Pelvic fracture urethral injuries associated with rectal injury: a review of acute and definitive urologic and bowel management with long term outcomes.

BACKGROUND: Pelvic fracture urethral injuries (PFUI) with simultaneous rectal lacerations are unique rarely reported injuries. This paper serves to define our management, outcomes and make recommendations to improve the care of these patients. METHODS: We retrospectively reviewed all patients with a PFUI and concurrent rectal injury treated from 1990-2018, initial surgical treatments, along with definitive surgical repair were reviewed. Statistical analysis considered P values <0.05 as significant. RESULTS: Eighteen patients were identified; median follow-up post injury is 4 years, range 1-12 years. Injuries that impacted urologic care included concurrent bladder neck lacerations (BNL) in 50% (9/18) and concurrent neurologic injuries in 28% (5/18). In the nine patients with a simultaneous BNL, 44% (4/9) underwent a primary sutured anastomotic repair of the BNL and urethra, 33% (3/9) underwent primary closure of the bladder neck and SPT drainage and 23% (2/9) had primary repair of BNL with urethral realignment. Continued urinary extravasation through the BN despite the initial surgery resulted in life threating pelvic sepsis in 56% (5/9) versus 0% (0/9) in the patients without a bladder neck laceration, P=0.012. Long term follow up revealed, 22% (2/9) are currently voiding per urethra, neither are continent, one with chronic diaper dependent incontinence, one with stress incontinence. Urinary continence was eventually obtained in 44% (4/9) with either closure of the bladder neck and creation of a continent catheterizable stoma (3 pts) or with cystectomy and creation of an Indiana pouch (1 pt), 33% (3/9) were managed with eventual cystectomy and an enteric urinary conduit. In the nine patients with no concurrent bladder neck injury all were managed with a suprapubic tube placement and consideration for a delayed urethral reconstruction. Delayed end to end urethroplasties were performed in 67% (6/9). Eighty-three percent (5/6) are continent, 50% (3/6) are voiding per urethra without sequale, 33% (2/6) developed recurrent urethral strictures, one was treated with a single DVIU and has retrained urethral patency, at four years post treatment, one is on daily intermittent catheterization to maintain patency. Stress incontinence is noted in 17% (1/6). Due to concurrent neurologic injuries 33% (3/9) of these pts did not undergo further attempt at repair and have been managed with a long-term suprapubic tube. CONCLUSIONS: PFUI with simultaneous rectal lacerations have significant comorbid injuries, especially, concurrent bladder neck lacerations and neurologic injuries that affect the urologic prognosis. In patients with a concurrent BNL we recommend initial intervention include primary lower urinary tract reconstruction with simultaneous proximal urinary diversion to help prevent the complication of persistent urinary extravasation with resultant pelvic sepsis.

Infection risk of undergoing multiple penile prostheses: an analysis of referred patient surgical histories.

Inflatable penile prosthesis (IPP) is the gold standard for medically refractory erectile dysfunction. Infectious complications remain a significant concern in IPP revision surgery. We sought to evaluate the impact of number of IPP surgeries on subsequent infection rates. A retrospective analysis was performed on all new patients (self or outside provider referred) presenting for consideration of IPP revision or salvage surgery between 2013 and 2015. Histories were reviewed including number of prior IPPs, reason for evaluation, and rate, number, and timing of prior IPP infections. No patients were operated on by the primary investigator prior to data acquisition. We identified 44 patients with at least one prior IPP presenting for consultation regarding IPP revision/salvage. There were 88 IPPs placed by 28 different surgeons. In patients with two or more devices, 55% had at least two different surgeons. The most common reason for presentation was malfunction (52%). The risk of specific device infection was strongly correlated and increased based on number of prior IPPs: 1st (6.8%; 3/44), 2nd (18.2%; 4/22), 3rd (33.3%; 4/12), 4th (50%; 4/8), and 5th (100%; 2/2) (R2 = 0.90, p = 0.01). Similarly, overall rates of infection positively correlated with number of prior IPP-related surgeries performed (R2 = 0.97, p < 0.01). The median time to development of infection after most recent IPP surgery was 2 months (IQR 1-3.3 months). Infection rates of revision/salvage IPP surgery increase with each subsequent IPP placement or following IPP-related surgeries. The majority of patients referred for penile implant surgery can expect to have experienced at least one infection by their 4th device. These data represent a change in paradigm on revision prosthetic surgery.

Self-reported Clinical Meaningfulness Early in the Treatment Course Predicts Objective Outcomes in Men Undergoing Collagenase Clostridium histolyticum Injections for Peyronie Disease.

OBJECTIVE: To compare perceived meaningfulness early in the course of collagenase Clostridium histolyticum (CCH) with final outcomes to evaluate its use as a predictor of efficacy. MATERIALS AND METHODS: A registry of patients undergoing CCH from March 2014 to September 2016 was maintained. Patients were recommended to complete 4 injection cycles. After each cycle, patients completed a questionnaire that included, "If you stopped at this point, would you consider this a meaningful improvement for you?" Curve assessments were performed before and at therapy completion. Analyses were performed to compare objective curve changes and reported meaningfulness. RESULTS: Complete information was available on 52 patients, including 79% who reported meaningful results. Median improvement (interquartile range) was 25 degrees (15;35) in the meaningful (+) group compared with 5 degrees (0;15) in the meaningful (-) group (P = .0007). When stratified by perception early during therapy, patients who found the second series meaningful experienced a greater final curve improvement (P = .005). More than 50% of patients with curvature improvements of ≥10 degrees or ≥10% found the therapy meaningful. Among men with ≤5-degree improvement after 2 series, 83% (5/6) experienced further curve improvements (median 20 degrees). Interestingly, 50% of patients with improvement ≤10 degrees reported meaningfulness, including 40% without objective improvement. CONCLUSION: Objective curve outcomes can be stratified by early subjective clinical meaningfulness with CCH, and the majority of patients with ≥10-degree or ≥10% curve improvement found CCH meaningful. Men failing to achieve objective curve benefits after 2 series experience further curve improvements in the majority of cases.

