Lower Urinary Tract Symptoms in Young Men-Causes and Management.

PURPOSE OF REVIEW: This review explores the subject of lower urinary tract symptoms (LUTS) in young men. RECENT FINDINGS: Young men (aged 39 or younger) can be affected by a variety of conditions that can cause LUTS. Approximately half of young men report LUTS. Storage or "irritative" voiding symptoms are nearly twice as common as "obstructive" symptoms in young men. Infectious or inflammatory causes such as prostatitis are the most common cause of LUTS in this age group, while other etiologies include urethral strictures, primary bladder neck obstruction, as well as neurogenic and non-neurogenic bladder dysfunction. A thorough clinical evaluation is critical for determining the correct diagnosis and directing the appropriate treatment plan. Young men experience lower urinary tract symptoms at relatively high rates. Clinical treatments range from behavioral therapy to medications and/or surgical interventions. Ambulatory urodynamics and wearable sensors may provide more accurate and real-world diagnostic assessment of bladder dysfunction in this relatively under-studied group. More study is needed to characterize the disease burden and impact in this specific group of patients.

Risk of urethral stricture recurrence increases over time after urethroplasty.

OBJECTIVE: To report a single institutional experience with urethroplasty outcomes and success rates at long-term follow up. METHODS: A retrospective review was carried out of all urethroplasties performed by a single surgeon from 2000 to 2010. A total of 347 patients underwent urethroplasty during this time period, of which 227 had minimum 1-year follow-up data available. Demographic, clinical, pathological and outcome data were reviewed. Recurrence was defined by patient reported urinary symptoms or need for subsequent intervention. Statistical analyses were carried out using SPSS statistical software. RESULTS: A total of 26% of all patients had a recurrence at a mean follow up of 62 months (range 13-147 months). The recurrence rate after anastomotic urethroplasty was 18%, as compared with 31% after substitution urethroplasty. Mean time to recurrence was 34 months (range 5-87). On univariate analysis, use of abdominal skin graft, history of prior urethroplasty, lichen sclerosus and length of follow up were statistically significant predictors of recurrence. On multivariate analysis, only history of prior urethroplasty and length of follow-up time exceeding 48 months were statistically significant predictors of recurrence. CONCLUSIONS: Urethroplasty for urethral stricture is the most durable treatment modality, regardless of surgical approach. However, there is an ongoing risk of recurrence with the passage of time. Patients should be counseled appropriately on the potential for late recurrence of stricture disease after urethroplasty.

Treatment of post-prostatectomy incontinence with male slings in patients with impaired detrusor contractility on urodynamics and/or who perform Valsalva voiding.

PURPOSE: Male slings have emerged as a popular and efficacious treatment for men with post-prostatectomy stress urinary incontinence. Traditionally slings have been used with caution or avoided in men with impaired detrusor contractility or Valsalva voiding because of concern that patients will not be able to overcome the fixed resistance of a sling during micturition. We propose that men with post-prostatectomy urinary incontinence who have impaired contractility and/or void with abdominal straining for urodynamics can be safely treated with slings. MATERIALS AND METHODS: A retrospective review of patients with post-prostatectomy urinary incontinence who underwent an initial sling procedure between January 2004 and January 2010 was conducted at a single institution. Preoperative urodynamic characteristics, and postoperative Patient Global Impression of Improvement, post-void residual and noninvasive uroflow data were examined. Patients were grouped by poor bladder contractility or Valsalva voiding status. Exclusion criteria were lack of preoperative urodynamics and/or postoperative post-void residual. A total of 92 patients were analyzed. The variables were compared using the Student t test and the chi-square test. RESULTS: No statistically significant difference was shown in postoperative post-void residual (mean 4 months postoperatively) or urinary retention when comparing by bladder contractility or Valsalva voiding. In the subset of patients with available postoperative uroflow data, there were no differences in postoperative maximum flow rate or voided volume. CONCLUSIONS: Men with post-prostatectomy urinary incontinence with urodynamic findings suggesting impaired contractility or Valsalva voiding can be safely treated with sling surgery if they have normal preoperative emptying.

Impact of kidney cancer surgery on oncologic and kidney functional outcomes.

