average 21 months). All patients reported satisfactory resolution of the HG or indent. No patient reported worsened erectile function. Two patients (11.8%) reported slight penile hypoesthesia, with one of these having had multiple previous penile degloving surgeries for trauma. Ten of the patients reported being "very satisfied" and six reported being "satisfied" with the procedure. One was neutral. All reported that they would recommend the ETG procedure to a friend, and all would repeat the same surgery again. CONCLUSIONS: The ETG procedure is a straightforward approach to HG and indent deformities to correct the penile deformity and to provide structural support to prevent penile buckling during intercourse. The procedure does not violate the TA and does not require dissection of the NVB. Thus, ETG carries a very low risk of de novo impotence or hypoesthesia as highlighted by this patient series. With such low risk and high patient-reported satisfaction rates, the ETG procedure is a valuable surgical technique for the treatment of complex penile deformities.

Utilization of penile prosthesis and male incontinence prosthetics in Saudi Arabia.

BACKGROUND: Erectile dysfunction is a prevalent disease affecting over 50% of men between the ages of 40 and 70 years. Penile prosthesis represents the end of the line treatment when other less invasive therapies fail or are contraindicated. Male stress urinary incontinence can significantly diminish quality of life and lead to embarrassment and social withdrawal. Surgical therapies, such as male urethral slings and artificial urinary sphincters (AUS), are considered effective and safe treatments for male stress incontinence. No data exist on the utilization of penile prosthesis or male incontinence surgical treatment in Saudi Arabia. Generally, urological prosthetic surgery is performed either in private hospitals or in government hospitals. Our aim was to assess the trend of penile prosthesis and male incontinence device utilization in Saudi Arabia. MATERIALS AND METHODS: We utilized sales' data of penile prosthetics, male slings, and AUS from the only two companies selling these devices in Saudi Arabia (AMS® and Coloplast®), from January 2013 to December 2016. RESULTS: There were 2599 penile prosthesis implantation procedures done in the study period, with 67% of them performed in private institutions. There was a progressively increased use of penile prosthetics which nearly doubled from 2013 to 2016. The main type of prosthesis utilized was the semirigid type 70% versus 11% of the 2-piece inflatable and 17% of the 3-piece inflatable device. Only 10 slings and 31 AUS were inserted during the same study period. CONCLUSIONS: There is an increased utilization of penile prosthetics in Saudi Arabia. The private sector performs the majority of penile prosthesis procedures, and most of them are of the semirigid type. The governmental sector is more likely to perform inflatable penile prosthesis and male incontinence device procedures. Male incontinence prosthetics' use is very limited in Saudi Arabia.

Comparison of spinal cord contusion and transection: functional and histological changes in the rat urinary bladder.

OBJECTIVE: To compare the effect of complete transection (tSCI) and contusion spinal cord injury (cSCI) on bladder function and bladder wall structure in rats. MATERIALS AND METHODS: A total of 30 female Sprague-Dawley rats were randomly divided into three equal groups: an uninjured control, a cSCI and a tSCI group. The cSCI group underwent spinal cord contusion, while the tSCI group underwent complete spinal cord transection. At 6 weeks post-injury, 24-h metabolic cage measurement and conscious cystometry were performed. RESULTS: Conscious cystometry analysis showed that the cSCI and tSCI groups had significantly larger bladder capacities than the control group. The cSCI group had significantly more non-voiding detrusor contractions than the tSCI group. Both injury groups had more non-voiding contractions compared with the control group. The mean threshold pressure was significantly higher in the tSCI group than in the control and cSCI groups. The number of voids in the tSCI group was lower compared with the control group. Metabolic cage analysis showed that the tSCI group had larger maximum voiding volume as compared with the control and cSCI groups. Vesicular acetylcholine transporter/smooth muscle immunoreactivity was higher in the control than in the cSCI or tSCI rats. The area of calcitonin gene-related peptide staining was smaller in the tSCI group than in the control or cSCI groups. CONCLUSIONS: Spinal cord transection and contusion produce different bladder phenotypes in rat models of SCI. Functional data suggest that the tSCI group has an obstructive high-pressure voiding pattern, while the cSCI group has more uninhibited detrusor contractions.

