Narrative review of flaps and grafts in robotic reconstructive urologic surgery.

Background and Objective: Flaps and grafts are used for filling dead space, ureteral substitution, and as mesh alternatives. The surgical robot is invaluable in urologic reconstructive surgery due to the ability of the robot to reach the deep pelvis, its minimally invasive access, the ability to use indocyanine green to identify structures and assess tissue perfusion and viability, and ergonomics for the surgeon. Robotic reconstruction can involve tissue transfer in the form of flaps and grafts to provide form and function to organs that have been damaged by iatrogenic injuries, trauma, infections, cancer, radiation injury, or congenital abnormalities. Common flaps and grafts can be readily adapted to the robotic approach. In this literature review, we examine the robotic use of flaps and grafts in reconstructive urology. Methods: A thorough literature review was conducted via a PubMed search for predefined terms. Key Content and Findings: Flaps and grafts in reconstructive urology are used for interposition, ureteral substitution, and as mesh alternatives. Omental flaps are used for tissue interposition, or to provide structure and nutrients, and are easily employed with the robot. Various robotic applications of peritoneal flaps have been described. Vascular rectus abdominis musculocutaneous flaps are well-vascularized flaps that occupy dead space and provide structural support, which can be harvested readily with the robot. Sigmoid epiploica are an excellent flap for pelvic reconstruction. Gracilis flaps and fascia lata grafts are well-tolerated and provide space occupying tissue. Boari flaps aid in robotic ureteral reconstruction, especially in the setting of long defects. Oral mucosa is excellent for ureteral or bladder neck reconstruction. Rectal mucosa is well-tolerated and easy to harvest robotically for a variety of urinary tract reconstructive applications. The appendix or ileum can be interposed for repair of damaged ureters. Conclusions: Various flaps and grafts have been adapted for robotic reconstructive urology. As the field develops, refinement of techniques and innovation in flaps and employment of the robot will propel this field forward. More studies, especially comparative studies, are needed to elucidate the flaps and grafts that are most likely to be successful with the least morbidity for each use case.

Flaps and Grafts in Robotic Reconstructive Surgery.

PURPOSE OF REVIEW: The robotic approach is increasingly popular in reconstructive urology. Reconstructive surgeons have commonly used flaps and grafts for obliterating dead space including tissue interposition or as an alternative to mesh in addressing lower urinary tract dysfunction. Advantages of the robotic approach are less incisional pain, excellent visualization in the deep pelvis, and improved surgeon ergonomics. In this literature review, we describe flaps and grafts used in lower urinary tract robotic reconstructive urology, serving as an almanac for these techniques. RECENT FINDINGS: Omental, peritoneal, vertical rectus abdominis musculocutaneous (VRAM), sigmoid epiploica, gracilis flaps, and Alloderm™ have been reported for tissue interposition during fistula repair. Fascia lata has been described as a mesh alternative for robotic sacrocolpopexy. Besides providing interposition, flaps support native tissue healing and blood supply. Grafts are easy to use with low patient morbidity, but rely on the blood supply at the recipient site. Robotic reconstruction is an emerging field, and more studies are needed to define the best uses for each flap and graft as well as strategies to maximize outcomes and minimize morbidity.

Insight to urology patients' preferences regarding telemedicine.

INTRODUCTION: Due to COVID-19, telemedicine has become a common method of healthcare delivery. Our goal was to evaluate urology patients' satisfaction with telemedicine, examine patient preferences, and identify opportunities for improvement in readiness, access, and quality of care. MATERIALS AND METHODS: A total of 285 adult urology patients who completed at least one telemedicine visit from September to December 2020 were eligible. A paper survey was disseminated by postal mail with an option to complete electronically. Those who returned completed surveys received a $15 gift card. RESULTS: Seventy-six subjects completed the survey (response rate of 27%). The most common age bracket of the respondents was 70-79 years (37%). Readiness - To prepare, many subjects (49%) read the provided instructions. Most (91%) thought they were adequately prepared. A majority (82%) were satisfied with the ease of set up. Access - Types of visits included established patients (71%), new patient visits (17%), and postoperative visits (9%). Most respondents (84%) did not have difficulty accessing the visit. Quality of care - All respondents were satisfied with the length of visit, and 90% were satisfied with the overall experience. Patient preferences - Compared to office visits, most patients found telemedicine equal or superior in several areas. Preference to utilize telemedicine in the future was dependent on the nature of the complaint, length of their drive and their schedule. CONCLUSIONS: Patients reported high levels of satisfaction and a willingness to engage with telemedicine visits. To minimize future technical disruptions, we offer mock telehealth visits before their scheduled appointment and improved our clinicians' work flow.