Intravesical formalin for hemorrhagic cystitis: A contemporary cohort.

INTRODUCTION: Hemorrhagic cystitis presents a difficult clinical challenge, yet data regarding treatment options is sparse. Here, we sought to evaluate outcomes of a contemporary cohort of patients treated with intravesical formalin for hemorrhagic cystitis. METHODS: We identified a retrospective cohort of eight patients managed with formalin for hemorrhagic cystitis from 2000-2014. All patients failed prior measures, including bladder irrigation, clot evacuation, and other intravesical agents. Treatment success was defined as hematuria resolution during the given hospitalization without use of additional invasive therapies. We also evaluated treatment complications and additional treatments following hospital dismissal. RESULTS: Etiology of cystitis was radiation for malignancy in all cases. The formalin concentration ranged from 1-4%, with escalation used in treatment failures. Five patients (62.5%) received a single dose of 1% formalin, two patients received two doses, and one patient received three doses. Notably, intraoperative cystography identified vesicoureteral reflux (VUR) in 50.0% of patients. Six patients (75.0%) achieved treatment success, with a median time to resolution of four days (range 1-17 days). Of those refractory to formalin, one was managed with indwelling nephrostomy tubes and one underwent cystectomy. Median followup was eight months. Of the responders, two eventually required cystectomy, one for recurrent hematuria and one for recalcitrant bladder neck contracture and bladder dysfunction. The remaining four patients (50%) required no additional therapy. CONCLUSIONS: Formalin remains an important tool for treating refractory hemorrhagic cystitis, with roughly 75.0% of patients requiring no additional therapy prior to hospital discharge. Notably, there is a risk of bladder dysfunction following formalin.

Clinical Experience With Penile Traction Therapy Among Men Undergoing Collagenase Clostridium histolyticum for Peyronie Disease.

OBJECTIVE: To evaluate the outcomes in men undergoing collagenase Clostridium histolyticum (CCH) with concurrent penile traction therapy (PTT) for the treatment of Peyronie disease (PD). MATERIALS AND METHODS: We identified patients treated with CCH between March 2014 and July 2016. Patients were recommended to perform modeling and PTT between injection series. A final curve assessment was performed after patients completed CCH. A prospective database was maintained, including patient-reported frequency and duration of PTT. Statistical analysis was performed to evaluate outcomes based on use and duration of PTT. RESULTS: A total of 51 patients completed CCH and had complete objective data available for analysis. Mean (standard deviation [SD]) baseline curvature was 66.7 (25.0) degrees, and mean (SD) improvement post CCH was 20.9 (17.3) degrees (P < .0001). Thirty-five (69%) men reported daily PTT for a mean (SD) of 9.8 (6.3) hours per week. No significant difference was identified in the degree of curve improvement based on frequency or duration of PTT (P = .40). Similarly, no associations between PTT and functional outcomes including intercourse restoration and surgery prevention were identified. Stretched penile length increased nonsignificantly by a mean (SD) of +0.4 (1.5) cm in the PTT group, compared with -0.35 (1.5) in the non-PTT group (P = .21). CONCLUSION: The current series represents a "true-to-life" experience, wherein utilization patterns, attrition, and compliance issues are relevant factors impacting efficacy. PTT use with the Andropenis declined in both frequency and duration with subsequent injection series, and there was no significant difference in curve improvement or stretched penile length with a mean 10 hours of weekly concurrent PTT.

Intravesical silver nitrate for refractory hemorrhagic cystitis.

OBJECTIVE: Hemorrhagic cystitis is a challenging clinical entity with limited evidence available to guide treatment. The use of intravesical silver nitrate has been reported, though supporting literature is sparse. Here, we sought to assess outcomes of patients treated with intravesical silver nitrate for refractory hemorrhagic cystitis. MATERIAL AND METHODS: We identified nine patients with refractory hemorrhagic cystitis treated at our institution with intravesical silver nitrate between 2000-2015. All patients had failed previous continuous bladder irrigation with normal saline and clot evacuation. Treatment success was defined as requiring no additional therapy beyond normal saline irrigation after silver nitrate instillation prior to hospital discharge. RESULTS: Median patient age was 80 years (IQR 73, 82). Radiation was the most common etiology for hemorrhagic cystitis 89% (8/9). Two patients underwent high dose (0.1%-0.4%) silver nitrate under anesthesia, while the remaining seven were treated with doses from 0.01% to 0.1% via continuous bladder irrigation for a median of 3 days (range 2-4). All nine patients (100%) had persistent hematuria despite intravesical silver nitrate therapy, requiring additional interventions and red blood cell transfusion during the hospitalization. There were no identified complications related to intravesical silver nitrate instillation. CONCLUSION: Although well tolerated, we found that intravesical silver nitrate was ineffective for bleeding control, suggesting a limited role for this agent in the management of patients with hemorrhagic cystitis.