Analysis of Complications of Pelvic Mesh Excision Surgery Using the Clavien-Dindo Classification System.

PURPOSE: We describe and categorize complications using the Clavien-Dindo classification system in patients who underwent vaginal mesh excision surgery. MATERIALS AND METHODS: With institutional review board approval we retrospectively reviewed the records of 277 patients who underwent vaginal mesh extraction between 2007 and 2015 at a single institution. Surgical complications were stratified using the Clavien-Dindo classification system. Complications were perioperative (prior to discharge) or postoperative (within 90 days). Indications for initial mesh placement, mesh revision procedure, time to resolution and medical comorbidities were assessed. RESULTS: Of the 277 patients 47.3% had at least 1 surgical complication, including multiple complications in 7.2%. A total of 155 complications were identified, which were grade II in 49.0% of cases, grade I in 25.8%, grade IIIb in 18.7%, grade IIIa in 5.2% and grade IVa in 1.3%. No grade IVb or V complications were identified. The indication for initial mesh placement did not significantly affect complication frequency. Patients who underwent combined stress urinary incontinence and pelvic organ prolapse mesh revision surgeries had an increased frequency of complications compared to those treated with mesh revision surgery for pelvic organ prolapse or stress urinary incontinence alone (p = 0.045). Most complications occurred postoperatively and resolved by 90 days. Age, body mass index, smoking status and diabetes were not associated with increased complications. CONCLUSIONS: Despite the complexity of mesh revision surgery most complications are minor. Serious complications may develop, emphasizing the need for proper patient counseling and surgical experience when performing these procedures.

Female Urethral Diverticula in the Contemporary Era: Is the Classic Triad of the "3Ds" Still Relevant?

OBJECTIVE: To evaluate the correlation between signs and symptoms of urethral diverticulum (UD), especially the classic triad of 3Ds including dysuria, dyspareunia, and postvoid dribbling, before and after transvaginal urethral diverticulectomy, in relation to anatomic configuration on imaging. MATERIALS AND METHODS: After IRB approval, records of 54 females who underwent transvaginal urethral diverticulectomy were retrospectively reviewed. Urinary symptoms before and after the procedure were correlated with the anatomical configuration of the UD on magnetic resonance imaging. RESULTS: The median age of the patients was 52 years (range 29-77). Common presenting symptoms were stress urinary incontinence (60%), dyspareunia (60%), and recurrent urinary tract infections (70%). The classic 3Ds were present collectively in only 5% of patients. Dyspareunia was the most common of the 3 "Ds." Twenty-seven percent of patients had none of the classic 3Ds. On physical examination, the most common finding was a tender anterior vaginal wall mass (52%). Presenting signs and symptoms did not correlate with anatomic configuration in terms of radial urethral involvement, size, or length of urethral involvement on preoperative magnetic resonance imaging. After median 14 months of follow-up, no patient reported the classic 3Ds after surgery. CONCLUSION: Recurrent urinary tract infections, stress urinary incontinence, dyspareunia, and vaginal mass are the most common presentations of UD. The classic triad "3Ds" is rarely seen in the individual patient. Preoperative anatomic configuration on imaging is not correlated with the severity or nature of presenting symptoms.

Removal of Polypropylene Sling Mesh From the Urethra: An Anatomic Technique.

OBJECTIVE: To describe a technique for removal of intraurethral mesh with minimal disruption of the periurethral anatomy. MATERIALS AND METHODS: Through a midline transvaginal approach the sling is located lateral to the urethra and divided. The medial portion of the divided sling is carefully dissected back to its entrance laterally into the urethral lumen. A stay suture is placed on the dissected sling. The sling is located on the contralateral side and likewise divided and dissected back to the urethral lumen. The completely dissected sling is pulled through such that the holding stitch is through and through the urethral lumen, allowing easy localization of the urethral defect on lateral walls of the urethra. These defects are closed with an absorbable suture and the vaginal incision is closed. RESULTS: Three patients have undergone a transvaginal removal of their intraurethral mesh using the described technique. At a mean follow-up of 6.0 months, there were no intraoperative or postoperative complications. All patients were obstructed preoperatively and all developed stress urinary incontinence postoperatively requiring 0-1 pads per day. CONCLUSION: Current approaches to the surgical repair of chronic intraurethral mesh have significant limitations that are minimized by the described technique. This anatomic removal of mesh from the urethra has several advantages including no disruption of the ventral wall of the urethra, complete removal of foreign body from the urethra, and simplified localization of the urethral wall defect to allow for anatomic closure.