Major genitourinary-related bicycle trauma: Results from 20 years at a level-1 trauma center.

BACKGROUND: Epidemiological studies have shown that bicycle trauma is associated with genitourinary (GU) injuries. Our objective is to characterize GU-related bicycle trauma admitted to a level I trauma center. MATERIALS AND METHODS: We queried a prospective trauma registry for bicycle injuries over a 20-year period. Patient demographics, triage data, operative interventions and hospital details were collected. RESULTS: In total, 1659 patients were admitted with major bicycle trauma. Of these, 48 cases involved a GU organ, specifically the bladder (n=7), testis (n=6), urethra (n=3), adrenal (n=4) and/or kidneys (n=36). The median age of cyclists with GU injuries was 29 (range 5-70). More men were injured versus women (35 versus 13). GU-related bicycle trauma involved a motor vehicle in 52% (25/48) of injuries. The median injury severity score for GU-related bicycle trauma was 17 (range 1-50). The median number of concomitant organ injuries was 2 (range 0-6), the most common of which was the lungs (13/48, 27%) and ribs (13/48, 27%). The majority of GU injured cyclists were admitted to an ICU (15/48, 31%) or hospital floor (12/48, 25%). Operative intervention for a GU-related trauma was low (12/48, 25%). The most common GU organ injured was the kidney (36/48, 75%) however most were managed nonoperatively (33/36, 92%). Bladder injuries most often required operative intervention (6/7, 86%). Mortality following GU-related bicycle trauma was low (2/48, 4%). CONCLUSIONS: In a large series of bicycle trauma, GU organs were injured in 3% of cases. The majority of cases were managed non-operatively and mortality was low.

Urethral catheters and medical malpractice: a legal database review from 1965 to 2015.

BACKGROUND: Urethral catheters (UCs) are commonly used in medicine and are associated with complications such as urinary tract infections (UTIs) and trauma. Given UC complications and their ubiquitous usage in healthcare, there is a potential for liability risk. We aim to explore litigation involving UC-related complications. METHODS: The LexisNexis legal database was queried for all state and federal cases from January 1965 through October 2015 using the terms "urethral catheter" or "Foley catheter" in combination with "medical malpractice", "negligence", "medical error", and "trauma". Each case was reviewed for reported medical characteristics and legal aspects, including the outcome of the case. RESULTS: Our search yielded 29 cases. Urologists were the most common providers cited as defendants (21%), all of whom were successful in their defense. The most common malpractice claim was for traumatic insertion (48%). Pain was the most common type of damage claimed by plaintiffs (28%), followed by UTI (24%). Nineteen (66%) cases favored defendants, while 10 (34%) cases favored the plaintiffs, of which 2 (7%) were settled out of the court. In settled cases, the mean settlement received by plaintiffs was $55,750 (range, $25,000-$86,500). The mean award to plaintiffs for cases determined by the court was $112,991 (range, $4,000-$325,000). CONCLUSIONS: Despite widespread usage of UC over a 50-year period, lawsuits centered on UC misuse are rare at the state and federal court levels. Of litigated cases, urologists are commonly involved yet have successful defenses.

Comparison of complication rates related to male urethral slings and artificial urinary sphincters for urinary incontinence: national multi-institutional analysis of ACS-NSQIP database.

