Use of isotonic contrast solution in the artificial urinary sphincter does not impact device longevity.

AIMS: The artificial urinary sphincter (AUS), the gold standard for treatment of male stress urinary incontinence, can be filled with normal saline (NS) or isotonic contrast solution. Surgeons have voiced concerns about the impact on device malfunction and longevity, but no studies address this issue. We used industry data to identify differences in outcomes between NS and contrast-filled AUS. METHODS: Our analysis included all men patients in the industry who maintained the AUS database (Boston Scientific) from 2001 to 2016. Patients were divided into two groups: AUS filled with NS or contrast. Patient demographics and device characteristics were compared. Device survival was defined as time to the need for reoperation. We compared device survival between AUS filled with NS versus contrast using a Kaplan-Meier curve adjusted for age, cuff size, and pressure regulating balloon (PRB) size. RESULTS: A total of 39,363 patients were included. 34,674 (88.1%) devices were filled with NS. The reoperation rate overall was 24.5%, with no difference between groups. The mean time to reoperation overall was 3 years (±3.0). After adjustment for age, cuff size, and PRB size, Kaplan-Meier analysis demonstrated a similar time to reoperation between the two groups. CONCLUSION: The use of contrast in the AUS does not appear to change rates of the device malfunction, fluid loss, or need for reoperation. Since filling the device with contrast does not appear inferior to saline in terms of longevity, we feel this should be considered a safe tool for the implanting surgeon.

Diet and Exercise Are not Associated with Skeletal Muscle Mass and Sarcopenia in Patients with Bladder Cancer.

BACKGROUND: There is limited understanding about why sarcopenia is happening in bladder cancer, and which modifiable and nonmodifiable patient-level factors affect its occurrence. OBJECTIVE: The objective is to determine the extent to which nonmodifiable risk factors, modifiable lifestyle risk factors, or cancer-related factors are determining body composition changes and sarcopenia in bladder cancer survivors. DESIGN, SETTING, AND PARTICIPANTS: Patients above 18 yr of age with a histologically confirmed diagnosis of bladder cancer and a history of receiving care at Duke University Medical Center between January 1, 1996 and June 30, 2017 were included in this study. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Bladder cancer survivors from our institution were assessed for their dietary intake patterns utilizing the Diet History Questionnaire II (DHQ-II) and physical activity utilizing the International Physical Activity Questionnaire long form (IPAQ-L) tools. Healthy Eating Index 2010 (HEI2010) scores were calculated from DHQ-II results. Body composition was evaluated using Slice-O-Matic computed tomography scan image analysis at L3 level and the skeletal muscle index (SMI) calculated by three independent raters. RESULTS AND LIMITATIONS: A total of 285 patients were evaluated in the study, and the intraclass correlation for smooth muscle area was 0.97 (95% confidence interval: 0.94-0.98) between raters. The proportions of patients who met the definition of sarcopenia were 72% for men and 55% of women. Univariate linear regression analysis demonstrated that older age, male gender, and black race were highly significant predictors of SMI, whereas tumor stage and grade, chemotherapy, and surgical procedures were not predictors of SMI. Multivariate linear regression analysis demonstrated that modifiable lifestyle factors, including total physical activity (p=0.830), strenuousness (high, moderate, and low) of physical activity (p=0.874), individual nutritional components (daily calories, p=0.739; fat, p=0.259; carbohydrates, p=0.983; and protein, p=0.341), and HEI2010 diet quality (p=0.822) were not associated with SMI. CONCLUSIONS: Lifestyle factors including diet quality and physical activity are not associated with SMI and therefore appear to have limited impact on sarcopenia. Sarcopenia may largely be affected by nonmodifiable risk factors. PATIENT SUMMARY: In this report, we aim to determine whether lifestyle factors such as diet and physical activity were the primary drivers of body composition changes and sarcopenia in bladder cancer survivors. We found that lifestyle factors including dietary habits, individual nutritional components, and physical activity do not demonstrate an association with skeletal muscle mass, and therefore may have limited impact on sarcopenia.

The Absence of a Validated English-Language Survey to Assess Prosthesis Satisfaction: A Prospective Cohort Using the Sexual Quality of Life After Penile Prosthesis.

