Persistent Opioid Usage After Urologic Intervention and the Impact of Tramadol.

OBJECTIVE: To determine if patients who receive tramadol are as likely to develop persistent usage compared to other opioids after urologic surgery and procedures. METHODS: We identified adults 18 to 64 years old who underwent a urologic procedure in the years 2014 to 2017 using the Truven MarketScan database and subsequently filled an opioid prescription within two weeks of discharge. Patients were excluded if they had any previous opioid prescriptions in the year before surgery. A multivariate logistic regression model was constructed to estimate influence of type of opioid on discharge and various comorbidities on persistent use to determine if persistent use was related to the choice of discharge opioid. We also compared these rates to a 1:3 comorbidities matched, non-surgical cohort of patients from the general population. RESULTS: Overall, 115,687 patients were included. After 1 year, 14.8% of the urologic surgery cohort had persistent opioid usage compared to 10.8% in the opioid naïve matched non-surgical cohort (OR = 1.37; 95% CI 1.35-1.39). Discharge with tramadol was associated with a higher odd of persistent usage compared to class II opioids controlling for type of urologic surgery, age, gender, and pain related comorbidities (OR = 1.23 95% CI 1.13-1.35). The odds of persistent usage varied slightly by type of urologic procedure, but all were higher than matched non-surgical cohort. CONCLUSION: Patients developed persistent opiate usage after urologic surgery compared to a comorbidity matched non-surgical cohort. In this model, tramadol specifically was associated with higher odds of novel persistent opioid usage compared to other opioids. Urologists should not consider tramadol to be a safer choice with regard to developing persistent usage and consider prospective validation of these results.

Long term renal function following selective angioembolization for iatrogenic vascular lesions after partial nephrectomy: A matched case-control study.

PURPOSE: Partial nephrectomy is associated with a 1%-2% risk of renal iatrogenic vascular lesion (IVL) that are commonly treated with selective angioembolization (SAE). The theoretical advantage of SAE is preservation of renal parenchyma by targeting only the bleeding portion of the kidney. Our study aims to assess the long-term effect of SAE on renal function, especially that this intervention requires potentially nephrotoxic contrast load injection. MATERIALS AND METHODS: A retrospective review of patients undergoing partial nephrectomy between 2002 and 2018 was performed, and patients who developed IVL were identified. A 1:4 matched case-control analysis was performed. Paired t-test and χ² test were used for continuous and categorical variables, respectively. Multivariable logistic and Cox proportional hazards regression analyses were used to identify risk factors and confounders for SAE and postoperative renal function. RESULTS: Eighteen patients found to have an IVL after partial nephrectomy were matched with 72 control patients. IVL's were more common in patients after minimally invasive partial nephrectomy (89% vs. 70%, p=0.008) and in those with higher RENAL nephrometry scores (8.8±2.0 vs. 6.5±1.8, p<0.001). On multivariable analysis, lower RENAL scores proved to decrease the odds of requiring postoperative SAE. No significant difference in renal function outcomes was seen at 24 months of follow-up after surgery. CONCLUSIONS: SAE for the management of IVL following partial nephrectomy is a safe and efficient procedure with no significant impact on short or long-term renal function. Less complex renal tumors with lower RENAL scores are less likely to require postoperative SAE.

Pediatric urology amidst SARS-CoV-2 pandemic: Building the future with current knowledge.

INTRODUCTION: The COVID-19 pandemic has ripped around the globe, stolen family members and forced healthcare systems to operate under an unprecedented strain. As of December 2020, 74.7 million people have contracted COVID-19 worldwide and although vaccine distribution has commenced, a recent rise in cases suggest that the pandemic is far from over. METHODS: This piece explores how COVID-19 has explicitly impacted the field of pediatric urology and its patients with a focus on vulnerable subpopulations. RESULTS: Various medical and surgical associations have published guidelines in reaction to the initial onset of the pandemic in early 2020. DISCUSSION AND CONCLUSION: As the number of patients with COVID-19 increases, long-term recovery and future preparedness are imperative and should be cognizant of patient subpopulations that have been subject to disproportionate morbidity and mortality burden. Development of a dedicated response team would aid in achieving preparedness by drafting and implementing plans for resource allocation during scarcity, including logistic and ethical considerations of vaccine distribution. LEVEL OF EVIDENCE: III.