PURPOSE: Male stress urinary incontinence (SUI) can significantly diminish quality of life and lead to embarrassment and social withdrawal. Surgical therapies, such as male urethral slings and artificial urinary sphincters (AUS), are considered effective and safe treatments for male SUI. Our objective is to evaluate 30-day complications in patients undergoing male slings and AUS placement from a national multicenter database. METHODS: Data from the American College of Surgeons National Surgical Quality of Improvement Program for 2008-2013 were used to identify patients who underwent male slings and AUS implantation. Trained coders abstracted complication data from the patient record independent of the surgical team. We compared 30-day postoperative complications for male slings and AUS. We examined the relationship between patient factors and complication rates for each procedure type. RESULTS: Overall, 1205 incontinence surgeries in men were identified: 597 male sling placements and 608 AUS implantations. Male sling placement had a lower 30-day postoperative complication rate compared to AUS (2.8 vs. 5.1 %, p = 0.046). Compared to AUS, male sling was associated with fewer urinary tract infections (0.3 vs. 2.0 %, p = 0.020) and return trips to the operating room (1.0 vs. 3.0 %, p < 0.001). Patients with higher BMI were more likely to have a complication, while age, race and Charlson comorbidity index were not associated with higher or lower complication rates. CONCLUSIONS: Complications rates for both male sling and AUS are low. Male sling is associated with a lower rate of complications than AUS. These findings allow for better patient perioperative counseling regarding 30-day perioperative complications.

Carbachol-induced signaling through Thr696-phosphorylation of myosin phosphatase-targeting subunit 1 (MYPT1) in rat bladder smooth muscle cells.

PURPOSE: Lines of evidence suggest that Rho-associated protein kinase (ROCK)-mediated myosin phosphatase-targeting subunit 1 (MYPT1) phosphorylation plays a central role in smooth muscle contraction. However, the physiological significance of MYPT1 phosphorylation at Thr696 catalyzed by ROCK in bladder smooth muscle remains controversial. We attempt to directly observe the quantitative protein expression of Rho A/ROCK and phosphorylation of MYPT1 at Thr696 after carbachol administration in rat bladder smooth muscle cells (RBMSCs). MATERIALS AND METHODS: Primary cultured smooth muscle cells were obtained from rat bladders. The effects of both concentration and time-course induced by the muscarinic agonist carbachol were investigated by assessing the expression of Rho A/ROCK and MYPT1 phosphorylation at Thr696 using Western blot. RESULTS: In the dose-course studies, carbachol showed significant increase in phosphorylation of MYPT1 at Thr696 (p-MYPT1) from concentrations of 15-100 µM based on Western blot results (p < 0.05, ANOVA test). In the time-course studies, treatment of cells with 15 µM of carbachol significantly enhanced the expression of p-MYPT1 from 3 to 15 h (p < 0.05, ANOVA test) and induced the expression of Rho A from 10 to 120 min (p < 0.05, ANOVA test). CONCLUSIONS: Carbachol can induce the expression of ROCK pathway, leading to MYPT1 phosphorylation at Thr696 and thereby sustained RBSMCs contraction.

Transurethral Unroofing of a Symptomatic Imperforate Cowper's Syringocele in an Adult Male.

Cystic dilatation of bulbourethral gland ducts (Cowper's gland syringocele) is a rare abnormality. The condition has been described among pediatric populations, but it is uncommon in adults. It can be asymptomatic or present with obstructive and irritative urinary symptoms. We report a case of a symptomatic imperforate Cowper's syringocele in a young patient that was successfully managed with transurethral unroofing of the cyst.

Comparison of Topical Hemostatic Agents in a Swine Model of Extremity Arterial Hemorrhage: BloodSTOP iX Battle Matrix vs. QuikClot Combat Gauze.