Factors influencing residents' pursuit of urology fellowships.

OBJECTIVE: To assess the predictors of residents' pursuit of fellowship training by surveying current urology residents and recent graduates. Postgraduate fellowship training of urologists could be an important source of urologic physician-scientists and continued innovation in urologic care. METHODS: A Web-based survey was electronically mailed to urology residents and recent graduates of urologic residency. Variables concerning sex, marital status, debt load, research and clinical exposure, publications, and postgraduate careers were recorded. RESULTS: Of the 71 respondents, 46 (65%) were married and 45% had children/dependents. Of the 69% who applied for fellowship, the "most important" factors influencing the pursuit of fellowship were intellectual appeal (82%), mentors (79%), the desire for an additional point of view for surgical training (58%), and the desire to pursue a career in academics (52%). Forty of those completing a fellowship (87%) versus two of those completing residency alone (13%) would pursue a career in academics. Residents with a mentor were 20 times more likely to pursue a urology fellowship. A shorter residency (5 years), encouragement by a program director, and manuscript publication during residency were also independent predictors. CONCLUSION: Mentorship, a shorter residency, and manuscript publication during residency were independent predictors of pursuing fellowship training. Debt load, age, marital status, and a desire to pursue a career in academic medicine were not significant factors.

Improving lymph node yield in retroperitoneal lymph node dissection using fluorescent molecular imaging: a novel method of localizing lymph nodes in Guinea pig model.

OBJECTIVES: To propose that fluorescent molecular imaging has utility in specifically identifying the lymph nodes, thereby enabling more definitive lymph node visualization and dissection. Retroperitoneal lymph node dissection (RPLND) is an invasive procedure with significant morbidity. A minimally invasive approach would be of great clinical benefit but has been limited by the extensive perivascular dissection required to remove all lymphatic tissue. Directed lymph node visualization would allow a limited dissection, making a laparoscopic approach more feasible. METHODS: Ten male Hartley guinea pigs underwent nonsurvival RPLND, 5 with the protease activatable in vivo fluorescent molecular imaging agent, ProSense and 5 without image guidance (control). ProSense was administered 24 hours before surgery and detected 24 hours later using a photodynamic detector. In group 1, RPLND was first performed without molecular imaging followed by image-guided lymph node dissection for residual nodes. In group 2, the near infrared detector was used initially for lymph node excision followed by traditionally unassisted extraction of the residual lymph nodes. The lymph nodes were extracted, counted, and sent for histopathologic analysis. RESULTS: With the assistance of molecular imaging, no additional lymph nodes were identified after complete dissection, and all tissue identified by ProSense was confirmed by histopathologic analysis to be lymph nodes. Without molecular imaging, all lymph nodes were not identified, and in 2 instances, the tissue was incorrectly thought to be lymphatic tissue. CONCLUSIONS: Molecular image-guided RPLND is a promising technique to improve in vivo, live visualization and dissection of lymph nodes and has the potential for application in improving the diagnosis and treatment of other urologic malignancies.

Quality of life in children with vesicoureteral reflux as perceived by children and parents.

PURPOSE: Significant research has been dedicated to the management of vesicoureteral reflux (VUR). However, few studies have been published to evaluate the impact of this disease on quality of life. The aim of this study was a prospective examination of the health-related quality of life (HRQoL) in children with VUR who have either been treated medically (antibiotics or surveillance) or by ureteral reimplant (UR) using a validated patient satisfaction survey. MATERIALS AND METHODS: A prospective, longitudinal study was conducted using a validated HRQoL questionnaire, the Pediatric Quality of Life Inventory (PedsQL™ 4.0 Generic Core). 353 children or parents of children with VUR, age 2-18 years, completed the survey. Statistical analysis was performed with significance set at p-value ≤ 0.05. RESULTS: Children and parents of children with VUR did not score lower on total or subscale domains of HRQoL when compared to a historical healthy control. On univariate analysis, patients who underwent UR scored lower on total as well as physical, social, and school subscale HRQoL domains, compared to patients managed medically. When controlling for gender, ethnicity, age, reflux grade, and antibiotic use, there was no difference in total HRQoL between patients who underwent UR compared to those managed medically. CONCLUSIONS: In terms of HRQoL, VUR is a benign clinical entity and neither antibiotic use nor UR is associated with lower HRQoL. Disease-specific quality of life surveys are needed to accurately evaluate patient and parent satisfaction in the management of VUR.

