Onabotulinumtoxin A (Botox): A reasonable alternative for refractory neurogenic bladder dysfunction in children and young adults.

AIMS: We aimed to describe the effectiveness of Onabotulinumtoxin A (Botox) in children with neurogenic bladder (NGB) unresponsive to medical therapy to determine urodynamic parameters predictive of success. METHODS: Children receiving Botox for refractory NGB, between 2008 and 2019, from a single academic center, were included in this study. Botox success was defined as improvement of incontinence and/or urodynamic parameters. RESULTS: Of 34 patients who received Botox, 13 (38.2%) had a positive response from their first injection, with improvement in capacity by a median of 35% of expected capacity for age compared to only a 9% increase in those who did not respond clinically. When patients were divided into groups by baseline urodynamic parameters, high-pressure (Pdetmax > 20 cm H2 O) patients had significantly greater improvement in compliance compared with low-pressure patients (p = 0.017). Low compliance patients (<10 ml/cm H2 O) had a dramatic improvement of 3.08 ml/cm H2 O in their compliance compared with minimal change in the high compliance group (p = 0.003). Finally, low-capacity (<50% of expected CC) patients had significant improvement in capacity and compliance when compared with high-capacity patients (p = 0.004 and p = 0.036, respectively). Improvement in detrusor overactivity (DO) was noted in both the clinical responders and non-responders. CONCLUSION: In our series, 38% had clinical success with intradetrusor Botox injections for refractory neurogenic bladder. When successful, improvement in capacity and compliance, DO, and/or incontinence was consistent with prior literature. While we could not determine which parameters predicted success, subdividing patients into categories based on baseline urodynamic parameters identified who would benefit from Botox treatment based on differential improvements in capacity and compliance. At least 1 injection of Botox should be considered for a subset of children with refractory NGB, before undertaking more invasive treatments.

Sex Offenders Seeking Treatment for Sexual Dysfunction--Ethics, Medicine, and the Law.

INTRODUCTION: The treatment of sexual dysfunction in patients with prior sexual offenses poses ethical and legal dilemmas. Sex offenders are not obligated by law to disclose this history to medical professionals. Over 20% of sex offenders experience sexual dysfunction; however, the number of sex offenders seeking evaluation for sexual dysfunction is unknown. AIMS: The aims of this study were to determine the incidence and characteristics of sex offenders seeking treatment in our clinic; and to review data regarding sex offender recidivism and ethics pertaining to the issue as it relates to treating physicians. METHODS: Sex offenders were identified via three methods: new patient screening in a dedicated sexual medicine clinic, chart review of those on intracavernosal injection (ICI) therapy for erectile dysfunction (ED), and review of patient's status-post placement of penile prosthesis. Charts were cross-referenced with the U.S. Department of Justice National Sex Offender Public Website. Patient characteristics and details of offenses were collected. MAIN OUTCOME MEASURES: The main outcome measures used were a self-reported sexual offense and national registry data. RESULTS: Eighteen male sex offenders were identified: 13 via new patient screening; 3 by review of ICI patients; 1 by review of penile prosthesis data; and 1 prior to penile prosthesis placement. All were primarily referred for ED. Of those with known offenses, 64% were level 3 offenders (most likely to re-offend). The same number had committed crimes against children. All those with complete data had multiple counts of misconduct (average 3.6). Ninety-four percent (17/18) had publicly funded health care. Twelve (67%) were previously treated for sexual dysfunction. CONCLUSIONS: Registered sex offenders are seeking and receiving treatment for sexual dysfunction. It is unknown whether treatment of sexual dysfunction increases the risk of recidivism of sexual offenses. Physicians currently face a difficult choice in deciding whether to treat sexual dysfunction in sex offenders.

Laser prostate enucleation techniques.

