A Cost Analysis of Phosphodiesterase Type 5 Inhibitors in the United States.

OBJECTIVE: To perform a cost analysis of generic and brand-name Phosphodiesterase Type 5 (PDE5) inhibitors at different dosages and pharmacies across the US. METHODS: Using an all-payer retail pharmacy-claims database, we analyzed prescription drug data for three generic and six brand-name oral PDE5 inhibitors at different dosages across US chain and independent pharmacies in 2019. RESULTS: We obtained cash price data from 60,186 pharmacies (35,976 chain and 24,210 independent). The nationwide mean cash price per unit (PPU) ranged from $8.6 ± 5.2 (sildenafil 20 mg at chain pharmacies) to $107.1 ± 71 (Adcirca 20 mg at independent pharmacies) equal to 1145.3% difference. Chain pharmacies provided significantly lower average prices for one brand-name and six generic PDE5 inhibitors. Tadalafil PPU was cheaper at higher quantities, however, PPU increased with quantity prescribed for sildenafil. Looking at the top 10 metropolitan statistical areas, the highest PPUs were observed for tadalafil (Cialis) 10 mg and sildenafil (Viagra) 50 mg in Atlanta ($67.4 ± 8.7) and Los Angeles ($50.3 ± 24.0), while New York ($9.7 ± 2.6) and Miami ($27.9 ± 16.4) had the lowest PPUs for tadalafil (Cialis) 5 mg and sildenafil (Viagra) 100 mg, respectively. CONCLUSION: A substantial variability in PDE5 inhibitor cash prices exists across manufacturer, dosage, quantity, pharmacy type, and location. In addition, the pricing does not necessarily correlate with the regional socioeconomic factors. This highlights the importance of provider awareness and patient counseling on drug price including potentially assisting patients in identifying opportunities for cost savings.

Real-World Complications of the SpaceOAR Hydrogel Spacer: A Review of the Manufacturer and User Facility Device Experience Database.

OBJECTIVE: To characterize adverse events related to use of the perirectal spacing agent SpaceOAR, we examined the Manufacturer and User Facility Device Experience (MAUDE) database. METHODS: The MAUDE database was queried for "SpaceOAR" and "Augmenix" from June 2015 (when SpaceOAR was approved by the Food and Drug Administration) to October 2022. Reports were reviewed for adverse events (AEs), operative procedures performed because of the AE, and changes to the radiation plan. AEs were categorized using Common Terminology Criteria for Adverse Events (CTCAE), version 5.0. RESULTS: Six hundred fifty-four reports were reviewed. Eighty-four were excluded and 4 reports reviewed 2 separate cases of SpaceOAR administration. Five hundred seventy-four cases were ultimately included. Three deaths were reported (0.5% of all AEs). One point six percent of cases represented CTCAE grade 4 injuries (life-threatening consequences; urgent intervention indicated), 15.9% grade 3 (severe but not immediately life-threatening; hospitalization), 24.2% grade 2 (moderate; local/noninvasive intervention), and 57% of events were CTCAE grade 1 (mild; asymptomatic or mild symptoms). Bowel diversion occurred in 29 cases (9%). CONCLUSION: Both asymptomatic (n = 311) and debilitating (n = 12) complications of SpaceOAR hydrogel use were identified. Death, gel embolization, anaphylaxis, rectal ulcerations, and infections requiring bowel or urinary diversions were among the complications reviewed. Providers should consider these potential complications before perirectal spacer administration and during patient counseling.

Oral phosphodiesterase type 5 inhibitors and priapism: A VigiBase analysis.