Valsalva leak point pressure (VLPP) greater than 70 cm H2O is an indicator for sling success: a success prediction model for the male transobturator sling.

INTRODUCTION AND OBJECTIVES: Urodynamic studies are often performed in the evaluation of post-prostatectomy urinary incontinence (PPUI). The male transobturator sling (TOS) is a minimally invasive treatment for PPUI. Others have reported their results with a specific Valsalva leak point pressure (VLPP) that predicts a good outcome with the male TOS. Our objective was to determine the relationship of the pre-operative VLPP on the success rate of the male TOS in a high-volume, single center. We hypothesized that a higher pre-operative VLPP better predicts successful outcomes. METHODS: We reviewed patients undergoing a male TOS placement from 2006 to 2012 at our institution. Patients who underwent TOS placement were identified using our patient data portal (DEDUCE). Demographic, urodynamic, and follow-up data were extracted by chart review. Post-operative success was defined by the use of 0 or 1 security pad, a negative stress test on exam, or pad weight of less than 8 g per 24 h. Cox and linear regression models were performed. RESULTS: 290 patients were included. All patients underwent a radical prostatectomy for prostate cancer and presented with PPUI. Mean age at surgery was 66.3 (± 7.4) years and 84% were Caucasian. Median time to follow-up was 5 months (IQR 1-15). A linear regression model shows an inverse prediction curve for sling failure versus VLPP (p = 0.02). The hazard ratio for failure with a VLPP of ≤ 70 cm H2O compared with a VLPP of > 70 cm H2O, adjusted for pelvic radiation and 24-h pad weight was 0.5 (95% CI 0.2-0.98). CONCLUSION: Patient selection is imperative in the success of the male TOS for patients with PPUI. In our cohort of patients with PPUI, those with a pre-procedural VLPP of > 70 cm H2O were 50% less likely to fail after TOS placement versus those with a VLPP ≤ 70 cm H2O. In our practice, we use these data to support the use of VLPP cut off of 70 cm H2O as an indicator for success to help in the evaluation and counseling of patients.

Multidisciplinary Approach to Hemipelvectomy for Pelvic Sarcomas.

¼ Pelvic sarcomas are a rare and diverse group of tumors in terms of size and histology.¼ Pelvic sarcomas present a treatment challenge to the orthopaedic oncologist.¼ The size and location of these tumors require a varied approach to resection and reconstruction, but the tumor's proximity to other internal structures within the pelvis (e.g., the bladder, the iliac vessels, and the bowel) makes extrication demanding.¼ The ideal treatment requires assembling a hemipelvectomy team that consists of an orthopaedic oncologist, a surgical oncologist, a urologist, a vascular surgeon, a gynecologic oncologist, a plastic and reconstructive surgeon, a dedicated anesthesia team, and a dedicated rehabilitation physical therapy team. Each member can use his or her expertise to address the individual aspects of the pelvic resection and achieve the optimal oncologic and functional outcome.

Living With Urinary Diversions: Patient Insights to Improve the Perioperative Experience.

OBJECTIVE: To evaluate the perioperative decision-making process, post-operative decision regret and reflection on the peri-operative experience of patients undergoing radical cystectomy and urinary diversion through patient interviews. METHODS: Patients identified as having undergone radical cystectomy for malignancy were interviewed 6-24 months from the time of surgery and stratified by diversion type. Following written consent, interviews were conducted either in person or over the phone using a semi-structured script. Patients were asked 9 open-ended questions, with additional unscripted follow-up questions based on themes raised by the patient. The interviews were reviewed for common themes, preferences, and recommendations. RESULTS: A total of 13 interviews were conducted. No patient expressed decision regret about their choice of urinary diversion. Ten out of 13 interviewees specifically stated that they had adequate information about diversion options pre-operatively, none felt they did not have adequate pre-operative counseling. One area identified as improvable was postoperative counseling- specifically, for ostomy appliances, catheters, or irrigation. The most striking recurrent theme was the desire for a "buddy system" in which patients could contact and maintain discussion about their surgical experience with an experienced patient. The overall impression was that this system would be most useful in the recovery/maintenance phase rather than in the pre-operative decision-making process. CONCLUSION: This data furnishes a basis to develop more accessible and effective counseling and highlights the need to concentrate on post-surgical maintenance care, including management of urostomy appliances, catheters, and reinforcing irrigation technique.

