Non-invasive and surgical penile enhancement interventions for aesthetic or therapeutic purposes: a systematic review.

OBJECTIVE: To systematically review the literature in order to investigate the efficacy and safety of surgical and non-invasive penile enhancement procedures for aesthetic and therapeutic purposes. METHODS: A systematic search for papers investigating penile enhancement procedures was performed using the MEDLINE database. Articles published from January 2010 to December 2019, written in English, including >10 cases, and reporting objective length and/or girth outcomes, were included. Studies without primary data and conference abstracts were excluded. The main outcome measure was objective length and/or girth improvement. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: Out of 220 unique records, a total of 57 were reviewed. Eighteen studies assessed interventions for penile enhancement in 1764 healthy men complaining of small penis. Thirty-nine studies investigated 2587 men with concomitant pathologies consisting mostly of Peyronie's disease and erectile dysfunction. Twenty-five studies evaluated non-invasive interventions and 32 studies assessed surgical interventions, for a total of 2192 and 2159 men, respectively. Non-invasive interventions, including traction therapies and injection of fillers, were safe and mostly efficacious, whereas surgical interventions were associated with minor complications and mostly increased penile dimensions and/or corrected penile curvature. Overall, the quality of studies was low, and standardized criteria to evaluate and report efficacy and safety of procedures, as well as patient satisfaction, were missing. CONCLUSION: The quality of the studies on penile enhancement procedures published in the last decade is still low. This prevents us from establishing recommendations based on scientific evidence regarding the efficacy and safety of interventions that are performed to increase the penis size for aesthetic or therapeutic indications.

Villous Adenoma Arising in the Urethra of a Female with Bladder Augmentation History: A Case Report and Review of the Literature.

Villous adenomas (VAs) in the female urethra are rare with only seven cases in the English literature to our knowledge. In patients with bladder augmentation cystoplasty, the neoplasia development risk increases and most of these develop in the neobladder or anastomosis line. Only two cases of VA developing from the native bladder mucosa have been reported. Physical examination of a 76-year-old female who had a history of augmentation cystoplasty revealed a caruncula-like structure protruding from the urethral meatus. The urinary USG showed that the lesion had no relation with the bladder. The lesion was excised. Microscopically, it consisted of villous structures covered with pseudostratified intestinal type epithelium. Low-grade dysplasia was present in the epithelium but high-grade dysplasia or in-situ/invasive carcinoma was not observed. Immunohistochemical study showed positivity for CK7, CK20, EMA, CEA and CDX2. The case was reported as VA of the urethra. We presented the first VA case arising in the urethra of a female patient with intestinal bladder augmentation. Excision is curative for pure VAs. Transformation to carcinoma or recurrence has not been reported. However, in one third of the cases, a malignant tumor may accompany the lesion. Therefore, all excision material should be examined carefully. Routine endoscopic follow-up should be performed in cases with bladder augmentation.

Post-operative complications following feminizing genitoplasty in moderate to severe genital atypia: Results from a multicenter, observational prospective cohort study.

Disorders/differences of sex development (DSD) are congenital conditions in which there is atypical chromosomal, gonadal and/or phenotypic sex. While there remains controversy around the traditionally binary concept of sex, most patients with DSD are reared either male or female depending on their genetic sex, gonadal sex, genital phenotype and status of their internal genital tract. This study uses prospective data from 12 institutions across the United States that specialize in DSD care. We focused on patients raised female. Eligible patients had moderate to severe genital atypia (defined as Prader score >2), were ≤2 years of age at entry, and had no prior genitoplasty. The aim of this study is to describe early post operative complications for young patients undergoing modern approaches to feminizing genitoplasty. Of the 91 participants in the cohort, 57 (62%) were reared female. The majority had congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (n = 52), 1 had ovo-testicular syndrome, 2 had mixed gonadal dysgenesis and 2 had partial androgen insensitivity syndrome (PAIS). Of the 50 participants who received early genitoplasty, 43 (86%) had follow-up at 6-12 months post-surgery. Thirty-two participants (64%) received a clitoroplasty, 31 (62%) partial urogenital mobilization and 4 (8%) total urogenital sinus mobilization. Eighteen percent (9/50) experienced post-surgical complications with 7 (14%) being rated as Clavien-Dindo grade III. Both parents and surgeons reported improved satisfaction with genital appearance of participants following surgery compared to baseline. This information on post-operative complications associated with contemporary approaches to feminizing genitoplasty performed in young children will help guide families when making decisions about whether or not to proceed with surgery for female patients with moderate to severe genital atypia.