Identifying ureteropelvic junction obstruction by fluorescence imaging: a comparative study of imaging modalities to assess renal function and degree of obstruction in a mouse model.

PURPOSE: Radiological imaging is the mainstay of diagnosing ureteropelvic junction obstruction. Current established radiological modalities can potentially differentiate the varying degrees of obstruction but they are limited in functionality, applicability and/or comprehensiveness. Of particular concern is that some tests require radiation, which has long-term consequences, especially in children. MATERIALS AND METHODS: We investigated the novel use of Genhance™ 680 dynamic fluorescence imaging to assess ureteropelvic junction obstruction in 20 mice that underwent partial or complete unilateral ureteral obstruction. Ultrasound, mercaptoacetyltriglycine renography, magnetic resonance imaging and fluorescence imaging were performed. RESULTS: Our model of partial and complete obstruction could be distinguished by ultrasound, mercaptoacetyltriglycine renography and magnetic resonance imaging, and was confirmed by histological analysis. Using fluorescence imaging distinct vascular and urinary parameters were identified in the partial and complete obstruction groups compared to controls. CONCLUSIONS: Fluorescence imaging is a feasible alternative radiological imaging modality to diagnose ureteropelvic junction obstruction. It provides continuous, detailed imaging without the risk of radiation exposure.

Perioperative risk factors for major complications in pediatric surgery: a study in surgical risk assessment for children.

BACKGROUND: There are numerous studies in the adult literature correlating comorbidities and pre- and intraoperative parameters with postoperative outcomes. However, there is a paucity of similar data in the pediatric population. Our goal was to elucidate which pre- and intraoperative patient characteristics in children undergoing surgery are associated with an increased risk of major complication within 30 days. STUDY DESIGN: We identified 108 children who underwent surgery at our institution between June 2005 and May 2007 and had major complication or death within 30 days of surgery. Forty-two preoperative patient characteristics and 22 intraoperative variables were evaluated. The severity of the complications was graded based on the Clavien classification system, with major complications grade III or greater. We randomly selected 723 controls who had undergone surgery within a 3-month date range of the original cohort, but did not develop complications. Statistical significance was assessed by univariate and multivariate analyses. RESULTS: Most complications were cardiovascular, occurred 1 to 3 days after surgery, and were classified as grade IIIB. We identified 5 independent risk factors on multivariate analysis: ≤36 weeks of gestation, American Society of Anesthesiologists score >3, undergoing a cardiovascular or neurosurgical procedure, and receiving an intraoperative albumin transfusion. Three scoring systems (overall, preoperative, and intraoperative complication score) were developed to provide objective risk stratification. CONCLUSIONS: We found 5 patient-specific parameters that were independent risk factors for major complications or death after pediatric surgery. Future prospective studies will help to fully stratify risk and guide interventions to improve postoperative outcomes.

Perioperative risk factors for surgical complications in pediatric urology: a pilot study in preoperative risk assessment in children.

OBJECTIVES: To elucidate which perioperative patient characteristics are associated with an increased risk of complications in pediatric urological surgery. There are numerous published studies that have correlated comorbidities, preoperative, and intraoperative parameters with postoperative outcomes in adults. However, there is a paucity of similar data in the pediatric population. METHODS: Between July 2003 and September 2006, a total of 93 children had an adverse or unexpected event within 35 days of urologic surgery. Thirty-eight preoperative patient characteristics and 20 perioperative parameters were evaluated. The severity of the complications was graded based on the Clavien classification. A total of 163 controls were randomly selected. Statistical significance was assessed by univariate and multivariate analysis. RESULTS: The overall complication rate was 1.1%. Most complications were technical in nature, occurred within 3 days after surgery, and classified as Clavien's grade 3 B. On multivariate analysis, weight less than fifth percentile, pulmonary or hematologic comorbidity, surgery duration >2 hours, first operation, low intraoperative heart rate, and the use of intravenous anesthesia were determined to be independent risk factors, whereas "other" medication was the only independent protective factor. CONCLUSIONS: We observed that some of the parameters conventionally thought to be risk factors for surgical complications such as multiple medical comorbidities, repeat operation, and American Society of Anesthesiologists' Classification of Physical Status score were not significant predictors of postoperative complications, whereas others were unexpectedly significant. Future prospective studies will be needed to fully stratify risk and guide risk interventions to improve postoperative outcomes.