PURPOSE: To explore the differences of priapism events among a diverse cohort taking erectogenic medicines (i.e., phosphodiesterase type 5 inhibitors [PDE5i] and intracavernousal drugs). METHODS: We queried the World Health Organization global database of individual case safety reports (VigiBase) for records of the adverse drug reactions (ADR) with sildenafil, tadalafil, avanafil, vardenafil, papaverine, and alprostadil. Disproportionality analyses (case/non-case approach) were performed to assess the reporting odds ratio (ROR) of priapism reporting in PDE5i consumers compared to intracavernousal drug recipients. RESULTS: From a total of 133 819 ADR events for erectogenic medications, 632 were priapism (PDE5is: n = 550, 0.41%; intracavernousal drugs: n = 82, 9.92%). Priapism disproportionality signals from intracavernousal drugs were 25 times stronger than PDE5is (ROR = 34.7; confidence interval [CI] 95%: 27.12-43.94 vs. ROR = 1.38; 95% CI: 1.24-1.54). For all PDE5i agents, the 12-17 years age group had the highest ROR (9.49, 95% CI: 3.76-19.93) followed by 2-11 years (4.31, 95% CI: 1.57-9.4). Disproportionality signals for consumers under 18 for both all PDE5is as a whole (ROR = 4.57, 95% CI: 2.48-7.73) and sildenafil (ROR = 4.89, 95% CI: 2.51-8.62) were stronger than individuals 18 or older (ROR = 1.06, 95% CI: 0.93-1.21 and ROR = 1.08, 95% CI: 0.91-1.26, respectively). CONCLUSIONS: PDE5i use shows disproportionate priapism signals which are higher in young patients.

Management of pediatric renal trauma - Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study (Mi-PARTS).

BACKGROUND: Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A non-operative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury is not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This manuscript describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States. METHODS: Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010-2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management and outcomes. RESULTS: In total 1216 cases were included in this study. 67.2% were male, and 93.8% had a blunt injury mechanism. 29.3% had isolated renal injuries. 65.6% were high-grade (AAST Grade III-V) injuries. The mean Injury Severity Score (ISS) was 20.5. Most patients were managed non-operatively (86.4%) 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in polytrauma. The rate of avoidable transfer was 28.2%. CONCLUSION: The management and outcomes of pediatric renal trauma lacks data to inform evidence-based guidelines. Non-operative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population, and highlights opportunities for further investigation. With data made available through Mi-PARTS we aim to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries. LEVEL OF EVIDENCE: IV, Epidemiological (prognostic/epidemiological, therapeutic/care management, diagnostic test/criteria, economic/value-based evaluations, and Systematic Review and Meta-Analysis).

The Effect of Bike Seat Models on Perineal Pressure During Cycling: Implications for Patients After Lower Genitourinary Reconstructive Surgery.

OBJECTIVE: To understand the effect of bicycle saddle shape and size on the pressure transmitted to the perineum, as prolonged perineal pressure and microtrauma amongst avid cyclists may increase the risk for complications following lower genitourinary surgery. METHODS: We tested five seats (Bontrager, Waterloo, WI) with varying levels of padding and morphology (comfort, fitness, fitness gel, race, and performance) for two different riders. The seats were installed on a Peloton stationary exercise bike (New York City, NY). Force measurements were performed using a 9833E-50 Large F-Socket Sensor (Tekscan, South Boston, MA). We measured total and perineal forces in three conditions at the same resistance: (a) at rest (not pedaling); (b) at 8mph; (c) at 15mph. RESULTS: Significant differences across the bicycle seats were observed with fitness gel seats providing the lowest perineal pressure. In all measurements, perineal forces were significantly lower at 15mph compared to 8mph (P < .001). When a rider used an oversized seat, less force was exerted compared to the appropriate size at both 8mph (P < .001) and 15mph (P < .001) speeds. Conversely, an undersized seat significantly increased perineal pressures at both 8mph (P = .018) and 15mph (P = .007). CONCLUSION: Larger seats constructed of more impressionable materials absorb a greater total force and act to distribute the subject's weight thereby delivering less force to the perineum. More perineal pressure is delivered at lower speeds and at rest likely due to the cyclist lifting off the seat during times of strenuous activity.