A Comparative Observational Study to Evaluate the Efficacy of Mid-Urethral Sling with Botulinum Toxin A Injection in Urinary Incontinence Patients.

This study aimed to evaluate and compare the efficacy and safety of mid-urethral sling (MUS) with botulinum toxin A (BoNT-A) versus MUS only in women with mixed urinary incontinence. This was a comparative observational study, and total of 73 patients were enrolled. A total of 38 and 35 patients received MUS only and MUS with BoNT-A injection, respectively. The efficacy outcome included change in Urinary Incontinence Outcome Scores (UIOS), change in Overactive Bladder Symptom Score (OABSS), and use of antimuscarinic agent or beta-3 agonist. Safety assessments included adverse events including urinary retention, increased postvoid residual volumes, and urinary tract infection. MUS with BoNT-A injection was insignificantly better than MUS only in urinary incontinence outcome (88% vs. 71%, respectively, p = 0.085) at week three. Among the 33 patients with detrusor overactivity (DO), patients who received BoNT-A had a higher cure rate of incontinence (88% vs. 41%, p = 0.01) and less required antimuscarinic agent or beta-3 agonist (31% vs. 94%, p < 0.001) compared to patients who did not receive BoNT-A injection. There was no significant difference in the incidences of adverse events between two groups. BoNT-A injection with MUS demonstrated efficacy and safety in the treatment of mixed urinary incontinence, specifically for women with DO.

Deep Infiltrating Endometriosis: a Previous History of Surgery for Endometriosis May Negatively Affect Assisted Reproductive Technology Outcomes.

For patients with endometriosis-related infertility, the impact of previous surgery for endometriosis before assisted reproductive technology (ART) remains controversial, particularly in cases of deep infiltrating endometriosis (DE). To study the impact of previous surgery for endometriosis on ART cumulative live-birth rates in DE patients, a retrospective cohort study included 222 DE patients who underwent ART. DE diagnosis was based on strict imaging criteria and histological confirmation of the disease for women with a previous history of surgery for endometriosis. ART outcomes were compared for patients with and without a previous history of surgery for endometriosis. The main outcome measures were cumulative live-birth rates (CLBR). Prognostic factors were identified by comparing women who became pregnant and those who did not, using an adjusted multiple logistic regression model. Two hundred twenty-two DE patients underwent a total of 440 ART cycles (including fresh and associated frozen-thawed embryo transfers). One hundred fifty-five women (69.8%) had a prior history of surgery for endometriosis. The CLBR was 26% after four ART cycles in the "previous history of surgery for endometriosis" group, while it reached 51.3% after four cycles (p < 0.001) in patients who had not previously undergone surgery for endometriosis. After multivariate analysis, a previous history of surgery for endometriosis (p = 0.001) and a past surgery for endometrioma (p = 0.005) were established as independent factors associated with lower pregnancy rates. Our preliminary results suggest that for DE patients, a previous history of surgery for endometriosis may be associated with negative ART outcomes.

Observational analysis of mesh related complications in urogynecologic procedures.

Since the 1990s, the use of mesh has expanded in gynecologic surgeries in the aim of correcting pelvic organ prolapse. Because there has been a lot of complications that were reported, the U.S. Food and Drug Administration has requested the withdrawal of many products from the market. Recently, many countries have called for the suspension of vaginal mesh products from the market. The objective of this review is to analyze the incidence of the complications that arise after vaginal mesh surgeries with an insight to the American College of Obstetricians and Gynecologists recommendations on the management of those complications.

Predictive factors for persistence of preoperative overactive bladder symptoms after transvaginal mesh surgery in women with pelvic organ prolapse.