Impact of Non-guideline-directed Care on Quality of Life in Testicular Cancer Survivors.

BACKGROUND: Non-guideline-directed care (NGDC) is seen in ∼30% of testicular cancer patients and has been identified as a significant predictor of relapse. However, the potential impact of mismanagement on patient quality of life (QoL) is yet to be established. OBJECTIVE: To explore the impact of NGDC on long-term QoL in testicular cancer survivors (TCSs). DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of TCSs, who completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) in person or via mail ≥6 mo after completion of treatment, was conducted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The validated questionnaire evaluates global health status (GHS); cognitive, social, physical, emotional, and role functioning; financial burden; and treatment-specific side effects. RESULTS AND LIMITATIONS: A total of 120 men with a median age of 31.5 (interquartile range: 24-42) yr completed the questionnaire. Thirty-four (28%) men received NGDC: overtreatment (44%), improper imaging (32%), and undertreatment (29%). Men with NGDC presented with a more advanced clinical stage (≥IIA: 64% vs 32%, p = 0.007) and were less likely to undergo surveillance (19% vs 37%, p = 0.016). Patients receiving guideline-directed care reported higher GHS (84.1 vs 77.5, p = 0.015), higher physical function scores (98.5 vs 91.2, p = 0.013), and fewer financial difficulties (5.8 vs 18.6, p = 0.006) than those receiving NGDC. Multivariable linear regression showed a significant association between NGDC and poorer GHS (p = 0.002). Limitations of the study include its retrospective nature, modest sample size due to a 21% response rate, and quality-of-life assessment at a single time point rather than serially over time. CONCLUSIONS: In addition to treatment delay, avoidable morbidity, and higher rates of relapse, NGDC leads to inferior global QoL, worse physical functioning, and more financial stress. PATIENT SUMMARY: We have previously shown how mismanagement of testicular cancer results in a higher rate of disease relapse. In this study, we emphasize how the lack of adherence to standard treatment guidelines can lead to worse quality of life outcomes and financial stress in testicular cancer survivors.

Robot-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in children: Step-by-step and modifications to UChicago technique.

Objective: To describe the step-by-step techniques and modifications for robot-assisted augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in a pediatric population with updated institutional results. Introduction: Robot-assisted laparoscopic augmentation ileocystoplasty with Mitrofanoff appendicovesicostomy (RALIMA) protects the upper urinary tract and reestablishes continence in patients with refractory neurogenic bladder. Robotic assistance could provide the benefits of minimally invasive surgery without the challenges of pure laparoscopy. Here, we focus on the outcomes of RALIMA with salient tips and modifications of the technique. Methods: We performed a retrospective review of our robotic database and identified 24 patients who underwent attempted robot-assisted laparoscopic augmentation ileocystoplasty (RALI) between 2008 and 2017 by a single surgeon at an academic center. Outcomes of interest included operative time, hospitalization time, postoperative complications, and change in bladder capacity. RALI and all concomitant procedures were performed using the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Results: Of 24 patients, 20 successfully underwent RALI. Eighty percent underwent concomitant appendicovesicostomy (APV), 40% underwent antegrade continence enema channel formation (ACE), and 30% underwent a bladder neck procedure. Mean operative time was 573 minutes and the most recent RALIMA was 360 minutes. The average return to regular diet was 3.9 days and length of stay was 6.9 days. Mean change in bladder capacity was 244% postoperatively. Thirty-day complications were noted in 35% of patients; one Clavian grade I (5%) complication, five grade II (25%) complications, and one grade IIIb (5%) complication. With a median follow-up of 83.1 months we note a 25% incidence of bladder stones, 15% upper tract stones, 5% incidence of bladder rupture, and 5% small bowel obstruction. No patients required re-augmentation in the follow-up period. Conclusions: RALI has similar functional outcomes and complications when compared with the open augmentation ileocystoplasty literature. RALI is desirable due to favorable pain control with decreased length of stay. Long-term outcomes after RALI are similar to the open approach. As the operative time is currently the largest point of criticism with the robotic approach, we discuss modifications to decrease the operative time.

Adherence and barriers to penile rehabilitation over 2 years following radical prostatectomy.

