Corporal Burnett "Snake" surgical maneuver for the treatment of ischemic priapism: long-term followup.

PURPOSE: We provide long-term followup on a modification of the Al-Ghorab distal penile corporoglanular shunt surgery for the treatment of ischemic priapism. MATERIALS AND METHODS: We conducted a retrospective review of patients surgically treated for ischemic priapism at The Johns Hopkins Hospital from January 2008 to April 2012 with the Burnett "Snake" maneuver of the Al-Ghorab shunt. Electronic medical records were reviewed to collect demographic information and telephone followup was performed to verify treatment outcomes. Patients completed the SHIM (Sexual Health Inventory for Men) to assess current erectile function. RESULTS: A total of 10 patients were analyzed (age range 31 to 59 years). Mean followup was 6.7 months (range 0.5 to 17). Priapism etiologies were idiopathic (3), trazodone (2), trazodone and cocaine (3), intracavernous injection of trimix (1) and spinal cord injury (1). There were 6 patients who had previously undergone unsuccessful surgical attempts at priapism decompression and mean priapism duration was 75 hours (range 24 to 288). Of the 10 men 8 achieved successful resolution of priapism with no recurrence. There were 2 men with recurrent priapism refractory to all management who were definitively treated with insertion of an inflatable penile prosthesis. Of 9 men 6 had normal erectile function preoperatively, of whom 2 achieved at least partial erectile function postoperatively. Complications were sustained by 2 men, including wound infection with skin necrosis in 1, and an intraoperative urethral injury in the other with subsequent urethrocutaneous fistula formation and wound infection with skin necrosis. CONCLUSIONS: The modified Al-Ghorab corporoglanular shunt using the Burnett snake maneuver is successful in resolving ischemic priapism, particularly in cases refractory to first line management, and in preventing further episodes of priapism.

Radical cystectomy in patients with preexisting three-piece inflatable penile prosthesis.

INTRODUCTION: Radical cystectomy with urinary diversion is the treatment of choice for muscle-invasive, and certain populations with non-invasive, urothelial carcinoma of the bladder. There have not been any reports to date on patients undergoing this surgery who have had previous placement of an inflatable penile prosthesis. AIM: To present the outcomes of four patients with pre-existing inflatable penile prostheses (IPP) with reservoirs within the space of Retzius who were subsequently treated with radical cystectomy for bladder cancer management. METHODS: After obtaining institutional review board approval, the demographic, clinical, and pathologic data were reviewed in the Johns Hopkins Cystectomy Database for patients who underwent radical cystectomy for bladder cancer from 1994 to 2012. A case series of four patients is presented who had a preexisting IPP and their post-operative course and long-term outcomes are reviewed. RESULTS: All four patients had radical cystectomy and ileal conduit urinary diversion with no intra-operative or post-operative complications. One patient was not sexually active and therefore had the reservoir explanted and not replaced. The other three patients had the reservoir removed prior to bladder extirpation and the tubing capped, with reservoir replacement in the pseudocapsule at the termination of the procedure. In one patient an omental flap was used to ensure separation between the reservoir and ileal conduit. The devices were all functional intra-operatively and on follow-up. CONCLUSIONS: As erectile dysfunction is more commonly being diagnosed and treated with IPP insertion at younger ages, surgeons will increasingly encounter pre-placed abdominal reservoirs when performing pelvic surgery. This case series of four patients undergoing radical cystectomy with prior-placed IPPs reveals that the functionality of the IPP can be preserved while still performing oncologically sound extirpative procedures.

Accelerated cognitive aging in diabetic rats is prevented by lowering corticosterone levels.

Diabetes and normal aging are both characterized by increases in levels of glucocorticoids. Because long-term exposure to elevated glucocorticoids can be detrimental to hippocampal function, we evaluated the performance of young diabetic rats in the 14-unit T-maze, a task that is sensitive to hippocampal deficits. To assess the contribution of diabetes-induced elevations in corticosterone levels, we examined maze learning in diabetic rats that had levels of corticosterone 'clamped' through adrenalectomy and low-dose corticosterone replacement. For comparison, we also tested a separate group of young and aged rats in the maze. Adrenally intact diabetic rats learned poorly in the 14-unit T-maze. Preventing the increases in corticosterone levels that accompanies the onset of experimental diabetes also prevented deficits in complex maze learning. The pattern of errors made by adrenally intact diabetic rats was similar to the pattern of errors made by aged rats, suggesting that the cognitive profiles of diabetic and aged rats share common features.

Call Schedule and Sleep Patterns of Urology Residents Following the 2011 ACGME Reforms.

