A Modern Comparison of Urodynamic Findings in Diabetic Versus Nondiabetic Women.

OBJECTIVES: Few contemporary studies exist regarding urodynamic (UDS) findings in patients with diabetes mellitus (DM), and data are conflicting. Our aim was to compare UDS findings in women with and without DM. METHODS: Data from female patients in a prospectively maintained UDS database (2010-2014) were reviewed. Studies were performed according to International Continence Society standards. Clinical data, presenting symptoms, and UDS findings were compared in women with and without DM, controlling for demographic and pertinent variables. RESULTS: There were 384 patients who met the inclusion criteria, of whom 88 (26%) had DM. Symptoms at presentation were not statistically different in women with and without DM. Women with DM had larger bladder capacity (mean, 493 mL vs 409 mL; P = 0.005) and had more detrusor underactivity (30% vs 18%, P = 0.042) when compared with nondiabetic women. Diabetic women were more frequently diagnosed as having impaired sensation, or lack of desire to void, at 75% of capacity (17% vs 5%, P = 0.001). In women with diabetes, a serum hemoglobin A1c level of at least 7.5% was associated with delayed first sensation and first urge. Diagnosis of DM of more than 10 years was associated with greater volume at first urge, and maximal capacity, lower detrusor pressures, and higher postvoid residual. CONCLUSIONS: In this contemporary series, women with DM demonstrated similar presenting complaints to women without DM but had significantly altered UDS findings. Among diabetic female patients, diabetes control and duration of diabetes seem to impact bladder sensation and contractility. Urodynamics may be helpful in diabetic female patients to diagnose underlying concealed bladder dysfunction before initiation of treatment.

Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male.

For many transgender males, "lower" or "bottom" surgery (the construction of a phallus and scrotum) is the definitive step in their surgical journey for gender affirmation. The implantation of penile and testicular prostheses is often the final anatomic addition and serves to add both functionality and aesthetics to the reconstruction. However, with markedly distinctive anatomy from cis-gender men, the implantation of prostheses designed for cis-male genitalia poses a significant surgical challenge for the reconstructive urologist. The surgical techniques for these procedures remain in their infancy. Implantation of devices originally engineered for cis-men is an imperfect solution but not insurmountable if approached with ingenuity, patience, and persistence. Urologists and patients undergoing implantation should be aware of the high complication rates associated with these procedures as well as the current uncertainty of long-term outcomes. This review provides a comprehensive overview of the perioperative considerations, adaptive surgical techniques, and unique complications of penile and testicular prosthetic implantation in transgender men.

Evaluating the Role of Postoperative Oral Antibiotic Administration in Artificial Urinary Sphincter and Inflatable Penile Prosthesis Explantation: A Nationwide Analysis.

OBJECTIVE: To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown. MATERIALS AND METHODS: We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates. RESULTS: We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation. CONCLUSION: Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.

Thirty-day Morbidity of Abdominal Sacrocolpopexy Is Influenced by Additional Surgical Treatment for Stress Urinary Incontinence.

OBJECTIVE: To assess the impact of concurrent anti-incontinence procedure (AIP) at time of abdominal sacrocolpopexy (ASC) on 30-day complications, readmission, and reoperation. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2013 was queried to identify patients who underwent ASC with or without AIP. We assessed baseline characteristics and 30-day perioperative outcomes including complications, readmission, and reoperation. RESULTS: There were 4793 patients who underwent ASC, of whom 1705 underwent concurrent AIP (35.6%). The majority of patients (4414, 92.1%) were treated by a gynecologist, but those treated by a urologist were older, had higher American Society of Anesthesiologists (ASA) class, and had increased frailty. Rates of 30-day postoperative urinary tract infection (UTI) and overall complication were higher among women who underwent concurrent AIP (4.75% vs 2.33%, P <.001; 7.74% vs 6.02%, P = .02). On multivariate analysis controlling for age, body mass index, approach, ASA physical status, modified frailty index, resident involvement, and surgeon specialty, AIP was associated with increased odds of UTI (odds ratio 2.20, 95% confidence interval 1.14-4.13, P = .02) and increased odds of overall complication (odds ratio 1.80, 95%confidence interval 1.10-2.93, P = .02). Thirty-day readmission and reoperation rates did not differ between the groups. CONCLUSION: AIP performed at the time of ASC are associated with higher rates of 30-day postoperative UTI but do not impact 30-day readmission or reoperation. The decision to perform AIP at the time of ASC should be made following a thorough discussion of the risks and benefits, including the potential for increased UTI with concurrent AIP.

Best practice policy statement on urodynamic antibiotic prophylaxis in the non-index patient.