Ureteroenteric anastomosis in orthotopic neobladder creation: do urinary tract infections impact stricture rate?

PURPOSE: Radical cystectomy (RC) and urinary diversion in the treatment of muscle-invasive bladder cancer is associated with peri-operative complication rates as high as 60%. Ureteroenteric anastomotic stricture (UEAS) is a potential source significant morbidity often requiring secondary interventions. We sought to evaluate our experience with benign UEAS in our open ileal orthotopic neobladder (ON) population. METHODS: After Internal Review Board (IRB) approval, we performed a retrospective review of patients who had RC and ON between 2000 and 2015 at MD Anderson Cancer Center and had at least 6 months of follow-up. Baseline demographics and treatment characteristics, peri-operative and post-operative outcomes, as well as information regarding anastomosis technique and suture types were evaluated. Patients with malignant ureteral obstruction were excluded from the analysis. RESULTS: 418 patients had ON creation and the mean age was 59 years (SD 9.4 years) and 90% were males. The mean follow-up was 57 months (6-183 months). 37 patients (8.9%) developed UEAS in 42 renal units and the mean time to diagnosis was 15.8 months (0.85-90 months). Anastomosis and suture type were not predictive of UEAS (p = 0.594, p = 0.586). Perioperative UTI within 30 days of surgery, and recurrent UTI were predictive of UEAS, HR 2.4 p = 0.03, HR 5.1 p < 0.001, respectively. CONCLUSIONS: UEAS are associated with potentially significant morbidity following ON creation. UEAS may occur early following ON, but may occur as late as 7 years following surgery. Indeed, technical factors and surgeon experience contribute to the rates of UEAS, but perioperative UTI appears to herald future stricture development.

Treatment of Urinary Incontinence in Patients With Erectile Dysfunction.

INTRODUCTION: Concurrent urinary incontinence (UI) and erectile dysfunction (ED) can greatly damage a patient's quality of life. Owing to the intertwined anatomy, treatment options for one most certainly have implications on the other. OBJECTIVE: The aim of this review is to characterize and elucidate the treatment patients with postprostatectomy UI undergoing concurrent or subsequent treatment of ED. These principles can be extrapolated to all patients with UI and ED. METHODS: The literature on postprostatectomy UI treatment in the context of concurrent ED was reviewed through a Medline search. Original research using quantitative and qualitative methodologies was considered. RESULTS: The epidemiology, workup, and management of postprostatectomy UI being mindful of ongoing or future ED treatments are the main outcome measures. Owing to the intertwined anatomy, treatment options for UI and ED have implications on the other. It is essential for the surgeon to obtain an understanding of the patient's degree of bother for each process, personal preference on treatment options, and management of expectations. Surgical treatment options include a combination of the artificial urinary sphincter, sling, inflatable penile prosthesis, semi-rigid penile prosthesis, and new techniques such as the Mini-Jupette. The appropriate combinations will be determined by patient factors of dexterity, preference, degree of leakage, history of radiation, and so on. The decision of staged vs dual implant will be largely driven by the surgeons' preference, payor limitations, and comfort level. This issue is particularly challenging in redo cases where we advocate for cuff downsizing or tandem cuff before the transcorporal approach is used with the goal of preserving sexual function. CONCLUSION: The concurrent treatment of ED and UI requires thoughtful workup, meticulous attention to detail, and an armamentarium of surgical skills. It is crucial for the surgeon to understand and manage patient expectations in treating these delicate and difficult pathologies. Ajay D, Mendez MH, Wang R, et al. Treatment of Urinary Incontinence in Patients With Erectile Dysfunction. Sex Med Rev 2021;9:593-604.

The Future of Penile Prosthetic Surgical Training Is Here: Design of a Hydrogel Model for Inflatable Penile Prosthetic Placement Using Modern Education Theory.