BloodSTOP iX Battle Matrix (BM) and QuikClot Combat Gauze (CG) have both been used to treat traumatic bleeding. The purpose of this study was to examine the efficacy and initial safety of both products in a swine extremity arterial hemorrhage model, which mimics combat injury. Swine (37.13 ± 0.56 kg, NBM = 11, NCG = 9) were anesthetized and splenectomized. We then isolated the femoral arteries and performed a 6 mm arteriotomy. After 45 s of free bleeding, either BM or CG was applied. Fluid resuscitation was provided to maintain a mean arterial pressure of 65 mmHg. Animals were observed for three hours or until death. Fluoroscopic angiography and wound stability challenge tests were performed on survivors. Tissue samples were collected for histologic examination. Stable hemostasis was achieved in 11/11 BM and 5/9 CG subjects, with recovery of mean arterial pressure and animal survival for three hours (p < 0.05, Odds Ratio (OR) = 18.82 (0.85-415.3)). Time to stable hemostasis was shorter for the BM-treated group (4.8 ± 2.5 min vs. 58 ± 20.1 min; Median = 2, Interquartile Range (IQR) = 0 min vs. Median = 60, IQR = 120 min; p < 0.05) and experienced longer total stable hemostasis (175.2 ± 2.5 min vs. 92.4 ± 29.9 min; Median = 178, IQR = 0 min vs. Median = 120, IQR = 178 min; p < 0.05). Post-treatment blood loss was lower with BM (9.5 ± 2.4 mL/kg, Median = 10.52, IQR = 13.63 mL/kg) compared to CG (29.9 ± 9.9 mL/kg, Median = 29.38, IQR = 62.44 mL/kg) (p = 0.2875). Standard BM products weighed less compared to CG (6.9 ± 0.03 g vs. 20.2 ± 0.4 g) (p < 0.05) and absorbed less blood (3.4 ± 0.8 g vs. 41.9 ± 12.3 g) (p < 0.05). Fluoroscopic angiography showed recanalization in 5/11 (BM) and 0/5 (CG) surviving animals (p = 0.07, OR = 9.3 (0.41-208.8)). The wound stability challenge test resulted in wound re-bleeding in 1/11 (BM) and 5/5 (CG) surviving animals (p < 0.05, OR = 0.013 (0.00045-0.375)). Histologic evidence indicated no wound site, distal limb or major organ damage in either group. BM is more effective and portable in treating arterial hemorrhage compared to CG. There was no histologic evidence of further damage in either group.

National Variation in Urethroplasty Cost and Predictors of Extreme Cost: A Cost Analysis With Policy Implications.

OBJECTIVE: To determine which factors are associated with higher costs of urethroplasty procedure and whether these factors have been increasing over time. Identification of determinants of extreme costs may help reduce cost while maintaining quality. MATERIALS AND METHODS: We conducted a retrospective analysis using the 2001-2010 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). The HCUP-NIS captures hospital charges which we converted to cost using the HCUP cost-to-charge ratio. Log cost linear regression with sensitivity analysis was used to determine variables associated with increased costs. Extreme cost was defined as the top 20th percentile of expenditure, analyzed with logistic regression, and expressed as odds ratios (OR). RESULTS: A total of 2298 urethroplasties were recorded in NIS over the study period. The median (interquartile range) calculated cost was $7321 ($5677-$10,000). Patients with multiple comorbid conditions were associated with extreme costs [OR 1.56, 95% confidence interval (CI) 1.19-2.04, P = .02] compared with patients with no comorbid disease. Inpatient complications raised the odds of extreme costs (OR 3.2, CI 2.14-4.75, P <.001). Graft urethroplasties were associated with extreme costs (OR 1.78, 95% CI 1.2-2.64, P = .005). Variations in patient age, race, hospital region, bed size, teaching status, payor type, and volume of urethroplasty cases were not associated with extremes of cost. CONCLUSION: Cost variation for perioperative inpatient urethroplasty procedures is dependent on preoperative patient comorbidities, postoperative complications, and surgical complexity related to graft usage. Procedural cost and cost variation are critical for understanding which aspects of care have the greatest impact on cost.

Current Practice Patterns Among Members of the American Urological Association for Male Genitourinary Lichen Sclerosus.