AIMS: Antibiotic prophylaxis before urodynamic testing (UDS) is widely utilized to prevent urinary tract infection (UTI) with only limited guidance. The Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) convened a Best Practice Policy Panel to formulate recommendations on the urodynamic antibiotic prophylaxis in the non-index patient. METHODS: Recommendations are based on a literature review and the Panel's expert opinion, with all recommendations graded using the Oxford grading system. RESULTS: All patients should be screened for symptoms of UTI and undergo dipstick urinalysis. If the clinician suspects a UTI, the UDS should be postponed until it has been treated. The first choice for prophylaxis is a single oral dose of trimethoprim-sulfamethoxazole before UDS, with alternative antibiotics chosen in case of allergy or intolerance. Individuals who do NOT require routine antibiotic prophylaxis include those without known relevant genitourinary anomalies, diabetics, those with prior genitourinary surgery, a history of recurrent UTI, post-menopausal women, recently hospitalized patients, patients with cardiac valvular disease, nutritional deficiencies or obesity. Identified risk factors that increase the potential for UTI following UDS and for which the panel recommends peri-procedure antibiotics include: known relevant neurogenic lower urinary tract dysfunction, elevated PVR, asymptomatic bacteriuria, immunosuppression, age over 70, and patients with any indwelling catheter, external urinary collection device, or performing intermittent catheterization. Patients with orthopedic implants have a separate risk stratification. CONCLUSIONS: These recommendations can assist urodynamic providers in the appropriate use of antibiotics for UDS testing. Clinical judgment of the provider must always be considered.

Novel Technique for Proximal Bone Anchoring of Penile Prosthesis After Radial Forearm Free Flap Neophallus.

OBJECTIVE: To describe outcomes of bone anchoring of penile implant in a neophallus with an accompanying video focusing on operative technique and salient tips for surgeons performing these procedures. Penile prosthesis insertion allows individuals with a neophallus to achieve erectile function. Lack of corporal bodies to accommodate cylinders makes anchoring of any prosthesis challenging. Anchoring the device to the pubic bone is one strategy to achieve proximal stabilization. METHODS: A single-institution, retrospective chart review of 10 neophallus patients undergoing penile prosthesis placement from 2006 to 2015 was done. The pubic symphysis is exposed and corticotomy created for placement of the rear tip extender of the implant using a Stryker TPS bone drill. Anchoring sutures through the corticotomy defect, rear tip, and proximal cylinder seat the implant. The remainder of the implantation procedure mirrors that used in native tissue. RESULTS: The overall perioperative complication rate was 20%, with a mean follow-up of 49 months. Seventy percent of the patients required reoperation, with a mean of 1.4 prosthesis revision surgeries per patient. Primary causes of revision included infection, poor fixation of the rear tip, and prosthesis failure. Despite high revision rates, 80% of the patients have fully functioning prosthesis as of last follow-up. Limitations include retrospective study design and the small patient cohort. CONCLUSION: Penile prosthesis placement in the neophallus is feasible and effective. A bone-anchored rear tip is an option to provide proximal stabilization. Continued efforts to minimize the need for revisions are ongoing and necessary.

Lessons from 151 ureteral reimplantations for postcystectomy ureteroenteric strictures: A single-center experience over a decade.

OBJECTIVES: Ureteroenteric anastomotic strictures are common after cystectomy with urinary diversion. Endoscopic treatments have poor long-term success, although ureteral reimplantation is associated with morbidity. Predictors of successful open repair are poorly defined. Our objective was to characterize outcomes of ureteral reimplantation after cystectomy and identify risk factors for stricture recurrence. PATIENTS AND METHODS: We performed a retrospective review of 124 consecutive patients with a total of 151 open ureteral reimplantations for postcystectomy ureteroenteric strictures between January 2006 and December 2015. Baseline clinicopathologic characteristics and perioperative outcomes were examined. Predictors for stricture recurrence were assessed by univariable testing and univariate Cox proportional hazards regression. RESULTS: Most patients underwent preoperative drainage by percutaneous nephrostomy (PCN; 43%) or percutaneous nephroureterostomy (PCNU; 44%). Major iatrogenic injuries included enterotomies requiring bowel anastomosis (3.2%) and major vascular injuries (2.4%). Overall, 60 (48%) patients suffered 90-day complications, of which 15 (12%) patients had high-grade complications. Median length of stay was 6 days [interquartile range: 5, 8] and median follow-up was 21 months [interquartile range: 5, 43]. The overall success rate per ureter was 93.4%. On univariate analysis, the only significant predictor of stricture recurrence was preoperative PCNU placement compared with PCN placement or no drainage (success rates: 85.5% vs. 98.9%, respectively, P = 0.002). Cox proportional hazards regression demonstrated that preoperative PCNU placement yielded a hazard ratio of 10.2 (95% CI: 1.27-82.6) for stricture recurrence (P<0.005). Stricture recurrence was independent of previous endoscopic interventions (P = 0.42). Stricture length was unable to be assessed. CONCLUSIONS: Postcystectomy ureteral reimplantation was associated with relatively low rates of major iatrogenic injuries and high-grade complications. Preoperative PCN placement rather than PCNU may yield better results.