Kidney cancer is a common genitourinary malignancy. The incidence of kidney cancer has progressively increased in the past few decades, with the greatest increase noted for incidentally discovered small renal masses. Along with the change in presentation and diagnosis of kidney cancer, surgical treatment of kidney cancer also has evolved dramatically during the past 5 decades, moving from universal use of radical extirpation to more frequent nephron-sparing and minimally invasive surgeries. This article reviews the contemporary management of localized kidney cancers and discusses the impact of surgery on oncologic and nononcologic outcomes.

Outcomes and Complications After Intervention for Postradiation Prostatic Urethral Stenosis.

OBJECTIVE: To study and report on treatment outcomes after surgical intervention for postradiation prostatic urethral stenosis. METHODS: A retrospective chart review was performed, identifying all patients treated at our institution from July 2014-June 2018 with the ICD-10 code N42.89 for prostatic urethral stenosis. RESULTS: Twenty-two patients were identified with the diagnosis of prostatic urethral stenosis. Patients who had less than 3 months of follow up or etiologies other than postradiation were excluded from analysis. 16 patients were included in the final analysis with an average follow up of 2.6 years (range 3 months to 6.8 years). Average age was 74 years (range 63-84). The average number of interventions performed before referral to a reconstructive urologist was 2.2 (range 0-6). Following referral, an additional 1.2 procedures were performed. Transurethral resection of prostate was the most common intervention, performed in 11 patients; urethroplasty was performed in 2 and the remainder underwent endoscopic incision or dilation. None of the urethroplasty patients required any further intervention for recurrent stenosis. Five patients became severely incontinent and required placement of an artificial urinary sphincter. CONCLUSION: Prostatic urethral stenosis is a rare complication occurring after radiotherapy for prostate cancer. Endoscopic management can be successful in stabilizing patients, while urethroplasty can be feasibly performed in patients with short prostatic apical strictures.

Thoracic complications of urologic laparoscopy: correlation between radiographic findings and clinical manifestations.

BACKGROUND AND PURPOSE: The usefulness of plain film chest radiography (CXR) in evaluation for thoracic complications after laparoscopic urologic procedures is uncertain. Our objectives were to examine the association between radiographic findings and clinical manifestations of thoracic complications after laparoscopic urologic procedures and to determine the prevalence of postoperative CXR at our institution. PATIENTS AND METHODS: We performed a retrospective review of 195 patients who underwent laparoscopic renal/adrenal urologic procedures at our institution from 1998 to 2005. Chi-square analysis was used to compare the rate of radiographic abnormalities and thoracic complications between different types of laparoscopic procedures. RESULTS: A total of 96 patients (96/195, 49%) had postoperative CXR, and abnormalities were noted in 75 (75/96, 78%). The abnormalities seen on CXR included atelectasis, pleural effusions, pneumomediastinum, pneumothorax, subcutaneous emphysema, and pneumonia. Retroperitoneal laparoscopy had significantly more incidental subclinical pneumothoraces (P = 0.000469) and subcutaneous emphysema (P = 0.043) identified by CXR than either transperitoneal, hand-assisted, or cryosurgery. Overall, eight patients (8.3%) had clinical manifestations of a thoracic complication but only five (5.2%) were clinically significant complications detected by CXR. Thus, while 75 CXRs were noted as abnormal, 70 (93%) documented incidental findings that did not affect patient care. CONCLUSIONS: Thoracic complications after laparoscopic urologic procedures are uncommon events. Although the majority of CXRs after such procedures do contain abnormalities, most abnormalities are subclinical and do not affect postoperative management. Patients with significant radiographic findings demonstrated significant clinical symptoms. Thus, routine CXR after urologic laparoscopy does not appear to be necessary to identify thoracic complications and may be overused.

Donor insemination and infertility: what general urologists need to know.

Therapeutic donor insemination (TDI), also known as artificial insemination by donor, is one of the oldest forms of male infertility treatment. With the advent of assisted reproductive technologies and in vitro fertilization techniques over the past few decades, the use of TDI in male infertility treatment has decreased dramatically. Knowledge of its use, indications, efficacy, and related psychosocial issues has also declined among urologists treating male infertility. Despite the change in popularity of the procedure, though, TDI remains an appropriate therapeutic option for certain cases of male infertility, particularly in patients who have failed multiple cycles of in vitro fertilization/intracytoplasmic sperm injection or in men with no available sperm even after attempted microdissection testicular sperm extraction. Further consideration and research should be focused on the potential uses and indications for TDI.