BACKGROUND: We aimed to evaluate the effect of transvaginal mesh surgery on overactive bladder symptoms in women with pelvic organ prolapse and to identify predictive factors for persistence of a preoperative overactive bladder after surgery. MATERIALS AND METHODS: We retrospectively evaluated 102 patients who underwent transvaginal mesh surgery. All patients had stage 2 or greater pelvic organ prolapse accompanied by cystocele. The Overactive Bladder Symptom Score, International Prostate Symptom Score, uroflowmetry, and postvoid residual urine volume were evaluated preoperatively and 6 months postoperatively. To identify predictive factors for the persistence of a preoperative overactive bladder after surgery, preoperative parameters were statistically compared between patients with and without the persistence of preoperative overactive bladder symptoms. Receiver operator characteristic curves were generated, and the area under the curve was calculated. RESULTS: Preoperatively, 54 women (53%) had an overactive bladder. After surgery, the symptoms disappeared in 34 (63%) and persisted in 20 (37%) women. There were no significant differences in preoperative parameters including age, body mass index, parity, or severity of pelvic organ prolapse between patients with and without persistent preoperative overactive bladder. Preoperative Overactive Bladder Symptom Score and International Prostate Symptom Score were significantly higher in patients with persistent preoperative overactive bladder symptoms. The International Prostate Symptom Score storage subscore had the highest area under the curve, with a cutoff value of 9.5. CONCLUSION: Transvaginal mesh surgery eliminates overactive bladder symptoms in about two-thirds of pelvic organ prolapse patients. The preoperative International Prostate Symptom Score storage subscore was the most useful predictive factor for the persistence of preoperative overactive bladder symptoms after surgery.

Assessment of the influence of transrectal and transperineal prostate biopsies on erectile function: A prospective observational single-center study.

OBJECTIVES: To assess the impact of transrectal versus transperineal prostate biopsy on erectile function. METHODS: This was a single-center, observational, prospective study of consecutive patients who underwent a prostate biopsy (transrectal or transperineal/fusion biopsy). Study participants completed the International Index of Erectile Function-5 questionnaire before the procedure, and 3 and 6 months after. Prostatic biopsies were carried out following the standard procedure for both techniques. RESULTS: The study included 135 male patients with a mean age of 63.5 years. At baseline, 28 patients (21%) presented normal erectile function, whereas 107 patients (82%) presented erectile dysfunction, which was severe in four (3%), moderate in 49 (36%) and mild in 54 (40%), with an overall mean International Index of Erectile Function-5 score of 17.70. After 3 months, the rates were 29%, 3%, 27% and 38%, respectively (mean International Index of Erectile Function-5 score 17.95). At 6 months, the rates were 30%, 6%, 28% and 34%, respectively (mean International Index of Erectile Function-5 score of 17.77). No significant differences between pre- and post-biopsy International Index of Erectile Function-5 scores at 3 and 6 months were observed, even when analyzing transrectal and transperineal separately. The number of biopsy cores and number of previous biopsies did not influence the International Index of Erectile Function-5 scores. CONCLUSIONS: Our findings suggest that prostate biopsy technique, number of biopsy cores and history of previous biopsy do not significantly impact erectile function in the medium term up to 6 months.

The Management and Efficacy of Surgical Techniques Used for Erosive Mesh in the Urethra and Bladder: A Systematic Review.

BACKGROUND: This study reports the re-operation and symptom resolution rates of different techniques used in surgical excision of genitourinary mesh erosions. METHODS: A comprehensive systematic review was completed after searching electronic databases for studies involving outcomes of mesh erosion in humans that were managed surgically using a transvaginal, cystoscopic, or abdominal approach. Surgical outcomes were reported in percentages, ranges, and simple pooling to generate trends in management techniques. RESULTS: There were 177 cases that met our inclusion criteria. Forty-one patients underwent cystoscopic removal of eroded urethral mesh while 40 cases underwent transvaginal removal of urethral mesh. CONCLUSIONS: For mesh eroded into the urethra, a transvaginal vs. cystoscopic approach showed a trend toward resolution of symptoms and fewer interventions. For mesh eroded into the bladder, abdominal and cystoscopic approaches had similar symptom resolution, but abdominal approach required fewer interventions.