The Impact of Minimally Invasive Surgery on Major Iatrogenic Ureteral Injury and Subsequent Ureteral Repair During Hysterectomy: A National Analysis of Risk Factors and Outcomes.

OBJECTIVE: To identify risk factors for ureteral injury during hysterectomy and to assess outcomes of concurrent minimally invasive vs converted to open repairs. METHODS: We queried the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2013 to identify abdominal hysterectomy (AH), minimally invasive hysterectomy (MIH), or vaginal hysterectomy. Ureteral injury was identified based on intraoperative or delayed management. Multivariate logistic regression was performed to assess the effect of hysterectomy approach on risk of ureteral injury while controlling for covariates. For patients with ureteral injury during MIH, we compared 30-day outcomes following minimally invasive vs converted open repairs. RESULTS: There were 302 iatrogenic ureteral injuries from 96,538 hysterectomies, with 0.18%, 0.48%, and 0.04% from AH, MIH, and vaginal hysterectomy, respectively. Patients who underwent MIH were younger and had decreased comorbidities compared to patients who underwent AH (all P < .001). MIH resulted in lower overall complications (6.6% vs 14.8%, P < .001) but higher ureteral injury rate (0.48% vs 0.18%, P < .001) compared to AH. On multivariate analysis, the minimally invasive approach was associated with increased risk of ureteral injury (odds ratio 4.2, P < .001). Patients undergoing minimally invasive ureteral repairs (89%) during MIH had shorter operating room time and length of stay but similar overall perioperative complications compared to those with converted open repairs (11%). CONCLUSION: Using a large national series, we show that the minimally invasive approach for hysterectomy is an independent risk factor for iatrogenic ureteral injuries. During MIH, concurrent minimally invasive ureteral repairs resulted in comparable 30-day outcomes compared to converted to open repairs.

Trends in Simple Prostatectomy for Benign Prostatic Hyperplasia.

The definitive treatment for symptomatic large volume (>80 mL) benign prostatic hyperplasia (BPH) is simple prostatectomy (SP). This can be performed by utilizing a retropubic, suprapubic, or a combined approach. The latter two approaches allow for the management of concomitant bladder diverticulum or stones through the same incision. Each approach affords unique technical strengths and weaknesses that must be considered in light of patient characteristics and concomitant pathology. SP allows for removal of the entire prostatic adenoma while obviating some of the neurovascular and continence issues that can arise from radical prostatectomy. Concerns with SP include its relatively high perioperative morbidity, notably bleeding. Therefore, there is increasing interest in less invasive options, including enucleation procedures and minimally invasive SP. This review presents an update regarding trends and outcomes of SP, as well as the effectiveness and popularity of alternative treatments.

Assessing variability of the 24-hour pad weight test in men with post-prostatectomy incontinence.

PURPOSE: Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity. MATERIALS AND METHODS: 25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used. RESULTS: Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74-0.93), p<0.001). The mean difference between the minimum pad weight leakage and maximum leakage per patient was 133.4g (95% CI 80.4-186.5). The mean increase in 24-hour leakage for a one-point increase in self-reported activity level was 118.0g (95% CI 74.3-161.7, p<0.001). Pad weights also varied significantly when self-reported activity levels did not differ (mean difference 51.2g (95% CI 30.3-72.1), p<0.001). CONCLUSIONS: 24-hour pad weight leakage may vary significantly on different days of collection. This variation is more pronounced with changes in activity level. Taking into account patient activity level may enhance the predictive value of pad weight testing.

Iatrogenic Bladder Injury: National Analysis of 30-Day Outcomes.