BACKGROUND: Prior assessments of sexual quality of life (SQoL) after penile prosthesis implantation have been performed without validated implant-specific tools. The Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire was designed and validated in Italian to specifically evaluate SQoL after a penile prosthesis is placed. AIM: We aim to better characterize prosthesis-specific SQoL after inflatable penile prosthesis placement using the English translation of the QoLSPP questionnaire. METHODS: A total of 395 consecutive patients received an inflatable penile prosthesis between January 1, 2009 and November 27, 2017, and 270 had functional emails to whom the QoLSPP questionnaire was sent. 90 surveys were completed by 75 first-time implantees and 15 patients who underwent removal/replacement surgery. Responses were considered positive if ≥ 3. Among first-time implantees, subpopulation analysis was carried out by age at survey completion (<55 years, 55-65 years, and ≥66 years), age of penile prosthesis at survey completion (<1 year, 1-5 years, and >5 years), device model (Coloplast Titan, AMS 700 CX, and AMS LGX), history of a psychiatric diagnosis, etiology of erectile dysfunction, total device length > or ≤ 21 cm, diabetes status, and body mass index < /≥ 30. Responses were analyzed in R using t-tests for continuous variables and Chi-squared tests (Fisher's for small counts) for categorical variables. OUTCOMES: The main outcome measure of this study was sexual quality of life assessed by QoLSPP. RESULTS: Patients completed the survey on average 3.15 years from their most recent prosthesis placement. 84% of first-time implantees had positive responses. Among them, there were no significant differences in the proportion of positive responses by device type, age, history of a psychiatric diagnosis, total implanted device length, etiology of erectile dysfunction, diabetes, or body mass index statuses (all P > .05). There was no difference in SQoL between first-time implantees and those who underwent removal/replacement surgery (P = 1.0). CLINICAL IMPLICATIONS: Patients experience a positive impact on their SQoL following implantation of a penile prosthesis. STRENGTHS & LIMITATIONS: Our study is the first to apply the English language QoLSPP which demonstrates high prosthesis specific SQoL but is limited by size and a lack of a validated English language tool. CONCLUSIONS: The positive impact on patients' SQoL with penile prosthesis is 84% when assessed by the English QoLSPP questionnaire. While these results mirror those reported from Italy, the English-speaking patient population is plagued with a lack of a validated tool to assess satisfaction, a void the academic and prosthetic community must fill to better understand the impact prostheses have on their patients. Carlos EC, Nosé BD, Barton GJ, et al. The Absence of a Validated English-Language Survey to Assess Prosthesis Satisfaction: A Prospective Cohort Using the Sexual Quality of Life After Penile Prosthesis. J Sex Med 2020;17:2307-2310.

The nephroureterectomy: a review of technique and current controversies.

The nephroureterectomy (NU) is the standard of care for invasive upper tract urothelial carcinoma (UTUC) and has been around for well over one hundred years. Since then new operative techniques have emerged, new technologies have developed, and the surgery continues to evolve and grow. In this article, we review the various surgical techniques, as well as present the literature surrounding current areas of debate surrounding the NU, including the lymphatic drainage of the upper urinary tract, management of UTUC involvement with the adrenals and caval thrombi, surgical management of the distal ureter, the use of intravesical chemotherapy as well as perioperative systemic chemotherapy, as well as various outcome measures. Although much has been studied about the NU, there still is a dearth of level 1 evidence and the field would benefit from further studies.

Renal Thermal Ablation Trends of American Urologists.

Objective: To define current trends in the utilization of renal thermal ablation by urologists in the United States. Material and Methods: A six-month case log data for renal procedures submitted by certifying and recertifying American urologists from 2003 to 2018 were obtained from the American Board of Urology and stratified by current procedural terminology code. The utilization of thermal ablative techniques was examined with respect to overall trends, surgeon, and practice characteristics associated with its use. Results: Six thousand two hundred eleven unique urologists performed 54,075 renal procedures, including 1916 (3.5%) thermal ablations, 630 (1.2%) renal biopsies, 17,361 (32.1%) partial nephrectomies, 20,403 (37.8%) radical nephrectomies, and 7957 (14.7%) nephroureterectomies. Eight hundred twenty-five (13.3%) unique urologists performed renal ablations, including 1344 (70.2%), 418 (21.8%), and 154 (8.0%) laparoscopic, percutaneous, and open ablation procedures, respectively. The annual volume of ablation was highest in 2008, followed by 2010 and 2009. On multivariate modeling of those performing renal interventions, the first decade of practice, self-declared endourologist, urologist who completed an endourology fellowship, urologist who practices in the Mid Atlantic, North Central, South Central, and South Eastern United States (compared with New England) were more likely to perform thermal ablation for renal masses. Urologists who perform renal biopsies and partial nephrectomies are also more likely to perform ablation of renal masses. Conclusions: Thermal ablation accounted for a small percentage of renal interventions performed by urologists in the last 1.5 decades with definable associations to practice characteristics. Renal ablation was most commonly performed laparoscopically, with declining use in recent years.