External-internal ureteral catheterization technique in treatment of ureteral injuries

Background/aim: It was aimed to describe the external-internal ureteral catheterization technique and evaluate its safety, efficacy, and reliability in iatrogenic and traumatic ureteral injuries. Materials and methods: A retrospective review was performed on patients with iatrogenic and traumatic ureteral injury, treated using the external-internal ureteral catheterization technique between May 2012 and January 2018 in our hospital. A total of 14 patients were investigated with clinical, postoperative, and follow-up findings, as well as technical outcomes. Results: The urology, gynecology, and general surgery departments referred patients for treatment at a rate of 57% (n = 8), 36% (n = 5), and 7% (n = 1), respectively. The causes were urological procedures for lithiasis (43%, n = 6), gynecological surgery (36%, n = 5), rectosigmoid surgery (7%, n = 1), penetrating injury (7%, n = 1), and partial nephrectomy (7%, n = 1). The most commonly affected segment was the distal third of the ureter, at a rate of 79% (n = 11). The mean duration of catheterization in all of the patients was 39 days. The overall technical success was 100% and no major complications occurred. Conclusion: The external-internal ureteral catheterization technique in patients with ureteral injury is easy to apply and effective not only in reducing costs but also complications that may result from recurrent percutaneous interventions.

Urinary and Fecal Continence in 5-Year-Old Patients Who Underwent in utero Myelomeningocele Repair: A Prospective Study.

INTRODUCTION: After the successful results of in utero myelomeningocele (MMC) repair presented by the Management of Myelomeningocele Study, the concept of fetal surgery was introduced in our institution in 2011. Since then, we have been able to follow prospectively a group of patients with attention to urological care. In the present study, we were interested in estimating urinary and fecal continence in this new subset of patients. MATERIAL AND METHODS: We selected from our database patients aged 5 years or older for evaluation of urinary and fecal continence. We reviewed all charts and completed a questionnaire to study aspects of urinary and fecal continence. RESULTS: We identified 14 patients, i.e., 4 (28.6%) males and 10 (71.4%) females. The mean age at MMC surgery was 25.6 gestational weeks. The uro-dynamic class was high-risk in 6 (42.9%), incontinent in 4 (28.6%), hypocontractile in 1 (7.1%), and normal in 3 (21.4%) patients. Three patients had undergone surgery (2 augmentations, i.e., 1 in association with a left colon ACE Macedo-Malone procedure and 1 mini-sling urethroplasty). Twelve patients underwent clean intermittent catheterization (CIC) (85.7%). Only 3 (21.4%) patients had no urinary leakage. Eleven patients (78.6%) used diapers. Eight patients (57.2%) underwent retrograde rectal irrigation and 11 (78.6%) complained of fecal loss. Eleven patients (78.6%) did not report an impact on their self-esteem. CONCLUSION: Despite the use of CIC in 85.7% of the cases, the continence rate in MMC patients operated on in utero was low and 78.6% of the patients used diapers. This data can be used to educate parents about future conditions of their 5-year-old children and may stimulate the debate regarding further attempts (surgical or not) to improve fecal and urinary continence.

Validation of a Model Predicting De Novo Stress Urinary Incontinence in Women Undergoing Pelvic Organ Prolapse Surgery.

OBJECTIVE: To validate a previously developed prediction model for de novo stress urinary incontinence (SUI) after undergoing vaginal surgery for pelvic organ prolapse (POP). METHODS: Model performance was determined using a cohort of women who participated in two, 14-center randomized trials in the Netherlands that evaluated whether postoperative SUI 1 year after surgery was reduced with or without concomitant midurethral sling at the time of surgery for symptomatic women who had at least stage 2 POP. Age, number of previous vaginal births, urine leakage associated with urgency, history of diabetes, body mass index, preoperative stress test result, and placement of a midurethral sling were used to calculate the predicted probability of an individual developing de novo SUI. Predicted probabilities were compared with outcomes and quantitated using the concordance index and calibration curves. Model accuracy was compared with and without the preoperative stress test, and net reclassification improvement was measured using probability cutoffs of 0.2, 0.3, and 0.4. RESULTS: Of 239 participants who did not report preoperative SUI and underwent surgery, 152 were eligible for analysis with complete baseline and outcome data. Model discrimination was acceptable and consistent with performance in the original development cohort when the preoperative stress test result was included (concordance index 0.63; 95% CI 0.52-0.74) and had lower discrimination than when the stress test variable was not included (concordance index 0.57; 95% CI 0.46-0.67, P=.048). The model that included the stress test variable was most accurate when predicted probabilities of de novo SUI were between 0 and 50%, and it correctly reclassified upward 5.9% (95% CI -14.8 to 26.8) of participants with de novo SUI and correctly reclassified downward 16.9% (95% CI 6.6-27.7) of participants without de novo SUI. CONCLUSION: On external validation, the model was predictive of de novo SUI after vaginal prolapse surgery and may facilitate decision making regarding concomitant sling placement. CLINICAL TRIAL REGISTRATION: Nederlands Trial Register, NTRR 1197 en 1070.