Complete Vesicourethral Anastomotic Disruption Following Prostatectomy.

Vesicourethral anastomotic (VUA) disruption with bladder displacement into the abdominal cavity following robot-assisted laparoscopic prostatectomy (RALP) is an exceedingly rare complication. There have been no cited case reports after robotic surgery but case reports after open radical prostatectomy have been noted. Other complications related to VUA include bleeding with or without pelvic hematoma, bladder neck contracture, or severe stress urinary incontinence. Following radical prostatectomy, studies estimate the rate of VUA leakage to be 1.4% and no exact rate of complete disruption is known given its rarity. However, the majority of these cases are managed conservatively and rarely require reoperation. To date, there are no published studies that describe complete VUA and bladder displacement secondary to a large pelvic hematoma following prostatectomy. We report a rare case of VUA disruption after RALP successfully managed with conservative treatment.

Simultaneous urethrocutaneous and urethrocavernous fistula after proximal corporospongiosal shunt for priapism.

Proximal corporospongiosal shunts are used for the most refractory cases of priapism. Here, we present the case of a 58-year-old man whose priapism was only partially responsive to phenylephrine injections and distal shunting. Proximal shunting was required, and he subsequently developed fistulization of the proximal penile urethra into the skin and the corpora cavernosa. The formation of simultaneous urethrocutaneous and urethrocavernous fistulae is a rare complication of proximal corporospongiosal shunts that can be initially managed with urinary diversion with a suprapubic tube.

A Multi-institutional Evaluation of the Management and Outcomes of Long-segment Urethral Strictures.

OBJECTIVE: To evaluate the treatment options and surgical outcomes of long-segment urethral strictures-a review of the largest, international, multi-institutional series. METHODS: A retrospective review was performed of patients treated with strictures ≥8 cm at 8 international centers. Endpoints analyzed included surgical complications and recurrence. RESULTS: Four hundred sixty-six patients were identified. Treatment intervals ranged from December 27, 1984 to November 9, 2013. Dorsal onlay buccal mucosal graft (BMG) was the most common procedure (223, 47.9%); others included first- and second-stage Johanson urethroplasty (162 [34.8%] and 56 [12%], respectively), fasciocutaneous (FC) flaps (8, 1.7%), and a combination flap and graft (17, 3.6%). Overall success was achieved in 361 patients (77.5%) with a mean follow-up of 20 months. Second-stage Johanson urethroplasty was found to have a higher recurrence rate compared with that of 1-stage BMG urethroplasty (35.7% vs 17.5%, respectively; P <.01). This was also true in cases of lichen sclerosus (14.0% vs 47.8%, respectively; P <.01). Otherwise, success rates were similar. Urethroplasties performed with FC flaps had a higher complication rate compared with those without (32% vs 14%, respectively; P = .02). Prior dilation or urethrotomy, higher number of prior dilations or urethrotomies, abnormal voiding cystourethrogram, and skin grafts all portend a higher recurrence rate. On logistic regression analysis, only second-stage Johanson had an increased odds ratio of recurrence compared with that of BMG (2.82 [1.41-5.86]). CONCLUSION: Long-segment strictures can be treated with high success rates in experienced hands. BMG was more successful than second-stage Johanson urethroplasty. FC flaps, although successful, had high complication rates.

Distal urethroplasty for fossa navicularis and meatal strictures.

Distal urethral strictures involving the fossa navicularis and meatus represent a unique subset of urethral strictures that are particularly challenging to reconstructive urologists. Management of distal urethral strictures must take into account not only maintenance of urethral patency but also glans cosmesis. A variety of therapeutic approaches exist for the management of distal urethral strictures, including dilation, meatotomy, extended meatotomy, flap urethroplasty, and substitution grafting. Common etiologies for distal urethral strictures include lichen sclerosus, instrumentation, and prior hypospadias repair. Proper patient selection is paramount to the ultimate success and durability of the treatment, which should be individualized and include an assessment of the stricture etiology, location, and burden, and patient-centered goals of care.