A survey of antibiotic administration practices involving patients with sepsis in UK critical care units.

Background Alternative administration methods are emerging as a key area of research to improve clinical efficacy of antibiotics and address concerns regarding multi-drug resistance. Extended intermittent infusions or continuous infusions of antibiotics exhibiting time-dependent kill characteristics may be favourable in critically ill septic patients, but more evidence is needed to determine best practice. Objective To find out whether any common practice exists for intravenous antibiotic administration in critical care units across UK NHS Trusts, and identify factors influencing the adoption of extended or continuous infusions. Setting UK hospitals. Method UK critical care pharmacists were invited to participate in a survey on behalf of all 240 critical care units via a UK Clinical Pharmacy Association message board. The survey focused on administration practices for 22 antibacterial agents. Main outcome measure Antibiotic administration method. Results Responses were received covering 64 units, a response rate of 26.2%. Common, but not uniform administration methods were apparent for 17/22 antibiotics. Four antibiotics (piperacillin/tazobactam, doripenem, meropenem and vancomycin) were more likely to be administered as continuous or extended-intermittent infusions. Choice of administration method was especially influenced by altered pk/pd properties in sepsis or severe burns patients, or by the presence of organisms requiring high minimal inhibitory concentrations. Conclusion Unlicensed alternative practices of antibiotic administration are widespread but only weak evidence exists of any patient benefit, such as reduced length of stay in critical care, and none showing improvement in mortality. Further research is needed to determine whether extended infusion methods offer clinically meaningful advantages over shorter licenced administration methods in patients in critical care units.

Sexual Quality of Life and Satisfaction With Penile Prostheses.

INTRODUCTION: Penile prosthesis (PP) implantation is associated with high patient satisfaction and improved sexual quality of life (SQoL). The SQoL benefits of PP implantation are generalizable across subpopulations of PP implant patients, but the literature is heterogeneous in design and largely without instruments to specifically measure SQoL changes due to PP, requiring extrapolation from less granular measures. AIM: To provide a comprehensive review of available literature regarding SQoL with a penile prosthesis. In addition, the strengths and limitations of each study will be described with respect to design, number of patients included, data acquisition, and clinical significance. METHODS: A PubMed search was performed for articles from 1989 to 2018 related to penile prostheses and SQoL. Emphasis was placed on patient/partner satisfaction scores, quality of life assessments, and patient-reported outcome measures. MAIN OUTCOME MEASURE: The SQoL benefits due to penile prostheses were reviewed. The measurement tools for patient satisfaction and sexual quality of life across multiple subpopulations within patients receiving penile prosthesis implantation were reviewed and the outcomes analyzed. RESULTS: Patient satisfaction rates with penile prostheses are higher than 85%, and SQoL is improved in both patients and their partners. There now is a validated questionnaire that is the first to specifically measure changes in SQoL due to a penile prosthesis. CONCLUSION: Overall, patient satisfaction with a penile prosthesis is high and SQoL is improved. These results are largely generalizable across multiple subpopulations of patients. Although literature is heterogeneous in study design and assessment methods, there now is a validated and specific penile prosthesis SQoL questionnaire that can provide for more granular analysis moving forward. Barton GJ, Carlos EC, Lentz AC. Sexual Quality of Life and Satisfaction With Penile Prostheses. J Sex Med Rev 2019;7:178-188.

Early Intervention during Acute Stone Admissions: Revealing "The Weekend Effect" in Urological Practice.