Furosemide Use and Time to Confirmation of Ureteral Patency During Intraoperative Cystoscopy: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effect of intravenous administration of furosemide on the time to confirmation for ureteral patency during intraoperative cystoscopy. METHODS: In a double-blind randomized controlled trial, intravenous administration of furosemide 10 mg was compared with placebo (normal saline) to investigate the effect of furosemide on the time to confirmation for ureteral patency during intraoperative cystoscopy. The primary outcome was time to confirmation of ureteral patency. Secondary outcomes included adverse reaction to study medication and delayed diagnosis of ureteric injury. A sample size of 72 per group (N=144) was powered to detect a 3-minute difference in time to confirmation of ureteral patency between groups. RESULTS: From May 2017 to March 2018, 215 patients were eligible for inclusion and 150 were randomized, with 145 available for final evaluation. The two groups were similar in regard to baseline characteristics. The administration of intravenous furosemide 10 mg in a routine cystoscopy resulted in a shorter time to confirmation compared with the administration of the placebo (86.5 seconds, interquartile range 55.0-137.0 vs 165.0 seconds, interquartile range 77.0-280.0; P<.05). Furthermore, at any given time period, patients receiving intravenous administration of furosemide 10 mg were 2.3 times more likely to have ureteral patency confirmed compared with patients receiving normal saline (95% CI 1.59-3.23). There were no adverse events related to administration of intravenous furosemide and no delayed diagnoses of ureteric injury. CONCLUSION: Compared with placebo, intravenous administration of 10 mg furosemide at time of intraoperative cystoscopy resulted in a statistically significantly shorter time to confirmation of ureteral patency, though the clinical significance of this finding is small. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02960412.

Comparing Force of Stream With a Standard Fill Voiding Trial After Surgical Repair of Apical Prolapse: A Randomized Controlled Trial.

OBJECTIVE: To estimate whether the urinary force of stream method is noninferior to a standard fill voiding trial for rate of catheterization within 6 weeks after apical prolapse surgery in those discharged without a catheter. METHODS: A noninferiority randomized controlled trial was conducted in postoperative women comparing force of stream with standard fill voiding trials after vaginal, abdominal, or laparoscopic-robotic apical pelvic organ prolapse (POP) surgery. Before discharge, women in both groups were backfilled with 300 mL normal saline. Successful voiding criteria in the force of stream group was subjective force of stream of at least 50 using a visual analog scale; reporting less than 50 prompted a bladder scan. Successful voiding was defined as a postvoid residual volume of less than 500 mL. For the standard fill voiding trial group, voiding two thirds of the instilled amount indicated success. The primary outcome was the rate of catheterization within the 6-week postoperative period after surgical repair of apical prolapse among those discharged without a urinary catheter. Secondary endpoints included trial of void failure rates. A sample size of 59 patients per group who passed trial of void at discharge was needed to achieve 80% power using a noninferiority margin (delta of 10%). Total enrollment of 169 patients was necessary to account for an estimated 30% trial of void failure rate. RESULTS: From April 2016 and April 2017, 184 patients were enrolled (six enrolled before the trial registration date), with the first patient enrolled on April 1, 2016. One hundred seventy-four patients were randomized (86 in the force of stream group and 88 in the standard fill voiding trial group). No differences were observed in demographic or perioperative characteristics, except for stage 2 apical prolapse (52% in the force of stream group vs 36% in the standard fill voiding trial group). For the primary outcome, similar rates were found in those patients who passed their trial of void but subsequently needed catheterization for voiding dysfunction (force of stream 2.8% [2/71] vs standard fill voiding trial 3.1% [2/64]; difference -0.3%, 95% CI -8.69% to 8.08%). The incidence of trial of void failures at discharge was similar (force of stream 17.4% [15/86] vs standard fill voiding trial 26.4% [23/87]; risk ratio 0.65, 95% CI 0.37-1.18, P=nonsignificant). CONCLUSION: Force of stream was noninferior to standard fill voiding trial when comparing the rate of catheter insertion during the 6-week postoperative period after apical POP surgery in those discharged without a catheter. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02753920.