A novel endoscopic approach for management of hutch diverticulum concomitant vesicoureteral reflux with dextranomer/hyaluronic acid copolymer injection.

INTRODUCTION: There are various treatment options for symptomatic bladder diverticulum, including robotic-assisted laparoscopic bladder diverticulectomy, open and endoscopic techniques. But, to date, the optimal surgical technique remains unclear. OBJECTIVE: To present the preliminary long-term follow-up results of a novel technique of dextranomer/hyaluronic acid copolymer (Deflux) plus autologous blood injection for correction of hutch diverticulum in patients with concomitant vesicoureteral reflux (VUR). PATIENT AND METHOD: We retrospectively reviewed four patients who had hutch diverticulum with concomitant VUR and had undergone submucosal Deflux following autologous blood injection. Patients with neurogenic bladder, posterior urethral valve, or voiding dysfunction were excluded from the study. Success was defined as the resolution of the diverticulum, hydronephrosis, and hydroureter on ultrasonography at a 3-month follow-up and long-term symptom-free period. RESULTS: Four patients with hutch diverticula were included. The median age at the time of surgery was 6.1 (range 3-8) years. Three of them had unilateral VUR, and one had bilateral VUR. During the procedure, a mean of 0.625 ml Deflux plus a mean of 1.25 ml autologous blood were injected submucosally for correction of VUR. Additionally, a mean of 1.62 ml Deflux plus a mean of 1.75 ml autologous blood were injected submucosally to occlude the diverticulum. The median follow-up was 4.6 (range 4-8) years. This method had excellent success in all patients in the current study with no postoperative complications such as febrile urinary tract infection, or diverticulum, hydroureter, or hydronephrosis in follow-up ultrasounds. CONCLUSIONS: Submucosal injection of Deflux plus autologous blood injection can be a successful endoscopic intervention for treatments of hutch diverticulum in patients with concomitant VUR. Deflux injection can be a simple and cost-effective technique.

Radiation-induced Fistulas in Patients With Prior Pelvic Radiotherapy for Prostate Cancer: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically aggregate and summarize existing data on fistula prevalence among patients with a history of pelvic radiotherapy for prostate cancer. MATERIALS AND METHODS: We queried PubMed, Embase, and Web of Science on October 7, 2020 for peer-reviewed publications pertaining to radiation-induced fistulas in the pelvis. For meta-analysis, we used the random-effects model. We used the I2 statistic to quantify heterogeneity and the Newcastle-Ottawa Scale to assess risk of bias. RESULTS: Our final meta-analysis included 6 cohort studies with a total of 7665 patients exposed to pelvic radiotherapy between 1967 and 2013. Median follow-up time was 35.5 months (IQR 33.5-57.5). Pooled prevalence of radiation-induced fistula across all 6 cohort studies was 0.2% (95% CI: 0.1-0.4, I2 = 0.000%, P < .608). In subgroup analysis, we did not detect significant heterogeneity in fistula prevalence in patients who were re-irradiated (0.3%, 95% CI: 0.1-0.4; P = .762) or patients on concurrent chemotherapy (0.4%, 95% CI: -0.3 -1.2; P = .664) compared to those receiving their first course of radiotherapy alone. No randomized controlled trials met inclusion criteria due to ambiguous and inconsistent reporting language for fistula occurrence. CONCLUSION: There is limited published literature reporting fistula as an adverse event of prostate cancer radiotherapy, especially in the medium and long-term period. Patients undergoing pelvic radiotherapy for prostate cancer appear at low short-term risk for developing fistulas. Adverse event reporting in randomized controlled trials merits greater granularity where fistulas should be reported with specificity rather than aggregating into broad categories of genitourinary or gastrointestinal adverse events.

Inguinal lymph node dissection in the era of minimally invasive surgical technology.