INTRODUCTION: In response to the 2011 Accreditation Council for Graduate Medical Education duty hour restrictions, many residency programs adopted a night float system. Due to concerns regarding the effects of night float on sleep and subsequently on patient care, we examined sleep patterns of residents on different call schedules. METHODS: Urology residents assigned to day shift (Monday-Friday, 6am-6pm), night float (Sunday-Friday, 6pm-6am) or 24-hour home call and attending physicians were monitored for two-week periods using actigraphy bands. Total sleep time, light versus deep sleep time, sleep latency and number of sleep disruptions were measured. Comparative statistics and logistic regression were used to compare call systems and to determine predictors of sleep metrics. RESULTS: When comparing day shift, night float, and 24-hour home call, the only significant difference was in sleep latency. All sleep variables except sleep latency were significantly different among residents of various levels (junior, senior, research year). Compared to residents, attendings had shorter sleep latency and were woken less frequently. Being a research year resident was the only significant univariate predictor of total sleep. Age and being a research year resident were significant univariate predictors of sleep latency. CONCLUSIONS: This pilot study demonstrates the feasibility of actigraphy in measuring sleep patterns of urology house officers. It also suggests that night float does not significantly impact total sleep or quality of sleep. Further research is needed to confirm these findings and to determine the effects of night float rotations on resident quality of life and patient safety.

Risk Factors for Intraprostatic Incision into Malignant Glands at Radical Prostatectomy.

BACKGROUND: Histologically identified intraprostatic incision (IPI) into malignant glands is associated with an increase in biochemical recurrence following radical prostatectomy (RP). However, the predictor of IPI is poorly evaluated. OBJECTIVE: To evaluate the risk factors for IPI into cancer during RP for clinically localized prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS: Between January 1993 and July 2013, 19 986 men with clinically localized PCa underwent RP at our institution. This study includes 14 434 cases that had complete clinicopathologic data. IPI was defined as an iatrogenic incision into the prostate resulting in the presence of malignant glands at the inked surgical margin, regardless of accompanying pathologic features. INTERVENTION: Open, retropubic, robot-assisted laparoscopic and pure laparoscopic RP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Univariate and multivariable logistic regression analyses were conducted for risk factors of IPI in RP specimens. RESULTS AND LIMITATIONS: The overall incidence of IPI into malignant tissue was noted in 410 (2.8%) cases. In multivariable analysis, obesity, lower prostate weight, surgeon experience, and pure laparoscopic RP were associated with a higher risk of IPI. The odds ratios (OR) for body mass index and prostate weight were 1.05 (95% confidence interval [CI], 1.03-1.08; p<0.001) and 0.99 (95% CI, 0.98-0.99, p<0.001), respectively. The ORs for surgeon experience (>250 cases) and pure laparoscopic RP compared to open RP were 0.71 (95% CI, 0.55-0.90, p=0.005) and 2.05 (95% CI, 1.35-3.11; p=0.001), respectively. CONCLUSIONS: The risk of IPI during RP is higher in men with obesity and lower prostate weight. In addition, a pure laparoscopic RP and the early series of each surgeon were associated with a higher risk of IPI. However, tumor characteristics were not associated with the IPI occurrence. PATIENT SUMMARY: Intraprostatic incision occurrence is associated with obesity, small prostate, and surgeon experience and laparoscopic technique but not Gleason score and tumor stage.

Papillary urothelial hyperplasia: relationship to urothelial neoplasms.

AIMS: The current study assessed the prognosis of papillary urothelial hyperplasia as its significance is uncertain due to limited studies on this topic. METHODS: 53 patients with papillary urothelial hyperplasia were identified from the files of the senior author. RESULTS: There were 40 males and 13 females with ages ranging from 46 to 101 years (median 74 years). The two most common reasons for performance of cystoscopy with biopsy was follow-up for a papillary urothelial neoplasm (24 cases) and haematuria (19 cases). The most common cystoscopic findings were papillary tumour (24 cases), papillary irregularity (10 cases), and irregular mucosa (9 cases). Prior to the diagnosis of papillary urothelial hyperplasia, 30 patients had a history of 43 prior neoplasms, 79% of which were low grade papillary urothelial neoplasms. After allowing for a minimum of 6 months of follow-up, 15 patients had 20 subsequent neoplasms, 67% which were low grade. Eleven of 30 (37%) patients with prior urothelial neoplasia subsequently developed bladder tumours compared to four of 23 (17%) patients without a prior history of bladder neoplasia. The 5 year actuarial risk of subsequently developing urothelial neoplasia following the diagnosis of papillary urothelial hyperplasia was 27.4% and 47.8% for patients without and with a prior history of papillary neoplasia, respectively (p = 0.18), with a combined risk of 38.6%. All together 35 of 53 (66%) had a history of prior, concurrent, or subsequent urothelial neoplasia. CONCLUSIONS: Papillary urothelial hyperplasia appears to be a precursor lesion to papillary urothelial neoplasms, predominantly lower grade lesions, and follow-up is warranted.