Perioperative Adverse Events in Women Undergoing Concurrent Hemorrhoidectomy at the Time of Urogynecologic Surgery.

OBJECTIVE: The aim of this study was to describe the incidence and trends of outcomes after concurrent surgeries for symptomatic hemorrhoids and pelvic floor disorders. METHODS: This was a retrospective matched cohort study. Women who underwent concurrent vaginal urogynecologic and hemorrhoid surgery between 2007 and 2017 were identified by their surgical codes and matched to a cohort of women who underwent vaginal urogynecologic surgery only. The medical record was queried for demographic and perioperative data. RESULTS: Thirty-three subjects met the inclusion criteria; 198 subjects were matched accordingly (N = 231). Mean age and body mass index were 57 ± 12 years and 28.9 ± 5.6 kg/m, respectively. Subjects who underwent concurrent hemorrhoidectomy were more likely to have had previous prolapse surgery (27.3% vs 15.2%, P = 0.09) and preoperative fecal incontinence (27.3% vs 13.6%, P = 0.05). Concurrent cases were more likely to have unplanned office visits (27.2% vs 12.6%, P = 0.03) and phone calls (range, 1-7 vs 0-10; P = 0.001), mostly for pain complaints. Reoperation was higher in combined cases (3% vs 0%, P = 0.01); however, the overall rate of serious perioperative adverse events was low and not different between groups. Concurrent cases were more likely to be discharged home with a Foley (42.4% vs 18.2%, P = 0.002) and to have a postoperative urinary tract infection (33.3% vs 10.6%, P = 0.005). In the concurrent group, 33.3% of the patients experienced severe rectal pain. CONCLUSIONS: Patients undergoing concurrent hemorrhoidectomy at the time of vaginal urogynecologic surgery are at higher risk of minor events such as postoperative urinary tract infection and need for discharge home with a Foley, as well as risk of pain that may be greater than urogynecologic surgery alone.

Retrospective Cohort Study on the Perioperative Risk Factors for Transient Voiding Dysfunction After Apical Prolapse Repair.

OBJECTIVES: The primary aim was to compare the incidence of transient voiding dysfunction (TVD) between vaginal uterosacral ligament suspension, sacrospinous ligament fixation, and robotic sacrocolpopexy. Secondarily, we identified risk factors for TVD and associated postoperative complications. METHODS: This was a retrospective cohort study of women who underwent apical repair at 1 institution. Data were collected from electronic medical records and were presented as means (SD) or numbers (percent) as appropriate. Univariate and multivariate analyses were performed to identify risk factors for TVD and its associated postoperative complications. RESULTS: Three hundred sixty women were included in analysis. Two hundred nineteen (60.8%) passed their voiding trial and 141 (39.2%) experienced TVD. The TVD group demonstrated a higher age, age-adjusted Charlson Comorbidity Index score, and preoperative postvoid residual (all P < 0.05). Univariate analysis demonstrated higher rates of TVD in the vaginal uterosacral ligament suspension and sacrospinous ligament fixation groups compared with the robotic sacrocolpopexy group (P = 0.012). Transient voiding dysfunction occurred more frequently with a concomitant anti-incontinence procedure, anterior repair, and/or posterior repair (all P < 0.05). In multivariate analysis, only an anti-incontinence procedure and concomitant anterior repair were independently associated with a risk of TVD (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.37-3.62, and OR, 2.20; CI, 1.14-4.27, respectively). Transient voiding dysfunction was associated with a culture-proven urinary tract infection within 6 weeks (OR, 3.2; CI, 1.3-8.55). CONCLUSIONS: There was no difference in TVD between types of apical repair. Concomitant anti-incontinence procedure and anterior repair were associated with TVD. Women with TVD have an increased risk of postoperative urinary tract infections.

Determinants, time trends and dynamic consequences of postoperative hyperglycemia in nondiabetic patients undergoing major elective abdominal surgery: A prospective, longitudinal, observational evaluation.