BACKGROUND: Inguinal lymph node dissection (ILND) is an essential step in both treatment and staging of several malignancies including penile and vulvar cancers. Various open, video endoscopic, and robotic-assisted techniques have been utilized so far. In this review, we aim to describe available minimally invasive surgical approaches for ILND, and review their outcomes and complications. METHODS: The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000-2020. FINDINGS: There are different minimally invasive platforms available to accomplish dissection of inguinal nodes without jeopardizing oncological results while minimizing postoperative complications. Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy are safe and achieve the same nodal yield, a surrogate metric for oncological adequacy. When compared to open technique, Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy may offer faster postoperative recovery and fewer postoperative complications including wound dehiscence, necrosis, and infection. The relatively high rate and severity of postoperative complications hinders utilization of recommended ILND for oncologic indications. Minimally invasive approaches, using laparoscopic or robotic-assisted platforms, show some promise in reducing the morbidity of this procedure while achieving adequate short and intermediate term oncological outcomes.

Extramammary Paget's disease: Updates in the workup and management.

Objective: Extramammary Paget's disease (EMPD) is a rare cutaneous malignant disease. Due to its rarity, there is a paucity of data regarding best treatment strategy. EMPD primarily affects apocrine gland-bearing skin areas such as the vulva, scrotum, and penis. Our objective was to provide a present-day rationale for diagnosis, pathogenesis, and treatment of EMPD with a focus on recent progress in workup and management of the disease. Methods: Literature on EMPD until February 2022 was assessed through PubMed, MEDLINE databases, and Google scholar. A narrative review of the most relevant articles was provided. Results: EMPD usually presents with indolent growth while usually being diagnosed primarily as carcinoma in situ. The foundation of EMPD treatment centers around prompt and accurate diagnosis, wide local or Mohs micrographic surgical excision with proper management towards the margin status, and careful consideration for lymphadenectomy in patients with regionally positive disease. Conventional chemotherapies are alternative treatments modality for patients with distant metastases; however, they sometimes have suboptimal efficacy. At present, there is no agreement regarding adjuvant or systemic therapies, although recent studies have shown several insights into the molecular pathogenesis, tumor biology, and genomics of the development and advancement of EMPD, which may lead to novel and targeted treatment approaches for metastatic EMPD in the future. Conclusion: Patients with EMPD should seek care from physicians with expertise in disease management and patient counseling. These patients should be surveilled with close follow-up to evaluate them for disease recurrence or progression. Global collaborations with groups such as the Global Society for Rare Genitourinary Tumors, and especially patient support groups are crucial in designing clinical trials to help elucidate more robust data in this orphan disease.

Incidence of circumcision among insured adults in the United States.

PURPOSE: Although circumcision is the most commonly performed surgery in males, less is known about the incidence and indications of adult circumcision. In this study, we aim to present the incidence of adult circumcision across the United States. METHODS: Using IBM MarketScan® Commercial Database from 2015 to 2018, we obtained claims for circumcision in men between 18 and 64 years of age. We calculated the incidence of adult circumcision over the study period and across the United States. We also collected data on indications for surgery using International Classification of Diseases codes. RESULTS: We identified a total of 12,298 claims for adult circumcisions. The mean age was 39 (±12.9) years. The average incidence rates remained relatively constant from 98.1 per 100,000 person-years in 2015 to 98.2 per 100,000 person-years in 2018 (Δ+0.1%). The age-standardized incidence rates varied significantly across the United States (from 0 to 194.8 per 100,000 person-years) with South Dakota having the highest rate. The most common indications for adult circumcision were phimosis (52.5%), routine/ritual circumcision (28.7%), phimosis + balanitis/balanoposthitis (6.8%), balanitis (3.8%) and balanoposthitis (2.6%), and significantly varied by age groups. CONCLUSION: This study suggested a wide geographic variation in rates of adult circumcision between states with highest incidences in the Northeast United States. Future studies can identify the underlying causes for the observed variations.

