Conservative Management for Urethral Foreign Body: A Case Report of an Adolescent Boy With Repeated Events.

Placing foreign bodies into the urethra is not a common occurrence in the general population. Patients self-insert foreign bodies for a multitude of reasons such as sexual gratification, secondary gain, and psychiatric illness. From our own experience and what has been reported in the literature, there is a wide variability in the type of objects that patients place into the urethra. We report a unique case of a 17-year-old adolescent boy with repeated foreign body insertions into the urethra over a 1-year period. This patient suffers from significant psychiatric illness. Due to the number of events in this past year, we initiated a conservative observational approach that contrasts the traditional invasive protocol to treat with endoscopic removal. This management has proven to be successful in his case and can be replicated in other scenarios after careful consideration of the clinical presentation.

A Survey of Usage of Penile Prosthesis.

BACKGROUND: Implantation of an inflatable penile prosthesis (IPP) has high success and satisfaction rates, but there remains a paucity of evidence examining non-usage of IPP and reasons for discontinuation. AIM: To identify how frequent patients use their prosthesis and their personal reasons for no longer using it. METHODS: We conducted a survey of all patients who underwent an IPP implantation by a single surgeon over a 6-year period, between 2012 and 2018. After application of inclusion and exclusion criteria, a total of 114 patients formed the final cohort. Patients were initially surveyed via mail with a questionnaire; those who did not respond were surveyed via telephone. The factors determining patient selection for IPP implantation included suitability for general anesthesia, manual dexterity to use the device by the patient or their partner on a demonstration device, and presence of refractory erectile dysfunction, HbA1C lower than 8.5, or need for a revision of a previously placed IPP. Universally, a 3-piece AMS 700 Series implant was placed via the penoscrotal approach. Data were analyzed with Pearson chi square test, and survivability of the device was assessed with Kaplan-Meier survival curve. OUTCOMES: The main outcomes of this study are the frequency of IPP usage and reasons for discontinuation. RESULTS: The survey participation rate was 97%. The mean age of patient was 64 years (range 34-83 years), and the mean time between surgery and completion of survey was 2.98 years (range 0.25-7.4 years). Kaplan-Meier curve demonstrated that 68% of the patients were using the IPP at 5 years after implantation. Using the age 70 years as a cutoff, 18 (22%) patients younger than 70 years and 14 (42%) patients older than 70 years discontinued using the IPP (P = .029). The commonest reasons for discontinuation were poor health to engage in sexual activity (2.6%), loss of companion (19%), loss of interest in sex (2.6%), and device malfunction with no further interest in revision of prosthesis (14%). CLINICAL IMPLICATIONS: The clinical implication of this study was improved patient selection for device implantation. STRENGTHS AND LIMITATIONS: To our knowledge, no other study has investigated reasons for patients no longer using their prosthesis. Our study has several limitations including that it is a cross-sectional analysis, our survey is not validated, this is a single-surgeon experience, we have a small sample size, and we did not differentiate between virgin implant and reimplantation. CONCLUSION: Our study shows a high rate (28%) of non-usage of IPP, more so in men older than the age of 70 years in the first 5 years of implantation. Knoll P, Rai S, Talluri S, et al. A Survey of Usage of Penile Prosthesis. J Sex Med 2020;17:2287-2290.

Proteinuria impacts patient survival differentially based on clinical setting: A retrospective cross-sectional analysis of cohorts from a single health system: Retrospective cohort study.

BACKGROUND: Chronic kidney disease (CKD) staging is improved by adding proteinuria to glomerular filtration rate (GFR). While proteinuria independently predicts CKD progression and mortality, the clinical setting of proteinuria determination has not been well-studied previously. The objective of our study is to determine whether clinical setting differentially impacts survival outcomes. METHODS: Kaplan-Meier and Cox proportional hazards analyses of overall survival were performed retrospectively for cohorts of outpatients (n = 22,918), emergency patients (n = 16,861), and inpatients (n = 12,304) subjected to urinalysis (UA) at a single health system in 2010. GFR (G1-G5) and proteinuria (A1:<30 mg, A2:30-300 mg, A3:>300 mg) were classified under Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. RESULTS: GFR and proteinuria levels varied more in inpatients than in emergency and outpatients. For each clinical population, survival significantly decreased with increasing proteinuria (A1>A2>A3, p < 0.05 for each comparison). The effect of proteinuria on survival differed by clinical setting, with statistical differences in all categories other than A3 in outpatients and emergency patients (p = 0.98). The strongest predictors of mortality were cancer diagnosis (HR: 3.07, p < 0.0001) and very-high KDIGO classification (HR: 2.01, p < 0.0001). Limitations include the retrospective observational study design and single health system analysis. CONCLUSIONS: The value of UA to screen for proteinuria in each clinical setting is evident, but the impact of A2 and A3 level proteinuria on survival varies depending on the clinical scenario in which the determination was made. The clinical setting of proteinuria measurement should be factored into both patient care and clinical research activities.