BACKGROUND & AIMS: In retrospective studies an indisputable causal relationship between hyperglycemia and postoperative infections cannot be entirely disclaimed. We aimed investigate whether the time trends of blood glucose levels in the perioperative period could be a determinant of surgery-related infections. METHODS: Adult patients without diabetes who were candidates for elective major abdominal operation were prospectively enrolled in a longitudinal, observational multicenter study. The blood glucose level was measured every 6 h for 3 days. We calculated the association between blood glucose (BG) levels and the risk of occurrence of surgery-related infections using a joint regression modeling for longitudinal and time-to-event outcomes which accounts for the effect of other risk factors. RESULTS: Between January 2016 and November 2017, we obtained 6078 BG measures distributed on different time-points in 452 patients. There was a nearly 3-fold increased risk of having hyperglycemia, defined as BG ≥ 125 mg/dL, if the BG level at admission was >100 mg/dL (OR = 2.986, P < 0.001).The hazard of infection for each 10 mg/dL increase of BG levels over time was marginal (HR = 1.065, P = 0.045). The calculated risk of having an infection was 9.6% for BG going from 110 mg/dL during surgery to 84 mg/dL at the end of day 3, 10.5% for BG decreasing from 140 to 114, 11.8% for BG decreasing from 180 to 154 and 24.5% for BG increasing from 80 to 145, 24.7% for BG increasing from 110 to 175, and 25.4% for BG increasing from 140 to 205. CONCLUSIONS: The time trends of BG - as opposed to the absolute concentration -are major determinants of the risk of postoperative infections.

Keloid formation after pediatric male genital surgeries: an uncommon and difficult problem to manage.

INTRODUCTION: Penile and genital keloids are uncommon despite frequent surgeries in the genital area. Keloid scar pathogenesis is not well understood, and a uniform effective therapeutic regimen for keloids has not yet been established. In the present study, the clinical features and subsequent management in cases of severe keloid formation after pediatric genital surgery are described. METHODS: A retrospective review of keloid cases that had developed after genital procedures between 2000 and 2017 was conducted. Pre-operative characteristics, operative procedures, postoperative management, and follow-up were reviewed for each case. All cases were managed by a multidisciplinary team that included plastic surgeons and dermatologists. RESULT: Six cases developed genital keloids. The mean age at surgery was 5.6 years (± standard deviation 4.6 years). Procedures included phalloplasties, penile curvature correction, penoscrotal transposition, redo hypospadias repair, and circumcision. Treatment options included excision of the keloid ± topical steroid injections and postoperative use of silicone gel. Two cases of severe keloid lesions developed after using posterior auricular grafts. Ultimately, a successful outcome was achieved in all cases. CONCLUSION: Genital keloids are rare and difficult to treat. Many therapeutic options are available with varying degrees of proven clinical success. As a result, pediatric urologists must be aware of advances in other fields such as plastic surgery and dermatology to treat and ideally prevent the occurrence of this serious complication.

Impact of ureteral access sheath force of insertion on ureteral trauma: In vivo preliminary study with 7 patients.

BACKGROUND: Ureteral access sheaths (UASs) are commonly used in retrograde intra-renal surgery (RIRS). Despite their advantages, there is a risk of ureteral trauma during their placement and subsequent stricture following surgery. The aim of this study was to evaluate the UAS force of insertion (FOI) during placement and its impact on ureteral trauma. METHODS: Seven female patients who underwent RIRS for kidney stones were included in the study. A digital force gauge (Chatillon DFX II; Ametek Test and Calibration Instruments, Largo, Florida, USA) was connected to the distal end of the UAS and the UAS FOI was continuously measured during insertion. UASs of different sizes were used and ureteral injury was evaluated under direct vision with the Post-Ureteroscopic Lesion Scale (PULS) score. RESULTS: Five pre-stented patients and 2 non-stented patients were included in the study. The size of the UASs used in non-stented patients was 9.5/11.5-F and 10/12-F, whereas one 11/13-F and four 12/14-F sheaths were used in the pre-stented patients. The highest maximal UAS FOI observed was 5.9 Newton (N) in a pre-stented patient with a 12/14-F UAS, where a second attempt was performed after initial failure. The lowest maximal UAS FOI was 0.91 N in a non-stented patient using a 9.5/11.5-F UAS. A semirigid ureteroscopy with a 7.8-F sheath was performed in this patient prior UAS placement. The PULS score was 1 in the 2 non-stented patients and 0 in all of the pre-stented patients. CONCLUSION: In this small cohort, a preoperative JJ stent seemed to protect the ureter, even with larger diameter UASs of 12/14- F. Non-stented RIRS with a UAS is possible, but may cause low-grade ureteral trauma.