Posterior urethral stenosis: a comparative review of the guidelines.

PURPOSE: We aimed to provide a thorough comparative review of the available guidelines on the diagnosis, management, and follow-up for patients with posterior urethral stenosis by the American Urologic Association (2016), Société Internationale d'Urologie (2010), and European Urologic Association (2022). METHODS: The AUA, SIU, and EAU guidelines were evaluated for recommendations on the diagnosis, evaluation, and treatment of posterior urethral stenosis. We also included the EAU and AUA urologic trauma guidelines for the trauma-related stenosis. The level or strength of recommendations is included in case of disparity between the guidelines. RESULTS: The three guidelines align considerably in recommendations provided for the diagnosis, management, and follow-up of patients with posterior urethral stenosis. SIU and EAU emphasize the role of repeat endoscopic treatment in guidelines compared to AUA. CONCLUSION: The preferred method to repair bulbo-membranous stricture/stenosis following radiation therapy remains an area of active interest, focusing on continence preservation. Additionally, there may be a role for advanced endoscopic treatments with or without adjunct therapies to manage even obliterated stenoses.

Impact of the COVID-19 pandemic on emergency department visits for genitourinary trauma.

INTRODUCTION: The mean number of emergency department visits for all-cause traumas has declined significantly during the COVID-19 pandemic. We aim to identify how a global pandemic and social distancing could affect the trends and pattern of genitourinary traumas. METHODS: We queried the National Electronic Injury Surveillance System to obtain consumer product-related genitourinary injuries leading to emergency department visits. Using three key events in 2020, we divided the study period to three intervals: January 20, when the first COVID-19 case was confirmed in the United States; March 13, when a national state of emergency was declared; April 20, when Texas became the first state to start a phased reopening of economy. We compared the injury characteristics in 2020 to their identical intervals in 2019. RESULTS: Daily emergency department visits dropped significantly during the national lockdown (mean 131.5 vs. 78; Δ-40.7%; p < 0.01). The genitourinary injuries decreased significantly in children ≤ 17 years (p < 0.01), males (p < 0.001), and White population (p < 0.01). However, it did not change significantly in adults 18-64 years (p = 0.92), old adults ≥ 65 years (p = 0.37), females (p = 0.60), Black population (p = 0.90), other/unknown races (p = 0.93), and for injuries sustained at home (p = 0.75) and public (p = 0.11) locations. During the lockdown period, injuries associated with toilets/toilet seats (- 320, - 74.6%), day wear (- 266, - 77.7%), beds/bedframes (- 209, - 64.2%) decreased while injuries associated with knickknacks/statues/vases (+ 154, n/a), sofas/couches/divans (+ 130, 2,684%), and razors/shavers (+ 99, n/a) increased. CONCLUSIONS: The COVID-19 lockdown had a significant impact on genitourinary traumas. The contributing factors could be investigated further to prevent such injuries during deconfinement periods.

The Lived Experience of Patients with Adult Acquired Buried Penis.

PURPOSE: We describe the lived experience of adults with acquired buried penis (AABP) through thematic analysis of patient interviews. We examine the challenges that patients face and the impacts of surgery. MATERIALS AND METHODS: This mixed-methods study utilized validated instruments and semi-structured interviews to capture pre- and postsurgical outcomes. Semi-structured interviews were conducted with open-ended questions to elicit the impact of AABP on a patient's quality of life in several domains including urinary function, sexual function, interpersonal relationships and mental health. Recruitment was completed once we achieved thematic saturation. RESULTS: Twenty patients participated in the study; 11 underwent surgical treatment for AABP. Semi-structured interviewee responses were coded into 12 different themes and 39 subthemes. The most common themes were problems with urinary (19/20, 95%) and sexual function (19/20, 95%). Most participants (16/20, 80%) reported negative impacts of AABP on social life. Interviewees struggled with relationships (8/20, 40%) and mental health (11/20, 55%), often avoiding romantic relationships and reporting fear of rejection with concomitant depression and/or anxiety. The majority (70%, 14/20) experienced difficulties accessing care. Among patients who underwent surgery, the majority discussed improvement in urinary and sexual function (82% [9/11] and 73% [8/11], respectively). Though weight gain was a precipitating factor, weight loss did not result in symptom improvement. Rather, in 4/20 (20%), weight loss made their condition worse. CONCLUSIONS: Patients living with AABP experience profound negative impacts on quality of life including their urinary and sexual function, social life and mental health. Many patients face issues with access to care.