Robotic-assisted laparoscopic cryo-partial nephrectomy: a novel technique using cryoablation in lieu of hilar clamping in a porcine model.

Laparoscopic and robotic-assisted partial nephrectomy has become an increasingly viable approach for the resection of renal tumors. There are several technical limitations in performing laparoscopic partial nephrectomy, the most significant being the inability to easily obtain cold ischemia which allows for an extended operative time. In this study, we evaluated the feasibility and efficacy of cryoablation as an alternative to hilar clamping to maintain hemostasis during robotic-assisted laparoscopic partial nephrectomy in a porcine model. Twelve female swine underwent nine open and eight robotic-assisted laparoscopic partial nephrectomies using modified cryoablative methods to create hemostasis. Renal perfusion imaged with indocyanine green (ICG) and histological analysis was assessed immediately after the procedure and at 3 weeks post-operatively. With two freeze/thaw cycles, all nine open and eight robotic-assisted laparoscopic partial nephrectomies were successfully completed without the need for hilar clamping. The mean blood loss for the open and robotic-assisted groups was 230.6 and 99.4 ml, respectively. In all cases, maintenance of renal perfusion was confirmed by the presence of a renal pulse and intraoperative ICG imaging immediately and 3 weeks post-operatively. The histological anatomy was well preserved in the resected segment following cryo-resection. After 21 days following cryo-resection, histological analysis demonstrated normal viable tissue with minimal scarring in the remaining kidney. The use of cryoablation created a zone of hemostasis without compromising the vascularity of the remaining kidney, while preserving the renal cytoarchitecture of the segment remove for pathological analysis. Further studies will help to delineate its usefulness in laparoscopic partial nephrectomy.

Parental satisfaction after open versus robot assisted laparoscopic pyeloplasty: results from modified Glasgow Children's Benefit Inventory Survey.

PURPOSE: Since its inception, robot assisted laparoscopic pyeloplasty has rapidly become the minimally invasive surgical intervention of choice for treating ureteropelvic junction obstruction at our institution. The large initial investment in robot assisted surgery is frequently justified by its association with improved optics and instrument articulation, decreased postoperative pain, shorter length of hospitalization and improved cosmesis. However, there are no data specifically showing patient satisfaction with robot assisted laparoscopic pyeloplasty compared to traditional open surgery. MATERIALS AND METHODS: A previously validated satisfaction survey (Glasgow Children's Benefit Inventory) with 14 additional questions specifically addressing postoperative satisfaction was mailed to all parents (as patient proxy) of children who had undergone open or robot assisted laparoscopic pyeloplasty between January 2006 and December 2008. RESULTS: A total of 78 parents responded (response rate 70%). All responses achieving statistical significance favored robot assisted laparoscopic pyeloplasty. Parents of children who underwent robot assisted laparoscopic pyeloplasty reported significantly higher satisfaction with "overall life," confidence, self-esteem, burden of postoperative followup and size of incision scar. CONCLUSIONS: Parent satisfaction was greater with robot assisted laparoscopic pyeloplasty than with open surgery regarding amount of cosmesis and recovery. Interestingly the differences in satisfaction were not as large as anticipated, suggesting the impact of confounding factors such as age and preoperative parental expectations. Future large-scale prospective studies using validated surveys specific to pediatric surgery are needed to elucidate further the true benefits of minimally invasive surgical technology such as robot assistance.

Concurrent management of bilateral ureteropelvic junction obstruction in children using robotic-assisted laparoscopic surgery.