OBJECTIVE: To determine the practice patterns of urologists who treat male genitourinary lichen sclerosus (MGU-LS) via a national web-based survey distributed to American Urological Association members. METHODS: A 20-question survey was collected from a random sample of American Urological Association members. Respondents answered questions on their practice patterns for MGU-LS diagnosis, treatment of symptomatic urethral stricture disease, surveillance, and follow-up. RESULTS: In total, 309 urologists completed the survey. The majority of respondents reported practicing more than 20+ years (37.5%) within an academic (31.7%) or group practice (31.1%) setting. The majority of respondents saw 3-5 men with MGU-LS per year (32.7%). The most common locations of MGU-LS involvement included the glans penis (66.2%), foreskin (26.3%), and/or the urethra (5.8%). Respondent first-line treatment for urethral stricture disease was direct visual internal urethrotomy (26.6%) and second-line treatment was referral to subspecialist (38.4%). After controlling for the number of patients evaluated with MGU-LS per year, those with reconstructive training were more likely to perform a primary urethroplasty for men with symptomatic urethral stricture disease (adjusted odds ratio 13.1, 95% confidence interval 5.1-33.8, P < .001). They were also more likely to counsel men on the associated penile cancer risks (adjusted odds ratio 4.6, 95% confidence interval 1.7-12.5, P < .01). CONCLUSION: Reconstructive urologists evaluate the most number of patients with MGU-LS and are more likely to perform primary urethroplasty for urethral stricture disease. Men with MGU-LS should be referred to a reconstructive urologist to understand the full gamut of treatment options.

Urethral Stricture Score is Associated with Anterior Urethroplasty Complexity and Outcome.

PURPOSE: Several surgical techniques are available to treat anterior urethral stricture. The choice of surgical technique largely depends on the severity of stricture disease. The U-score (urethral stricture score) is based on urethral stricture characteristics, namely length (1 to 3 points), number (1 or 2 points), location (1 or 2 points) and etiology (1 or 2 points), which are tallied to provide a total score of 4 to 9 points. Our aim was to identify whether the U-score system is predictive of the surgical complexity and outcome of anterior urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent anterior urethroplasty from 2002 to 2012 by examining our prospectively collected urethroplasty database. We calculated the U-score and looked for an association with surgical complexity, recurrent stricture and time to recurrence. We defined recurrent stricture as the need for a secondary procedure. RESULTS: There were 341 patients who underwent low complexity urethroplasty (anastomotic, buccal mucosal graft and augmented anterior urethroplasty) with a mean U-score of 4.7 while 48 underwent high complexity urethroplasty (double buccal mucosal graft, flap and graft/flap combination) with a mean score of 6.9. Higher U-score was predictive of higher surgical complexity (p <0.001). U-score was also significantly associated with recurrence. There was a consistent increase in the risk of recurrence with each additional U-score point. However, there was no association of U-score with time to recurrence. CONCLUSIONS: We confirmed the validity of U-score to predict the complexity of surgery for anterior urethral strictures. For the first time to our knowledge we report an association between higher U-score and anterior urethroplasty outcome. The U-score could be used to risk stratify patients and help with perioperative counseling.

Urethral musculature and innervation in the female rat.

AIMS: The urethral sphincter and urethral muscle innervation are critically involved in maintaining continence, especially in the female. However, the urethral muscle type and distribution, as well as the urethral nerves are far from being well documented. Our aim was to clearly identify the distribution of urethral striated muscle, smooth muscle, and urethral nerves. METHODS: In a cohort analysis of 3-month-old female Sprague-Dawley rats, cross and longitudinal sections of female rat urethra were extensively investigated using morphological techniques. Urethras were harvested to the sections, in order to provide both global and detailed visions of the urethra. H&E, Masson's Trichrome, phalloidin and immunoflourence stains were used. The cytoarchitecture, nitrergic, and cholinergic innervations were mainly investigated. Different layers of the segments of urethra were traced to draw curve graphs that represent the thickness of each muscle layer of urethral wall. RESULTS: The results showed that the primary peak of striated muscle is in the middle urethra. The inner layer close to mucosa was found to contain longitudinal smooth muscle. Near the bladder orifice, the circular smooth muscle dominates, which becomes thinner distally throughout the rest of urethra. In the middle urethra the vast majority of the urethral muscle are circularly oriented striated muscle cells. Typical nerve endings were present in high power images to show the different characteristic features of nerve innervation. CONCLUSIONS: This study has illustrated the detailed morphological structure and innervations of the normal female rat urethra and can serve as a basis for further study of stress urinary incontinence (SUI).