Hematospermia is rarely associated with urologic malignancy: Analysis of United States claims data.

BACKGROUND: Hematospermia is an alarming symptom and can cause significant patient distress, but work-up is often negative. OBJECTIVE: To characterize the clinical evaluation of hematospermia and its association with the diagnosis of urologic malignancy. MATERIALS AND METHODS: Using MarketScan insurance claims database, we identified adult males 18-64 years old diagnosed with hematospermia from 2010 to 2018. Benign hematospermia was defined as the absence of hematuria and elevated prostate-specific antigen. Patients with urologic cancer prior to diagnosis of hematospermia were excluded. We identified those who were diagnosed with a urologic malignancy. RESULTS: The annual average incidence rate of hematospermia was 56.6 per 100,000 (95% confidence interval 55.4-57.8 per 100,000) in 2010 and increased to 73.6 per 100,000 (95% confidence interval 71.7-75.4 per 100,000) in 2018. A total of 56,157 patients presented with benign hematospermia. Most (57.5%) underwent at least one test, with the most common being urinalysis (51.7%), followed by prostate-specific antigen testing (11.9%). All other tests were performed in less than 3% of patients. Forty-seven patients were diagnosed with a urologic cancer, including 28 with prostate cancer (0.05%), nine with testicular cancer (0.016%), six with prostate carcinoma in situ (0.01%), and four with bladder cancer (0.007%). Stratified by age, there was only one cancer diagnosis (testicular) in 15,106 patients under 40 years (0.01%) and 46 cancer diagnoses in 40,611 patients 40 years old or above (0.11%). The median age of patients diagnosed with cancer was 56 years (interquartile range 52-61). DISCUSSION AND CONCLUSION: A small minority of patients with benign hematospermia were later diagnosed with urologic cancer in a large nationally representative sample. After excluding hematuria with urinalysis, physicians should conservatively manage and reassure patients with hematospermia, especially those under 40 years of age.

Incidence of venous thromboembolism in benign urologic reconstructive cases.

PURPOSE: To evaluate the rate of perioperative venous thromboembolism (VTE) among patients undergoing common benign urologic reconstructive cases. We hypothesize that this rate will be lower than previously described. METHODS: We utilized the American College of Surgeons National Surgical Quality Improvement Project database from 2015 to 2019 to evaluate 30-day perioperative risk of VTE. Patients ≥ 18 years old undergoing benign urologic reconstructive cases were selected using Current Procedural Terminology (CPT) codes. Demographic, comorbidity, and operative variables were captured. The primary outcome was VTE within the 30-day postoperative period. RESULTS: We identified 8467 patients who met inclusion criteria. The majority of patients were male (> 95%) with an average age of 65 and BMI of 29.6. There were 23 VTE events (0.27%) within the 30-day perioperative period. Fourteen (14/59) procedures had a perioperative VTE. Many of the traditional factors for VTE including operative time and obesity significantly increased risk of VTE in univariate analysis. In multivariate analysis, only BMI (OR 1.09; 95% CI 1.01-1.12) and inpatient status (OR 4.42; 95% CI 1.9-10.2) were correlated with increased perioperative VTE. CONCLUSION: The rate of VTE among patients undergoing benign urologic reconstructive cases is low. Providers should continue to have high index of suspicion particularly for inpatients with high BMI in addition to other known risk factors for VTE.