BACKGROUND: A variety of penile rehabilitation (PR) therapies are available to improve post-prostatectomy erectile dysfunction (ED) with mixed results. It is uncertain how adherent men are to PR therapies. The aim of this study is to determine adherence to and identify barriers to PR treatment. METHODS: A longitudinal cross-sectional approach was used in men who underwent radical prostatectomy over 2 years. Men were instructed to take a PDE5 inhibitor (PDE5i) three times per week, and if required, utilize a vacuum constriction device (VCD) daily. Outcomes were measured by multiple validated questionnaires. In addition, penile stretched length, side effects, compliance to PR regimen & barriers to participation were documented. RESULTS: Seventy-seven patients were enrolled, however only 49 completed evaluation at 3 or more timepoints and were included in analysis. This cohort was an average age of 58.1 years (±7.7), had robotic laparoscopic radical prostatectomy (91.7%), and had bilateral nerve sparing procedures (95.8%). Majority (62.5%) reported normal SHIM pre-operatively, however 79% used PDE5i. Erectile function as measured by IIEF and Erection Hardness Rating were negatively affected post-operatively, with gradual improvement in parameters throughout the 24 month follow up. Of the participants who had normal pre-op SHIM, only 23.1 and 28.6% regained baseline function at 1 and 2 years, respectively. Orgasm was significantly diminished immediately post-operatively, however, at the end of the study period only 37% of men reported diminished climax and no men reported absent orgasm. Adherence to penile rehabilitation therapies declined overtime. Men took oral PDE5i on average 2.3 times weekly at 12 and 24 months (p < 0.001). Men used the VCD 2.3-3.9 days a week, which declined overtime (p = 0.014). CONCLUSIONS: Improvement in erectile and orgasm parameters was observed over time, but most men did not return to baseline function. Despite comprehensive instructions and a frequent follow up schedule, PDE5i and VCD adherence was poor. High attrition rates were noted with only 55.8% of men remaining at 12 months and 45% of men completing 24 months. The most common barriers to PR adherence were cost, inconvenience and perceived ineffectiveness.

Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male.

For many transgender males, "lower" or "bottom" surgery (the construction of a phallus and scrotum) is the definitive step in their surgical journey for gender affirmation. The implantation of penile and testicular prostheses is often the final anatomic addition and serves to add both functionality and aesthetics to the reconstruction. However, with markedly distinctive anatomy from cis-gender men, the implantation of prostheses designed for cis-male genitalia poses a significant surgical challenge for the reconstructive urologist. The surgical techniques for these procedures remain in their infancy. Implantation of devices originally engineered for cis-men is an imperfect solution but not insurmountable if approached with ingenuity, patience, and persistence. Urologists and patients undergoing implantation should be aware of the high complication rates associated with these procedures as well as the current uncertainty of long-term outcomes. This review provides a comprehensive overview of the perioperative considerations, adaptive surgical techniques, and unique complications of penile and testicular prosthetic implantation in transgender men.

Surgical treatment of detrusor underactivity: a short term proof of concept study

ABSTRACT Objectives To compare the surgical outcomes of men with bladder outlet obstruction (BOO) due to benign prostatic obstruction (BPO) to those with detrusor underactivity (DU) or acontractile detrusor (DA). Materials and Methods This retrospective, IRB approved study included men who underwent BPO surgery for refractory LUTS or urinary retention. Patients were grouped based on videourodynamic (VUDS) findings: 1) men with BOO, 2) men with DU and 3) men with DA. The primary outcome measure was the Patient Global Impression of Improvement (PGII). Secondary outcome measures included uroflow (Qmax), post-void residual volume (PVR) and the need for clean intermittent catheterization (CIC). Results One hundred and nineteen patients were evaluated: 1) 34 with BOO, 2) 62 with DU and 3) 23 with DA. Subjective success rate (PGII) was highest in the BOO group (97%) and those with DU (98%), while DA patients had a PGII success of 26%, (p<0.0001). After surgery, patients with BOO had the lowest PVR (68.5mL). Fifty-six patients (47%) performed CIC pre-operatively (47% of BOO, 32% of DU and 87% of DA patients). None of the patients in the BOO and DU groups required CIC post operatively compared to16/23 (69%) of patients in the DA group (p<0.0001). Conclusions BPO surgery is a viable treatment option in men with presumed BOO and DU while DA is a poor prognostic sign in men who do not void spontaneously pre-operatively.

