Inflatable penile prosthesis outcomes after pelvic radiation.

INTRODUCTION Few studies have compared surgical outcomes after 3-piece inflatable penile prosthesis (IPP) surgery in patients exposed to pelvic radiation therapy (RT) compared to a radiation naïve control group. MATERIALS AND METHODS: A total of 715 consecutive patients underwent 3-piece IPP placement between 2007-2018. There were 101 men exposed to pelvic RT before or after IPP for a variety of malignancies and 153 men met inclusion criteria for the control group, which included men undergoing IPP surgery with a history of radical prostatectomy but no exposure to pelvic RT. RESULTS: Patients in the RT group had a higher body mass index (kg/m²) (28.7 versus 27.8, p = 0.003) and higher Charlson co-morbidity index score (6 versus 5; p < 0.001). At a median follow up of 5 years (IQR 2-8 years), there was an 18.4% surgical complication rate in the radiation group compared to 11.5% in the control group, though this was not statistically significant (p = 0.141). Timing of radiation, prior artificial urinary sphincter (AUS) status, co-implantation of an AUS, and brand of prosthesis were not associated with increased rate of complications. On multivariable logistic regression analysis, exposure to RT was not significantly associated with increased risks of complications (OR: 1.31; CI 0.55-3.12). CONCLUSIONS: This study shows no significant increase in risk of surgical complication in patients exposed to pelvic RT and supports the use of IPP in men with a history of RT and refractory erectile dysfunction.

Neurogenic bladder is an independent risk factor for complications associated with inflatable penile prosthesis implantation.

Men with neurogenic bladder (NGB) often have concomitant erectile dysfunction and may be considered for inflatable penile prosthesis (IPP) placement. However, it is unclear if NGB is a risk factor for complications associated with IPP placement. The aim of this study is to compare surgical outcomes after IPP placement in a contemporary cohort of patients with NGB to that of a non-neurogenic control group. To accomplish this, consecutive records of patients who underwent IPP implantation between 2007 and 2018 were retrospectively reviewed. Patients with a known neurologic lesion and documented NGB by clinical or urodynamic criteria were compared with a non-neurogenic control group of men with erectile dysfunction. We found that patients in the NGB cohort were younger (median age 48 vs. 62 years, p < 0.001) and less likely to void spontaneously prior to surgery (3% vs. 97%, p < 0.001). The most common cause for NGB was spinal cord injury (46%). There was a 24.3% overall rate of complication (infection, erosion, or mechanical failure) in the NGB cohort compared with a 7.5% rate in the non-neurogenic control group (p = 0.001). On multivariate logistic regression modeling, NGB (OR 3.47; 95% CI 1.13-10.71; p = 0.03) was independently associated with risk of IPP complication. First time penile prosthesis was associated with lower risk of IPP complication (OR 0.25 95% CI 0.09-0.71; p = 0.01). In conclusion, patients with NGB are at increased risk for complications after IPP placement. Patients should be counseled accordingly, and all efforts should be made to stabilize bladder function prior to surgery.

A Retrospective Comparative Outcomes and Cost Analysis of Office Based, Ultrasound Guided Renal Mass Biopsy Performed by Urologists and Standard Hospital Biopsies for Small Renal Masses.

INTRODUCTION: Renal mass biopsy is useful in the evaluation of small renal masses. We have previously reported that office based, ultrasound guided renal mass biopsy is safe, effective and feasible when performed by urologists. This study compares office based, ultrasound guided renal mass biopsy performed by urologists and hospital based renal mass biopsy. METHODS: We retrospectively studied 70 patients who underwent office based, ultrasound guided renal mass biopsy and 155 who underwent hospital based, ultrasound or computerized tomography guided renal mass biopsy for evaluation of a small renal mass (4.0 cm or less) between January 2010 and February 2016. RESULTS: A total of 70 patients underwent office based, ultrasound guided renal mass biopsy. Median age in this group was 69.5 years, median body mass index was 29.5 kg/m2 and 61.4% of the patients (43) were male. A total of 103 patients underwent hospital based, ultrasound guided biopsy. Median age in this group was 68.0 years, median body mass index was 29.3 kg/m2 and 53.4% of the patients (55) were male. Finally, 52 patients underwent hospital based, computerized tomography guided biopsy. Median age in this group was 69 years, median body mass index was 30.1 kg/m2 and 51.9% of the patients (27) were male. Median tumor size was 2.7 cm in patients undergoing office based, ultrasound guided renal mass biopsy, 2.2 cm in those undergoing hospital based, ultrasound guided biopsy and 2.1 cm in those undergoing hospital based, computerized tomography guided biopsy (p = 0.001). Renal cell carcinoma was found in 43 of 70 (61.4%), 74 of 103 (71.8%) and 33 of 52 (63.5%) respective biopsies. Respective diagnostic rates were 81.4% (57 of 70 cases), 88.3% (91 of 103) and 86.5% (45 of 52, p = 0.434). Concordance with surgical pathology was 97.7% (42 of 43 cases), 100% (35 of 35) and 100% (15 of 15), respectively. Complication rates were 4.3% (3 of 70 patients), 13.6% (14 of 103) and 13.5% (7 of 52), respectively (p = 0.096). Cost analysis revealed that when available, office based, ultrasound guided renal mass biopsy provides the health care system a total savings of approximately $46,011 yearly. CONCLUSIONS: Office based, ultrasound guided renal mass biopsy for small renal masses is a safe and efficacious option for select patients, and potentially offers greater convenience and availability as well as decreased health care costs.

