Intraurethral catheter placement does not change the external circumferential measurement of the urethra during AUS placement: A prospective observational trial.

AIMS: Measuring the urethral circumference accurately during artificial urethral sphincter (AUS) placement is an important technical aspect to optimize the selection of cuff size. Differing methods exist for this step with some experts recommending measurement with no urethral catheter in place. In this prospective observational trial, we compared urethral measurements with and without an indwelling catheter to determine if the presence of a catheter affects the circumferential measurement. METHODS: With IRB approval, we prospectively collected data on consecutive cases of transperineal male AUS implantation. Urethral circumference was measured with no urethral catheter (0 French [Fr]), 12Fr, and 16Fr Foley catheters in the urethra. The final measurements and cuff size chosen were recorded. A comparison was made between each measurement using Spearman's correlation coefficient. RESULTS: A total of 54 patients were included, the majority of whom (92.6%) underwent AUS placement for postprostatectomy incontinence. The three urethral circumference measurements were highly correlated (0Fr vs 12Fr, ρ = 0.96, P < .001, mean difference 1 mm) (0Fr vs 16Fr, ρ = 0.94, P < .001, mean difference 2 mm) (12Fr vs 16Fr, ρ = 0.96, P < .001, mean difference 1 mm). Patients with a history of radiation had a lower mean urethral circumference than those who had never been radiated (4.78 cm vs 5.3 cm, P = .01). CONCLUSIONS: Urethral circumference measurement during AUS implantation is not influenced by the presence of a 12 or 16Fr Foley catheter when compared to no catheter in the urethra. Measurement of the urethral circumference can, therefore, be accurately performed with or without a catheter in place, depending on the surgeon's preference.

Penile Melanoma In Situ: Long Term Follow Up.

Penile melanoma in situ is extremely rare. Various treatments have been reported with good success, however follow up is generally limited to 1 year or less. The optimal treatment regimen, pattern of disease progression and utility of sentinel lymph node biopsy are not established. We provide the longest reported follow up for penile malignant melanoma in-situ, highlighting a long-term pattern of recurrence and a route of progression which does not follow more reliable patterns of lymphatic spread known to penile squamous cell carcinoma. A cautious approach should be taken for organ-sparing approaches along with proper patient counseling and close, long-term follow-up.

Contemporary analysis of management of isolated pendulous urethral strictures using pedicled skin flap urethroplasty repair.

OBJECTIVES: To evaluate contemporary outcomes of urethroplasty employing a pedicled skin flap for isolated pendulous urethral strictures. SUBJECTS/PATIENTS: Inclusion of males > 18 years of age with isolated pendulous urethral strictures treated between 1996 and 2012. RESULTS: A total of 81 patients with isolated pendulous urethral stricture were identified. Twenty-eight patients underwent repair with a pedicled skin flap during the study period. The median age of the patients treated with a pedicled skin flap was 47 years old (range 21-74). The etiology of the strictures was considered to be idiopathic in 10 patients (35.7%), iatrogenic in 9 patients (32.1%), as a complication of prior hypospadias repair in 6 patients (21.4%), infectious in 2 patients (7.1%), and traumatic in 1 patient (3.6%). The median follow-up was 27 months (range 1-214). Urethroplasty success was noted in 19/21 patients (90.5%). Urethral stricture recurrence occurred in 2 of the 21 patients (9.5%). CONCLUSIONS: The pedicled skin flap repair for pendulous urethral strictures remains a durable and safe technique in patients without LS.

Short-term Complication Rates Following Anterior Urethroplasty: An Analysis of National Surgical Quality Improvement Program Data.

OBJECTIVE: To determine the characteristics and predictors of perioperative complications after male anterior urethroplasty. MATERIALS AND METHODS: The American College of Surgeons-National Surgical Quality Improvement Program is a validated outcomes-based program comprising academic and community hospitals in the United States and Canada. Data from 2007 to 2015 were queried for single-stage anterior urethroplasty using Current Procedure Terminology codes. The primary outcome was frequency of complications within the 30-day postoperative period. Preoperative and intraoperative parameters were correlated with morbidity measures, and univariate and multivariate regression analyses were used. RESULTS: A total of 555 patients underwent anterior urethroplasty, of whom 180 (32.4%) had graft or flap placement. Of the patients, 127 (22.9%) went home the same day after surgery, 255 (45.9%) stayed for 1 night, and 173 (31.2%) stayed for 2 or more nights. No deaths, cardiovascular complications, or sepsis were noted. Forty-seven patients (8.5%) had complications in the 30-day period. The most common complications were infection (57.4%), readmission (42.9%), and return to the operating room (17%). On univariate analysis, patients who had substitution urethroplasty (P = .04) and longer operative times (P = .002) were more likely to have complications, but only longer operative time showed significance on multivariate analysis (P = .006). Age, American Society of Anesthesiologists score, and length of stay were not predictive of complication frequency. CONCLUSION: Anterior urethroplasty has low postoperative morbidity. Longer operative times were associated with increased rate of complications. Longer hospital stay after surgery is not protective against perioperative complications.