BACKGROUND: There is a significant need for a non-biohazardous, educational platform to equip and maintain the surgical skills required by urology trainees and low-volume implanters for inflatable penile prosthetic (IPP) placement. AIM: To design and develop an anatomic, hydrogel-based simulation platform for training and evaluate IPP placement using modern education theory. METHODS: The backward design concept was used as a framework in the design and development of an IPP simulation platform. Steps included delineating requirements from a physicians' perspective, translating requirements into engineering tasks (deliverables), developing a prototype, and pilot validation. Using a combination of 3-dimensional printing and hydrogel casting, a genitourinary tract model was constructed to replicate the appropriate steps of IPP placement guided by expert feedback. Full-immersion IPP simulations were performed through both infrapubic and penoscrotal approaches by 4 expert surgeons under operative conditions. Questionnaires evaluating the simulation's realism, value as a training tool, and further recommendations were completed. OUTCOMES: Using backward design educational pedagogy, a high-fidelity, full-procedural IPP simulation was fabricated and verified as an adequate educational tool for training and assessment. RESULTS: An expert consensus on the anatomic landmarks, steps and substeps, instruments, and errors to be included in the model was reached using a hierarchical task analysis and was successfully translated into a prototype hydrogel model. Experts performed all appropriate steps of IPP surgery and rated the simulation highly in terms of its realism and value as a training tool. On average, experts agreed that the model could function as a training tool, assessment tool, prerequisite for IPP accreditation, and requirement before live surgery. Experts stated they would have their trainees ideally complete an average of 1.75 models before live surgical training. All experts believed an operative checklist would be an ideal assessment tool. Witthaus MW, Saba P, Melnyk R, et al. The Future of Penile Prosthetic Surgical Training Is Here: Design of a Hydrogel Model for Inflatable Penile Prosthetic Placement Using Modern Education Theory. J Sex Med 2020;17:2299-2306.

Outcomes and Risk Factors of Revision and Replacement Artificial Urinary Sphincter Implantation in Radiated and Nonradiated Cases.

PURPOSE: Risk factors for complications after artificial urinary sphincter surgery include a history of pelvic radiation and prior artificial urinary sphincter complication. The survival of a second artificial urinary sphincter in the setting of prior device complication and radiation is not well described. We report the survival of redo artificial urinary sphincter surgery and identify risk factors for repeat complications. MATERIALS AND METHODS: A multi-institutional database was queried for redo artificial urinary sphincter surgeries. The primary outcome was median survival of a second and third artificial urinary sphincter in radiated and nonradiated cases. A Cox proportional hazards survival analysis was performed to identify additional patient and surgery risk factors. RESULTS: Median time to explantation of the initial artificial urinary sphincter in radiated (150) and nonradiated (174) cases was 26.4 and 35.6 months, respectively (p=0.043). For a second device median time to explantation was 30.1 and 38.7 months (p=0.034) and for a third device it was 28.5 and 30.6 months (p=0.020), respectively. The 5-year revision-free survival for patients undergoing a second artificial urinary sphincter surgery with no risk factors, history of radiation, history of urethroplasty, and history of radiation and urethroplasty were 83.1%, 72.6%, 63.9% and 46%, respectively. CONCLUSIONS: Patients without additional risk factors undergoing second and third artificial urinary sphincter surgeries experience revision-free rates similar to those of their initial artificial urinary sphincter devices. Patients who have been treated with pelvic radiation have earlier artificial urinary sphincter complications. When multiple risk factors exist, revision-free rates decrease significantly.

Wilms Tumor After Orthotopic Liver Transplant in a Patient With Alagille Syndrome.

We present a case of Wilms Tumor in a patient with Alagille syndrome 10 months after liver transplant. We explore a suggested genetic connection between these 2 diseases. In children with Wilms Tumor, we propose a pathoembryologic explanation for not just the tumor, but also for the cause of associated benign ureteral and renal parenchymal aberrancies that are commonly seen in the Alagille population. We also discuss the diagnostic and therapeutic challenges that can arise in a liver transplant patient with Alagille syndrome who subsequently develops a renal mass.

Lower Urinary Tract Symptoms and Incontinence in Children with Pompe Disease.