INTRODUCTION: Bilateral ureteropelvic junction (UPJ) obstruction occurs infrequently. When surgical management is deemed necessary, staged pyeloplasties traditionally have been recommended to minimize the morbidity associated with performing procedures concurrently. With the advent of robotic-assistance, concurrent surgical management can more readily be performed laparoscopically. In this report, we evaluated the safety and outcome of managing patients with bilateral UPJ obstruction with concurrent robotic-assisted laparoscopic pyeloplasty. MATERIALS AND METHODS: We performed a retrospective review of five patients with bilateral ureteropelvic junction obstruction who underwent concurrent bilateral robotic-assisted pyeloplasties at our institution between October 2003 and April 2007. Technical consideration for patient positioning, robotic set-up, port placement, and the use of a hitch stitches was assessed. The operative time, complications, analgesic needs, length of hospitalization, and overall success of the procedure were evaluated. RESULTS: Operative time ranged from 235 to 541 minutes (mean = 384). Estimated blood loss was 5-100 cc (mean = 48.0). Length of hospitalization ranged from 1.3 to 3.6 days (mean = 2.4). Ureteral stents were removed 3-8 weeks postoperatively. There were no complications. All kidneys demonstrated decreased hydronephrosis on postoperative ultrasound or improved drainage parameters on diuretic renography or IVP. CONCLUSIONS: Simultaneous bilateral robotic-assisted laparoscopic pyeloplasties utilizing 4-port access is feasible and safe. It provides an effective method of managing patients with bilateral UPJ obstruction, avoiding the burden and morbidity of performing staged surgeries.

Cohen cross-trigonal ureteral reimplantation: is a one-year postoperative renal ultrasound scan necessary after normal initial postoperative ultrasound findings?

OBJECTIVES: To determine the utility of the 1-year postoperative renal ultrasound scan in children undergoing uncomplicated Cohen cross-trigonal ureteral reimplantation. METHODS: A retrospective review of 108 patients (233 ureters) who had undergone uncomplicated Cohen cross-trigonal ureteral reimplantation during a 6.5-year period with a postoperative follow-up of 1 year was performed. Renal ultrasound scans were obtained at 1 month and 1 year postoperatively. RESULTS: Of the 108 patients who had undergone ureteral reimplantation, 26 patients (24%) had mild to moderate hydronephrosis at 1 month postoperatively. Of these 26 patients, 20 had preexisting hydronephrosis and 6 had new hydronephrosis. Of the 20 patients with preoperative hydronephrosis, 19 (95%) had similar hydronephrosis on the 1-month postoperative ultrasound scan and in 1 (5%), the hydronephrosis had resolved. At 1 year, 13 (69%) of the 20 patients with preoperative hydronephrosis had stable hydronephrosis, and it resolved in 6 (31%). In the 6 patients with new-onset hydronephrosis at 1 month postoperatively, the hydronephrosis had resolved by 1 year in 4 patients (67%) and was mild in 2 (33%). Three patients developed transient obstruction requiring stent placement. CONCLUSIONS: It has been recommended that a renal ultrasound scan be obtained in children 1 year after open ureteral reimplantation to rule out delayed obstruction. Our results suggest this is of low yield in patients with uncomplicated open ureteral reimplantation.

Concurrent management of bilateral ureteropelvic junction obstruction in children using robotic-assisted laparoscopic surgery

INTRODUCTION: Bilateral ureteropelvic junction (UPJ) obstruction occurs infrequently. When surgical management is deemed necessary, staged pyeloplasties traditionally have been recommended to minimize the morbidity associated with performing procedures concurrently. With the advent of robotic-assistance, concurrent surgical management can more readily be performed laparoscopically. In this report, we evaluated the safety and outcome of managing patients with bilateral UPJ obstruction with concurrent robotic-assisted laparoscopic pyeloplasty. MATERIALS AND METHODS: We performed a retrospective review of five patients with bilateral ureteropelvic junction obstruction who underwent concurrent bilateral robotic-assisted pyeloplasties at our institution between October 2003 and April 2007. Technical consideration for patient positioning, robotic set-up, port placement, and the use of a hitch stitches was assessed. The operative time, complications, analgesic needs, length of hospitalization, and overall success of the procedure were evaluated. RESULTS: Operative time ranged from 235 to 541 minutes (mean = 384). Estimated blood loss was 5-100 cc (mean = 48.0). Length of hospitalization ranged from 1.3 to 3.6 days (mean = 2.4). Ureteral stents were removed 3-8 weeks postoperatively. There were no complications. All kidneys demonstrated decreased hydronephrosis on postoperative ultrasound or improved drainage parameters on diuretic renography or IVP. CONCLUSIONS: Simultaneous bilateral robotic-assisted laparoscopic pyeloplasties utilizing 4-port access is feasible and safe. It provides an effective method of managing patients with bilateral UPJ obstruction, avoiding the burden and morbidity of performing staged surgeries.