Surgical treatment of detrusor underactivity: a short term proof of concept study.

OBJECTIVES: To compare the surgical outcomes of men with bladder outlet obstruction (BOO) due to benign prostatic obstruction (BPO) to those with detrusor underactivity (DU) or acontractile detrusor (DA). MATERIALS AND METHODS: This retrospective, IRB approved study included men who underwent BPO surgery for refractory LUTS or urinary retention. Patients were grouped based on videourodynamic (VUDS) findings: 1) men with BOO, 2) men with DU and 3) men with DA. The primary outcome measure was the Patient Global Impression of Improvement (PGII). Secondary outcome measures included uroflow (Qmax), post-void residual volume (PVR) and the need for clean intermittent catheterization (CIC). RESULTS: One hundred and nineteen patients were evaluated: 1) 34 with BOO, 2) 62 with DU and 3) 23 with DA. Subjective success rate (PGII) was highest in the BOO group (97%) and those with DU (98%), while DA patients had a PGII success of 26%, (p<0.0001). After surgery, patients with BOO had the lowest PVR (68.5mL). Fifty-six patients (47%) performed CIC pre-operatively (47% of BOO, 32% of DU and 87% of DA patients). None of the patients in the BOO and DU groups required CIC post operatively compared to16/23 (69%) of patients in the DA group (p<0.0001). CONCLUSIONS: BPO surgery is a viable treatment option in men with presumed BOO and DU while DA is a poor prognostic sign in men who do not void spontaneously pre-operatively.

Would a new definition and classification of nocturia and nocturnal polyuria improve our management of patients? ICI-RS 2014.

The following is a report of the proceedings of the Nocturia Think Tank sessions of the annual International Consultation on Incontinence-Research Society, which took place September 22-24, 2014 in Bristol, UK. The report is organized into sections pertaining to the main topic of discussion focussing on the question as to whether a new definition and classification of nocturia and nocturnal polyuria would improve the outcome of management in our patients. First, discussions identified theoretical and practical shortcomings of current definitions. Secondly, the utility of several nocturnal polyuria definitions was tested in a real life population in relation to the symptom nocturia, in order to display weaknesses of these definitions. Thirdly, we explored in a clinical population the utility of bladder diary based parameters by asking the question: when nocturia improves, which of these parameters improve most? Based on the above explorations the Think Tank summarized elements of the current definitions that need reconsideration and suggests proposals for further research to reach more practical and more clinically meaningful definitions.

Timing-dependent modulation of the posterior parietal cortex-primary motor cortex pathway by sensorimotor training.

Interplay between posterior parietal cortex (PPC) and ipsilateral primary motor cortex (M1) is crucial during execution of movements. The purpose of the study was to determine whether functional PPC-M1 connectivity in humans can be modulated by sensorimotor training. Seventeen participants performed a sensorimotor training task that involved tapping the index finger in synchrony to a rhythmic sequence. To explore differences in training modality, one group (n = 8) learned by visual and the other (n = 9) by auditory stimuli. Transcranial magnetic stimulation (TMS) was used to assess PPC-M1 connectivity before and after training, whereas electroencephalography (EEG) was used to assess PPC-M1 connectivity during training. Facilitation from PPC to M1 was quantified using paired-pulse TMS at conditioning-test intervals of 2, 4, 6, and 8 ms by measuring motor-evoked potentials (MEPs). TMS was applied at baseline and at four time points (0, 30, 60, and 180 min) after training. For EEG, task-related power and coherence were calculated for early and late training phases. The conditioned MEP was facilitated at a 2-ms conditioning-test interval before training. However, facilitation was abolished immediately following training, but returned to baseline at subsequent time points. Regional EEG activity and interregional connectivity between PPC and M1 showed an initial increase during early training followed by a significant decrease in the late phases. The findings indicate that parietal-motor interactions are activated during early sensorimotor training when sensory information has to be integrated into a coherent movement plan. Once the sequence is encoded and movements become automatized, PPC-M1 connectivity returns to baseline.