BACKGROUND: Pompe disease (PD) is a disorder of lysosomal glycogen storage. The introduction of enzyme replacement therapy (ERT) has shifted the focus of care from survival to quality of life. The presence of lower urinary tract symptoms (LUTS) and incontinence has not been previously described in children with PD. METHODS: Children with PD followed in the Duke Lysosomal Storage Disease Clinic completed a validated bladder control symptom score (BCSS) and additional questions regarding urinary tract infections (UTIs), giggle, and stress incontinence. Descriptive statistics were used to discriminate urinary symptoms between gender, age, and different types of PD. RESULTS: Sixteen of 23 children (aged 4-14 years) seen in our clinic participated. Seven were girls; ten had classic infantile PD, two atypical infantile PD, and four childhood presentation late-onset PD (LOPD). When stratified by PD subtype, median BCSS was worst for the classic PD subtype followed by atypical PD and LOPD. Daytime urinary incontinence accompanied by constipation was noted in six. Eight reported urinary incontinence with laughing: giggle incontinence in six and stress incontinence in two. Four girls reported a history of UTI. Longitudinal follow-up in 11 patients showed stable BCSS in six, improvement in three, and worsening in two. Worsening corresponded with changes in bowel function and improvement with increase in ERT dose or treatment of constipation. CONCLUSIONS: LUTS and incontinence are common in children with PD with greater symptoms noted with infantile-type PD. Improved bowel function and increase in ERT dose may lead to improvements in BCSS.

The Artificial Urinary Sphincter is Superior to a Secondary Transobturator Male Sling in Cases of a Primary Sling Failure.

PURPOSE: We compared continence outcomes in patients with post-prostatectomy stress urinary incontinence treated with a salvage artificial urinary sphincter vs a secondary transobturator sling. MATERIALS AND METHODS: We retrospectively reviewed the records of patients undergoing salvage procedures after sling failure from 2006 to 2012. Postoperative success was defined as the use of 0 or 1 pad, a negative stress test and pad weight less than 8 gm per day. We performed the Wilcoxon test and used a Cox regression model and Kaplan-Meier survival analysis. RESULTS: A total of 61 men presenting with sling failure were included in study, of whom 32 went directly to an artificial urinary sphincter and 29 received a secondary sling. Of the artificial urinary sphincter cohort 47% underwent prior external beam radiation therapy vs 17% of the secondary sling cohort (p = 0.01). Average preoperative 24 hour pad weight and pad number were higher in the artificial urinary sphincter cohort. Median followup in artificial urinary sphincter and secondary sling cases was 4.5 (IQR 4-12) and 4 months (IQR 1-5), respectively. Overall treatment failure was seen in 55% of patients (16 of 29) with a secondary sling vs 6% (2 of 32) with an artificial urinary sphincter (unadjusted HR 7, 95% CI 2-32 and adjusted HR 6, 95% CI 1-31). CONCLUSION: In this cohort of patients with post-prostatectomy stress urinary incontinence and a failed primary sling those who underwent a secondary sling procedure were up to 6 times more likely to have persistent incontinence vs those who underwent artificial urinary sphincter placement. These data are useful for counseling patients and planning surgery. We currently recommend placement of an artificial urinary sphincter for patients in whom an initial sling has failed.

The Ohmmeter Identifies the Site of Fluid Leakage during Artificial Urinary Sphincter Revision Surgery.

PURPOSE: While the AMS 800 artificial urinary sphincter improves continence in up to 90% of patients, revision surgery may be needed in up to 50%. We determined whether an ohmmeter could accurately assess the site of fluid leak from individual components of the artificial urinary sphincter at the time of revision surgery. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent artificial urinary sphincter revision surgery between 1996 and 2013. Patients in whom fluid loss was identified preoperatively by plain film radiography and who subsequently underwent revision surgery using the ohmmeter were assessed for outcomes. RESULTS: The ohmmeter was used intraoperatively in a total of 20 surgeries in 19 patients and it correctly identified the location of fluid loss in 18 of 20 (90%). Fluid leakage was found from the pressure regulating balloon in 13 cases, from the cuff in 4 and from the tubing to the pressure regulating balloon in 1. None had fluid loss from the pump. In the 17 cases in which only the malfunctioning component was replaced a satisfactory postoperative outcome with a fully functional device was documented in all. Repeat surgery was performed in 5 of 17 cases (29.4%) at a median of 17 months (range 2 to 39). No patient underwent repeat surgery due to failure to accurately diagnose a component leak. CONCLUSIONS: In cases of suspected fluid loss as a cause of artificial urinary sphincter malfunction an ohmmeter can identify the site of fluid loss during component revision surgery.