OBJECTIVE: To examine the risk factors and outcomes of BI, a rare complication of abdominopelvic surgery. METHODS: We queried the National Surgical Quality Improvement Program database to identify intraoperative bladder injury (BI) defined by the Current Procedural Terminology code for cystorrhaphy from 2005 to 2013. Propensity-score matching balanced the differences between patients with BI and the controls. The factors matched included age, body mass index, race, modified frailty index, and procedure category. RESULTS: There were 1685 cases of BI in 1,541,736 surgeries (0.11%). Although 49.5% of surgeries were performed in an open fashion, this approach accounted for 69.3% of BI (P < .001). Prior to matching, mortality rates and morbidity were increased for the BI group (P < .001). Moreover, age, recent chemotherapy or radiation or steroid history, and smoking were among the risk factors for BI (all P < .05). Resident involvement increased the odds of BI and complications after BI, but decreased the risk of readmission (all P < .05). After matching, 30-day mortality was no longer increased for patients with BI (P < .001). Patients with BI requiring repair did have increased median length of stay (6 days [interquartile range {IQR}: 3-11] vs 5 [IQR: 2-9]; P < .001) and operative time (203 min [IQR: 140-278] vs 134 [IQR: 86-199]; P < .001). BI patients were more likely to undergo reoperation (7.7% vs 5.3%; P = .005). Urine infection, sepsis, and bleeding were more likely in the BI group compared with the matched controls (all P < .001). Delayed repair was rare. CONCLUSION: We present the largest national series assessing iatrogenic BI and subsequent repair. BI increases 30-day complications, reoperation, and length of stay but does not increase 30-day mortality compared with matched controls. More complex surgical cases and increased baseline comorbidity were risk factors for BI.

Open Vs Minimally Invasive Adult Ureteral Reimplantation: Analysis of 30-day Outcomes in the National Surgical Quality Improvement Program (NSQIP) Database.

OBJECTIVE: To examine 30-day outcomes of robotic-assisted and pure laparoscopic ureteral reimplantation (LUR) vs open ureteral reimplantation (OUR) in adult patients for benign disease. METHODS: We identified adult patients undergoing LUR or OUR by urologists between 2006 and 2013 using the American College of Surgeons National Surgical Quality Improvement Program database, excluding those with concomitant partial cystectomy or ureterectomy. Multivariable regression modeling was used to assess for the independent association of minimally invasive surgery (MIS) with 30-day complications, reoperations, or readmissions. RESULTS: Of 512 patients identified, 300 underwent LUR and 212 underwent OUR. Baseline characteristics including age, race, body mass index, and cardiovascular comorbidities were similar between LUR and OUR (all P > .05). Patients who underwent LUR had higher median preoperative serum creatinine (1.1 mg/dL vs 1.0 mg/dL, P = .03), increased presence of a resident (51% vs 34%, P < .01), and shorter hospitalization (1 [interquartile range 0-3] days vs 4 [interquartile range 3-6] days, P < .01) compared to patients who underwent OUR. LUR had lower overall complications (9% vs 28%, P < .01), especially with regard to transfusions (1% vs 11%, P < .01), superficial wound infections (0% vs 5%, P < .01), and urinary tract infections (5% vs 11%, P = .03). On multiple regression analyses, MIS was an independent predictor of lower overall complication rate (odds ratio [OR] 0.24 [0.14-0.40], P < .01), but was not predictive of readmission (OR 0.93 [0.44-1.98], P = .16) or reoperation (OR 2.09 [0.90-4.82], P = .10). CONCLUSION: In the largest current series assessing the impact of MIS on adult ureteral reimplantation, data from the National Surgical Quality Improvement Program demonstrate that LUR results in decreased 30-day complications.

30-Day Morbidity and Reoperation Following Midurethral Sling: Analysis of 8772 Cases Using a National Prospective Database.

OBJECTIVE: To determine 30-day complications, risk of readmission, and reoperation for midurethral slings (MUS). METHODS: The National Surgical Quality Improvement Program database from 2006 to 2013 was queried for MUS alone by excluding concurrent reconstructive, urologic, or gynecologic procedures. We assessed baseline characteristics, 30-day perioperative outcomes and 30-day readmission. Logistic regression analysis identified risk factors for the frequent complications. RESULTS: There were 8772 women who underwent MUS, of which 3830 (43.7%) and 4942 (56.3%) were performed by urologists and gynecologists, respectively. Patients of urologists were older, had higher frailty, and were more likely diabetic (all P < .05). Patients of gynecologists were more likely to have resident involvement compared to urologists (16.4% vs 11.2%, P < .001). Mean operative time was shorter for urologists compared to gynecologists (35.6 ± 29.2 minutes vs 38.1 ± 34.3 minutes, P < .001). The overall 30-day rate of any complication was 3.52%. Urinary tract infection (UTI) occurred in 2.2% vs 3.5% of the urologic and gynecologic patients, respectively (P=.001). After adjusting for frailty, body mass index, steroid use, age, operative time, and residency involvement, gynecologic performed surgery incurred an increased risk of UTI (OR 1.67, 95% CI 1.27-2.19; P=.001). Sixty-five (0.90%) patients were readmitted within 30 days, most commonly due to urinary symptoms. Sling revision for urinary obstruction occurred in 15 patients; 10 underwent repair of the bladder, urethra, or vagina. CONCLUSION: To our knowledge, we present the largest American cohort of MUS 30-day outcomes to date, stratified by specialty of performing surgeon. Overall, morbidity is low. UTI is the most common complication, and occurs at increased frequency for patients of gynecologists.