PURPOSE: Obstructing nephrolithiasis is a common condition that can require urgent intervention. In this study we analyze patient factors that contribute to delayed intervention during acute stone admission. MATERIALS AND METHODS: We retrospectively reviewed the HCUP SID (Healthcare Cost and Utilization Project State Inpatient Database) for Florida and California from 2007 to 2011. Patients who were admitted urgently with nephrolithiasis and an indication for decompression (urinary tract infection, acute renal insufficiency and/or sepsis) were included in the study. Intervention was timely or delayed, defined as a procedure that occurred within or after 48 hours, respectively. Adjusted multivariate models were fit to assess factors that predicted a delayed procedure as well as mortality. RESULTS: Overall 10,301 patients were admitted urgently for nephrolithiasis with indications for decompression. Early intervention occurred in 6,689 patients (65%) and was associated with a decrease in mortality (11, 0.16%), compared to delayed intervention (17 of 3,612, 0.47%, p=0.002). On multivariate analysis timely intervention significantly decreased the odds of inpatient mortality (OR 0.43, p=0.044). Weekend day admission significantly influenced time to intervention, decreasing patient odds of timely intervention by 26% (p <0.001). Other factors decreasing patient odds of timely intervention included nonCaucasian race and nonprivate insurance. Presenting medical diagnoses of urinary tract infection, sepsis and acute renal failure did not appear to influence time to intervention. CONCLUSIONS: Delayed operative intervention for acute nephrolithiasis admissions with indications for decompression results in increased patient mortality. Nonmedical factors such as the "weekend effect," race and insurance provider exerted the greatest influence on the timing of intervention.

The Effect of Compression Stockings on Cerebral Desaturation Events in Obese Patients Undergoing Shoulder Arthroscopy in the Beach-Chair Position.

PURPOSE: To determine if the use of thigh-high compression stockings could decrease the incidence of cerebral desaturation events (CDEs) in patients with a body mass index (BMI) of 30 kg/m(2) or greater undergoing shoulder arthroscopy in the beach-chair position (BCP). METHODS: Between December 2013 and May 2014, 23 patients aged 18 years or older with a BMI of 30 kg/m(2) or greater undergoing shoulder arthroscopy in the BCP were monitored intraoperatively using near-infrared spectroscopy while wearing thigh-high compression stockings. Data obtained on these patients were compared with data from a previous cohort at our institution comprising 24 patients with a BMI of 30 kg/m(2) or greater who underwent elective shoulder arthroscopy in the BCP with the same monitoring but without wearing compression stockings. The incidence of CDEs was identified in each group. RESULTS: The incidence of CDEs in the group with compression stockings was 4% (1 of 23) compared with 18% (7 of 24) in the group without compression stockings (P = .048). There were no statistically significant differences in mean age (53.0 years v 53.3 years, P = .91), mean BMI (34.5 kg/m(2)v 36.2 kg/m(2), P = .21), or various medical comorbidities between the treatment group and control group. There was a significant difference in the operative time between the treatment group (156.6 minutes) and control group (94.1 minutes) (P < .001). CONCLUSIONS: The use of thigh-high compression stockings may decrease the incidence of CDEs in obese patients undergoing shoulder arthroscopy in the BCP. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Transhumeral Portal for Arthroscopic Glenohumeral Resurfacing Procedures: A Cadaveric Study of the Safety and Accuracy.

PURPOSE: To evaluate the safety and accuracy of a transhumeral portal to arthroscopically access and prepare the glenohumeral articular surface without subscapularis transection or glenohumeral dislocation. METHODS: In 10 fresh-frozen cadaveric shoulders, we used a transhumeral portal and an anterior mini-open rotator interval exposure to arthroscopically prepare the humeral and glenoid articular surfaces. To evaluate our technique, we measured the distance from the portal to the branches of the axillary nerve and the biceps groove on the humeral extra-articular surface, the angle of trajectory of the portal through the humerus, and the accuracy of targeting the center-center of the humeral and glenoid surfaces. RESULTS: The transhumeral portal allows perpendicular access to the humeral and glenoid articular surfaces without damage to the subscapularis, supraspinatus, or axillary nerve. The transhumeral portal courses an average of 20.7 ± 15.0 mm from the closest terminal branch of the anterior branch of the axillary nerve, enters the humerus 8.8 ± 2.7 mm lateral to the biceps groove, and traverses the humerus at an angle of 46.0° ± 4.3° relative to the humeral intramedullary axis. Arthroscopic guidance resulted in an average distance of 8.1 ± 5.6 mm from the humeral center and 3.9 ± 1.0 mm from the glenoid center. CONCLUSIONS: Creating an arthroscopic transhumeral portal allows perpendicular access to the humeral and glenoid articular surfaces without injury to the axillary nerve, subscapularis transection, or dislocation of the glenohumeral joint. However, this transhumeral portal did traverse within 5 mm of a terminal branch of the anterior branch of the axillary nerve in 20% of our specimens. CLINICAL RELEVANCE: These findings describe an arthroscopic transhumeral portal that achieves perpendicular access to the glenohumeral joint surfaces without transection of the subscapularis or dislocation of the glenohumeral joint. This transhumeral portal may assist in articular cartilage repair and resurfacing of the glenohumeral joint.