Office-based Ultrasound-guided Renal Core Biopsy Is Safe and Efficacious in the Management of Small Renal Masses.

OBJECTIVE: To evaluate the safety and efficacy of ultrasound (US)-guided percutaneous renal mass biopsy (RMB) performed in the office setting by urologists. MATERIALS AND METHODS: This is a retrospective study involving patients who underwent office-based US-guided percutaneous RMB between April 2010 and October 2015. Baseline vital signs and US were performed prior to the procedure. Patients were then observed for 1 hour after the procedure and repeat vital signs and US were performed. Hemodynamically stable patients who did not develop hematoma were discharged. RESULTS: In 108 patients, 70 (64.8%) were male, median age was 69.5 years, and median mass size was 3.3 cm (interquartile range: 2.5-4.6). Biopsy yield was as follows: 72 (66.7%) had renal cell carcinoma, 14 (13.0%) had benign renal parenchyma, 11 (10.2%) had oncocytoma, 6 (5.6%) had angiomyolipoma, 2 (1.9%) had lymphoma, and 3 (2.8%) had other disease. The initial nondiagnostic rate was 14 of 108 (13.0%). There were 28 of 108 (25.9%) patients observed whereas 79 of 108 (73.2%) received surgery or ablative therapy. Final pathology was concordant with biopsy results in 66 of 68 (97.1%) cases. Three patients experienced a grade I Clavien-Dindo surgical complication, all of which were managed conservatively. CONCLUSION: Office-based US-guided RMB is safe and efficacious in the management of appropriately selected SRM. It potentially offers improved dynamic characterization of solid renal mass, greater convenience to patients, as well as cost savings. Further studies are needed to evaluate this promising technique.

Robot-Assisted Laparoscopic Nephroureterectomy for Transitional Cell Carcinoma of a Right Pelvic Kidney.

BACKGROUND: Nephroureterectomy is the standard of care for transitional cell carcinoma (TCC) involving the upper urinary tract. However, few published case reports exist describing the surgical treatment of ectopic kidneys with TCC. Surgical removal of a pelvic kidney can be complicated by aberrant vasculature supply, a tortuous ureter and abutting anatomical structures. Thus, it is necessary to determine the most appropriate surgical technique for treatment of pelvic kidneys with suspected malignancy. CASE PRESENTATION: A 65-year-old female who presented with hematuria and lower abdominal pain was found to have a right pelvic kidney with a heterogeneous mass on computed tomography (CT) urogram. A robot-assisted laparoscopic nephroureterectomy of the right pelvic kidney was performed. Histopathological analysis revealed high-grade TCC with microscopic extension through the muscularis propria of the renal pelvis and superficially into the renal parenchyma. CONCLUSION: This case demonstrates the successful use of robot-assisted laparoscopic nephroureterectomy in the treatment of a pelvic kidney with TCC. Preoperative CT angiography is critical to define vascular anatomy and to prevent significant blood loss and damage to surrounding structures during surgery. This case was presented because TCC of a pelvic kidney is a rare occurrence and the use of robot-assisted nephroureterectomy for treatment of this disease is novel.

Innovative use of intravesical tacrolimus for hemorrhagic radiation cystitis.

Hemorrhagic cystitis is a rare and severe late complication of pelvic radiation, and there is no regulatory-approved drug treatment. We present an 81-year-old man with a history of localized prostate cancer, which was treated with external beam radiation therapy and subsequently developed severe hemorrhagic radiation cystitis for which he has failed several treatments. We present the novel use of intravesical tacrolimus for the treatment of refractory radiation cystitis and gross hematuria. The patient tolerated the treatment well, and it resulted in the resolution of his gross hematuria without further consideration for formalin instillation or cystectomy and diversion. Intravesical tacrolimus is a safe, minimally invasive, and promising treatment option for radiation hemorrhagic cystitis.