Should partial nephrectomy be considered "elective" in patients with stage 2 chronic kidney disease? A comparative analysis of functional and survival outcomes after radical and partial nephrectomy.

PURPOSE: To compare renal function and survival outcomes in patients with baseline chronic kidney disease (CKD) stage 2 undergoing partial (PN) or radical nephrectomy (RN), as nephron-sparing surgery is considered to be elective in this group. METHODS: Retrospective analysis of patients with CKD stage 2 and T1/T2 renal mass undergoing PN or RN from 2001 to 2015. Patients were stratified into substage CKD 2a or CKD 2b and analyzed between types of surgery. Primary outcome was overall survival (OS), eGFR < 45 at last follow-up was the secondary outcome. Multivariable analysis (MVA) was conducted for predictors of eGFR < 45 and OS. Kaplan-Meier analyses were conducted for freedom from eGFR < 45 and OS. RESULTS: 1213 patients analyzed (CKD 2a 609/CKD 2b 604) on MVA, RN (OR 3.68, p = 0.001) and CKD 2b (OR 3.3, p = 0.002) were independently associated with development of eGFR < 45 at last follow-up and RN (OR 3.76, p = 0.005) and eGFR < 45 (OR 2.51, p = 0.029) were associated with decreased OS. Kaplan-Meier analyses revealed that patients with CKD 2a/PN had the highest 5-year freedom from eGFR < 45 (94.3%) compared to CKD 2a/RN patients (91.5%), CKD2b/PN patients (87.6%) and CKD 2b/RN patients 82.0% (p < 0.001). Kaplan-Meier analyses for OS demonstrated that patients with CKD 2a/PN had significantly greater 5-year OS (97.6%) compared to CKD 2a/RN patients (95.2%), CKD 2b/PN patients (93.2%), and CKD 2b/RN patients (92.4%, p = 0.043). CONCLUSIONS: Patients with baseline CKD stage 2, particularly CKD 2b and undergoing RN, are at increased risk of GFR < 45, which was associated with decreased OS. In patients with CKD 2b, a nephron-sparing strategy is indicated and should be prioritized when feasible.

Determination of Prostate Volume: A Comparison of Contemporary Methods.

RATIONALE AND OBJECTIVES: Prostate volume (PV) determination provides important clinical information. We compared PVs determined by digital rectal examination (DRE), transrectal ultrasound (TRUS), magnetic resonance imaging (MRI) with or without three-dimensional (3D) segmentation software, and surgical prostatectomy weight (SPW) and volume (SPV). MATERIALS AND METHODS: This retrospective review from 2010 to 2016 included patients who underwent radical prostatectomy ≤1 year after multiparametric prostate MRI. PVs from DRE and TRUS were obtained from urology clinic notes. MRI-based PVs were calculated using bullet and ellipsoid formulas, automated 3D segmentation software (MRI-A3D), manual segmentation by a radiologist (MRI-R3D), and a third-year medical student (MRI-S3D). SPW and SPV were derived from pathology reports. Intraclass correlation coefficients compared the relative accuracy of each volume measurement. RESULTS: Ninety-nine patients were analyzed. Median PVs were DRE 35 mL, TRUS 35 mL, MRI-bullet 49 mL, MRI-ellipsoid 39 mL, MRI-A3D 37 mL, MRI-R3D 36 mL, MRI-S3D 36 mL, SPW 54 mL, SPV-bullet 47 mL, and SPV-ellipsoid 37 mL. SPW and bullet formulas had consistently large PV, and formula-based PV had a wider spread than PV based on segmentation. Compared to MRI-R3D, the intraclass correlation coefficient was 0.91 for MRI-S3D, 0.90 for MRI-ellipsoid, 0.73 for SPV-ellipsoid, 0.72 for MRI-bullet, 0.71 for TRUS, 0.70 for SPW, 0.66 for SPV-bullet, 0.38 for MRI-A3D, and 0.33 for DRE. CONCLUSIONS: With MRI-R3D measurement as the reference, the most reliable methods for PV estimation were MRI-S3D and MRI-ellipsoid formula. Automated segmentations must be individually assessed for accuracy, as they are not always truly representative of the prostate anatomy. Manual segmentation of the prostate does not require expert training.