INTRODUCTION: Laser treatment of benign prostatic hyperplasia (BPH) through enucleation techniques has become increasingly more utilized in the field of urology. Laser enucleation of the prostate (LEP) is a transurethral procedure that employs several different types of lasers to dissect the adenoma from the surgical capsule in a retrograde fashion. MATERIALS AND METHODS: We review basic laser physics and current laser prostate enucleation techniques. Holmium-LEP (HoLEP), Thulium-LEP (ThuLEP), Greenlight-LEP (GreenLEP) and Diode-LEP (DiLEP) applications are discussed. We summarize the current literature with respect to functional outcomes and complications. RESULTS: Although each laser device used for prostate enucleation has the same goal of removal of the adenoma from the surgical capsule, each has unique characteristics (i.e. wavelength, absorption rates) that must be understood by the practicing surgeon. Mastery of one LEP technique does not necessarily translate into facile use of an alternative enucleation energy source and/or approach. The various LEP techniques have demonstrated similar, if not superior, postoperative results to transurethral resection of the prostate (TURP), the current gold standard in the treatment of BPH. CONCLUSIONS: This article outlines the current LEP techniques and should serve as a quick reference for the practicing urologist.

Robotic dismembered pyeloplasty surgical simulation using a 3D-printed silicone-based model: development, face validation and crowdsourced learning outcomes assessment.

Ureteropelvic junction obstruction (UPJO) is an uncommonly encountered pathology, posing a challenge for resident training. We describe the development and face validation of a robotic pyeloplasty simulation using a 3D-printed silicone-based model of UPJO for surgical training, in combination with crowdsourced scoring to objectively assess performance and learning outcomes. The organs were created using 3D modeling software and printed using a silicone-based material by Lazarus 3D, LLC. They were secured in a laparoscopic box trainer and the robotic system was docked. Eight residents and three faculty each performed two robotic-assisted right dismembered pyeloplasties on separate occaisions. Face validity was evaluated on a 5-point Likert scale. Crowd-Sourced Assessment of Technical Skills (C-SATS Inc.) scored surgical performance using the Global Evaluative Assessment of Robotic Skills (GEARS) criteria, based on video review of each simulation. All participants completed the simulation twice with fully patent anastomoses. Average time to complete the first and second trials was 44.4 min and 43.2 min, respectively. The average GEARS score was 17.1 and 17.6 for the first and second trials respectively. Participants improved on average in all 5 GEARS categories, with significant improvement in depth perception (p = 0.006). The model received mean scores (out of 5) of 4.36 for aesthetics, 4.18 for overall feel, 3.55 for realism, 4.72 for usability, and 4.72 for suturability. Residents had a significant increase in confidence between initial and final surveys on a 5-point Likert Scale: 1.63 vs. 2.38 (p = 0.03). Using 3D-printed silicone-based models, participants completed robotic-assisted dismembered pyeloplasties for training and skill acquisition. We demonstrated face validity of the simulation, which was also found to improve participant speed and significantly improve resident confidence. Crowdsourced assessment demonstrated significant improvement in depth perception.

Closed suction drain outputs at 12 and 24 hours after primary three-piece inflatable penile prosthesis surgery.

This is a single-institution retrospective study of closed suction drain outputs in primary three-piece IPP cases performed between 2014 and 2017 by a single surgeon. The aim was to investigate the impact of closed suction drains (CSD) during penile prosthesis placement. One hundred and sixty-nine patients underwent intraoperative placement of a closed suction drain. Drain outputs were measured at 12 and 24 h, and postoperative complications were documented. There were no hematomas or infections observed within the patient cohort. The drain output decreased significantly between the first and subsequent 12 h period. Surgical time was associated with statistically significant increases in CSD output at 12 and 24 h with a near linear relationship between surgical times and CSD at 12 and 24 h. Penile prosthesis placement in patients on aspirin did not affect the CSD output volume. Closed suction drains should be considered in all patients undergoing placement of inflatable penile prosthesis, particularly in those cases with longer operative time.