Spontaneous spinal epidural abscess in patients 50 years of age and older: a 15-year institutional perspective and review of the literature: clinical article.

OBJECT: A spinal epidural abscess (SEA) is a rare but severe infection requiring prompt recognition and management. The incidence of SEA has doubled in the past decade, owing to an aging population and to increased use of spinal instrumentation and vascular access. The optimal management of SEAs in patients 50 years of age and older remains a matter of considerable debate. In an older patient population with multiple comorbidities, whether intravenous antibiotics alone or in combination with surgery lead to superior outcomes remains unknown. The present study retrospectively analyzes cases of SEAs, in patients 50 years of age and older, treated at Duke University Medical Center over the past 15 years. METHODS: Eighty-two patients underwent treatment for a spinal epidural abscess between 1999 and 2013. There were 46 men and 36 women, whose overall mean age (± SD) was 65 ± 8.58 years (range 50-82 years). The mean duration of clinical follow-up was 41.38 ± 86.48 weeks. Thirty patients (37%) underwent surgery for removal of the abscess, whereas 52 (63%) were treated more conservatively, undergoing CT-guided aspiration or receiving antibiotics alone based on the results of blood cultures. The correlation between pretreatment variables and outcomes was evaluated in a multivariate regression analysis. RESULTS: Back pain and severe motor deficits were the most common presenting symptoms. Compared with baseline neurological status, the majority of patients (68%) reported being neurologically "better" or "unchanged." Twelve patients (15%) had a good outcome (7 [23%] treated operatively vs 5 [10%] treated nonoperatively, p = 0.03), while clinical status in 41 patients (50%) remained unchanged (10 [33%] treated operatively vs 31 [60%] treated nonoperatively, p = 0.01). Overall, 20 patients (25%) died (9 [30%] treated operatively vs 11 [21%] treated nonoperatively, p = 0.43). In a multivariate logistic regression model, an increasing baseline level of pain, the presence of paraplegia or quadriplegia on initial presentation, and a dorsally located SEA were independently associated with poor outcomes. CONCLUSIONS: The results of the study suggest that in patients 50 years of age and older, early surgical decompression combined with intravenous antimicrobial therapy was not associated with superior clinical outcomes when compared with intravenous antimicrobial therapy alone.

A case of Jikoshu-Kyofu treated with cognitive behavioural therapy.

Jikoshu-Kyofu (JKF) is a subtype of Taijin-Kyofu-Sho (TKS), a form of social anxiety first described in Japanese sufferers. Unlike the Diagnostic and Statistical Manual of Mental Disorders - 4th edition text revised definition of social anxiety disorder, TKS is characterised by a fear of offending others, whereas in the case of JKF, it is the fear of giving off a smell, thus causing offence. We describe the symptoms of JKF in a young woman who was treated with cognitive behavioural therapy (CBT). After only four sessions, the patient's anxiety ratings, as measured on the Social Phobia Inventory and Brief Social Phobia Scale, dropped considerably. This case illustrates the successful treatment of a patient with JKF-like symptoms using CBT.

Immunotherapy with tumor vaccines for the treatment of malignant gliomas.

With an average life expectancy of 14 months, Glioblastoma multiforme (GBM), is the most aggressive primary brain tumor. Our growing understanding of the immune system and its role in oncogenesis has helped develop cancer vaccines as a promising treatment modality against this disease. What follows is a comprehensive discussion on the history of immunotherapy and the various vaccine based therapies being developed and utilized for the treatment of malignant gliomas.

Convection enhanced delivery of macromolecules for brain tumors.

The blood brain barrier (BBB) poses a significant challenge for drug delivery of macromolecules into the brain. Convection-enhanced delivery (CED) circumvents the BBB through direct intracerebral infusion using a hydrostatic pressure gradient to transfer therapeutic compounds. The efficacy of CED is dependent on the distribution of the therapeutic agent to the targeted region. Here we present a review of convection enhanced delivery of macromolecules, emphasizing the role of tracers in enabling effective delivery anddiscuss current challenges in the field.