Acute appendicitis in childhood: oral contrast does not improve CT diagnosis.

INTRODUCTION: We compared the diagnostic accuracy of CT performed without and with oral contrast for suspected appendicitis in children. METHODS: In this retrospective cohort study, we reviewed abdomen/pelvis CT scans with IV contrast performed between 2011 and 2015 for suspected appendicitis. Oral contrast was used routinely before August 2013 and eliminated from the CT protocol thereafter. Diagnostic accuracy of CT was compared with operative/pathology reports, and included a 30-day follow-up period for non-surgical patients. For a secondary analysis, the oral contrast group was subdivided into "complete" (contrast extending into the cecum) or "partial" contrast. We also compared groups for CT turnaround time, the frequency of appendiceal perforation and abscess, and the potential influence of a prior appendix ultrasound. RESULTS: Five hundred fifty-eight patients were included: 51.6% (n = 288) without oral contrast and 48.4% (n = 270) with oral contrast (of which 52% (n = 140/270) had "complete" contrast). There was no difference in diagnostic accuracy between the oral contrast and non-contrast groups (p = 0.903), with sensitivity/specificity of 93.8% (95% CI 84.8-98.3)/98.5% (CI 95.8-99.7) and 94.6% (CI 84.9-98.9)/98.3% (CI 95.7-99.5), respectively. Similarly, there was no difference in accuracy when comparing only "complete" contrast vs. non-contrast groups (p = 0.755). CT turnaround time for the non-contrast group was significantly faster (43.8 ± 37.6 min), on average, than the oral contrast group (137.4 ± 47.5 min). CONCLUSION: For children evaluated by CT with IV contrast for suspected appendicitis, administering oral contrast increased wait time by > 90 min, did not reach the cecum in 48% of cases, and did not improve diagnostic accuracy. Oral contrast for pediatric CT appendicitis evaluation is not warranted.

Prevalence of Proteinuria and Other Abnormalities in Urinalysis Performed in the Urology Clinic.

OBJECTIVE: To compare the prevalence of proteinuria in the urology clinic with other outpatient settings. Chronic kidney disease is classified according to cause, glomerular filtration rate, and proteinuria. Proteinuria may be more prevalent in patients with known chronic kidney disease, renal disorders (benign or malignant), or after urologic surgery. METHODS: A cross-sectional study of 3 populations undergoing urinalysis (UA) testing was carried out: general outpatients (n = 20,334), urology outpatients (n = 5023), and kidney cancer patients (n = 1016). Proteinuria was classified under Kidney Disease: Improving Global Outcomes guidelines: A1 (<30 mg), A2 (30-300 mg), and A3 (>300 mg). RESULTS: Proteinuria was detected throughout a community-based health system in 8.6% of UA (8.2%: A2; 0.4%: A3). In comparison, 18.6% of urology office-performed UA had proteinuria (16.0%: A2, 2.5%: A3) (P < .0001 vs non-urology). Kidney cancer patients were more likely to have proteinuria (17.9%: A2, 3.8%: A3). The proportion with A3 was significantly higher in urology and kidney cancer patients when compared with other outpatients (each P < .0001), and in the kidney cancer subgroup compared with all urology patients (P < .0001). Additional abnormalities were frequently present on microscopic analysis of UA in the urology clinic, including hematuria (20.9%), pyuria (21.8%), and bacteriuria (3.1%). CONCLUSION: The value of UA in the urology clinic as a screening test for proteinuria and other conditions appears high, with >56% having at least 1 abnormality. The population risk of proteinuria in the urology clinic is 18.5%, which is higher than that observed in non-urology clinics. Patients with kidney cancer appear more likely to have proteinuria than the average urology patient. We recommend evaluation of urology patients with UA to identify proteinuria.