How to Care and Minimize the Sequelae of Lower Extremity Lymphedema.

OBJECTIVE: The objective of this review is to provide information regarding the care of patients with lower extremity lymphedema in the setting of urologic cancer. DATA SOURCES: Literature regarding lower extremity lymphedema was examined. Relevant information was integrated to create a review of the pathophysiology, management, and potential complications of lower extremity lymphedema. CONCLUSION: Lower lymphedema is a chronic, debilitating condition with no definitive cure. It may affect patients undergoing treatment for malignancies, especially those undergoing lymph node removal. Management of this condition is multimodal, and complex decongestive therapy is currently the gold standard. For patients who do not respond to this management, surgical options exist. More research should be done in understanding the prevalence and management of lower extremity lymphedema in patients suffering from urologic cancers because this is underdeveloped research. IMPLICATIONS FOR NURSING PRACTICE: To care for patients with lower extremity lymphedema postoperatively, a multimodal approach is warranted. Different techniques include complex decongestive therapy, intermittent pneumatic compression, physical therapy, skin care, patient education, social support, and, in some cases, surgery.

Foley Catheter Balloon Rupture and Risk of Free Fragment Formation.

OBJECTIVES: To assess the volume of foley catheter balloon rupture and the incidence of free fragment formation. MATERIALS AND METHODS: Forty Latex and 30 Silicone catheters of common sizes (14-20 French) were inflated with sterile water in an aqueous environment without positive pressure. Catheters producing fragments, fragment size, and maximum instilled volume prior to rupture ("burst volume") were recorded. A subset of catheters was inflated to recommended balloon volume and the balloon was needle punctured. RESULTS: Of the 40 latex catheters, 32 (80%) produced a free fragment during spontaneous rupture. Fragments ranged from 2.1 to 3.2 cm with an average size of 2.74 ± 0.33 cm. Latex catheters had average burst volume of 83 mL, 90 mL, 112 mL,120 mL, and 422 mL for 14 Fr, 16 Fr, 18 Fr, 16 Fr 3-way, and 20 Fr 30 cc, respectively. Of the 30 silicone catheters, spontaneous rupture produced no fragments. Average burst volume for silicone catheters was 57 mL, 45 mL, and 55 mL for 14 Fr, 16 Fr, and 18 Fr, respectively. No catheter balloons produced fragments when needle punctures at recommended balloon volumes. CONCLUSION: Latex catheter balloons tolerate higher fill volumes but have a high likelihood of releasing fragments. Silicone catheters burst at lower volumes, but do not release fragments. At normal fill volumes, needle puncture is safe, and cystoscopy is likely unnecessary.

Comparative review of the guidelines for anterior urethral stricture.

PURPOSE: We aimed to provide a detailed comparison between the American Urologic Association (AUA), Société Internationale d'Urologie (SIU), and the European Association of Urology (EAU) guidelines on the evaluation, management, and follow-up of the patients with anterior urethral stricture disease (USD). METHODS: The urethral stricture guidelines from SUI, AUA, and EAU were collected and evaluated regarding the recommendations on diagnosis, evaluation, and treatment of anterior USD. The strength of evidence for each statement was included and discussed when guidelines differed. RESULTS: While the guidelines remarkably align in terms of the diagnostic workup and follow-up, there is discordance in the management of anterior urethral strictures, specifically for the use of endoscopic treatment and stenting. Further, the EAU offers more comprehensive recommendations regarding urethroplasty techniques and patient follow-up. The EAU guidelines are the most recent and first to offer guidance for USD in transgender people and women. CONCLUSION: Reconstructive urology is a rapidly adapting field, and best practices change accordingly. Guideline statements have become more inclusive and expansive but will require further research to improve the level of evidence and continue to provide patients and providers with the best treatment plans.