Discharge Plans for Geriatric Inpatients with Delirium: A Plan to Stop Antipsychotics?

BACKGROUND: Studies show inpatient geriatric patients with reversible conditions like delirium may continue on antipsychotic medications without clear indications after hospital discharge. We conducted this study to determine how often geriatric patients were discharged on a newly started antipsychotic during admission with a plan for discontinuation of the antipsychotic documented in the discharge summary. DESIGN: We conducted retrospective chart review identifying geriatric inpatients in our health system started on a new antipsychotic during admission. In patients discharged from the hospital on a new antipsychotic, we examined the discharge summary for a discontinuation treatment plan. RESULTS: Of 487 patients started on a new antipsychotic, 147 (30.2%) were discharged on the antipsychotic. Of those, 121 (82.3%) had a diagnosis of delirium. Discharge summaries of 15 (12.4%) patients discharged on an antipsychotic with a diagnosis of delirium included instructions for discontinuation of the antipsychotic. Of those patients discharged with instructions for discontinuation, 12 (80%) received a psychiatric or geriatric medicine consult. CONCLUSION: In our health system, the majority of geriatric patients with delirium, discharged on a new antipsychotic had no instructions outlined to outpatient providers for discontinuation management. Further interventions could target increasing antipsychotic guidance at transitions of care.

How Can We Effectively Address the Medical and Psychological Concerns of Survivors of Pelvic Malignancies?

Sexual and urinary morbidities resulting from treatment of pelvic malignancies are common. These treatment sequelae are significantly bothersome to patients and challenging to address. Awareness of these complications is critical in order to properly counsel patients regarding potential side effects and to facilitate prompt diagnosis and management. Addressing these issues often necessitates a coordinated multidisciplinary approach; however, the effort required often translates into improvement in patient quality of life. Herein we review the sexual and urinary side effects that may arise during or after treatment of pelvic malignancies.

Risk Factors Associated With Recurrent Urinary Tract Infection in Neurogenic Bladders Managed by Clean Intermittent Catheterization.

OBJECTIVE: To identify risk factors for recurrent urinary tract infection (UTI) in patients who perform clean intermittent catheterization (CIC). METHODS: A 6-year retrospective chart review of patients with spina bifida or tethered cord who perform clean intermittent catheterization (8 months to 58 years) was conducted. A strict case definition for UTI was applied, and per-subject UTI events, demographic, and clinical data were abstracted. Data were compared between groups defined by no or infrequent UTI (≤1.0 UTI/study year) and frequent UTI (>1.0 UTI/study year). RESULTS: Of 194 total patients, 146 (75%) had no UTIs or infrequent UTIs, and 48 (25%) patients had frequent UTIs. On univariate analysis, only younger age and suprasacral cord lesions were associated with frequent UTIs (P = .002 and P = .007, respectively). Among the 128 patients with urodynamic studies, bladder capacity, compliance, detrusor overactivity, and detrusor leak point pressure were not associated with frequent UTI on univariate analysis. On multivariate analysis, increasing age was found to be associated with decreased odds of UTI by 7% per year (odds ratio 0.93, P = .016). CONCLUSION: The risk of UTI among individuals with spina bifida or tethered cord declines with increasing age. Bladder function based on urodynamic parameters did not correlate with frequent UTIs.

Effect of Lichen Sclerosis on Success of Urethroplasty.

Lichen sclerosis (LS) is a chronic, relapsing disease with a variable presentation. In men, genitourinary LS may affect the penile foreskin, glans, meatus, and urethra. Treatment is multifaceted, ranging from pharmacotherapy to surgery. Urethral reconstruction due to stricture disease from LS is frequently plagued by a high recurrence rate. At the authors' institution, the high recurrence rate has shifted their practice toward potent steroids and minimally invasive surgical techniques. Management of recurrence includes dilation, meatotomy/meatoplasty, 1-stage and 2-stage repairs. Recalcitrant cases may necessitate abandonment of most of the urethra resulting in a perineal urethrostomy.

Efficacy of Fluoroquinolone/Probiotic Combination Therapy for Recurrent Urinary Tract Infection in Children: A Retrospective Analysis.

PURPOSE: Children with normal urinary tract anatomy and function and highly recurrent urinary tract infection (rUTI) may have a lack of alternatives when antibiotic prophylaxis and "watchful waiting" approaches fail. This retrospective review reports the outcomes in children who received a fluoroquinolone/probiotic combination in an attempt to quantify a reduction in rUTI that was perceived by both clinicians and patients' families. METHODS: Data from all children with rUTIs previously managed with a fluoroquinolone/probiotic combination at the Pediatric Infectious Diseases Clinic at Duke University Medical Center (Durham, North Carolina) were identified and analyzed. FINDINGS: Data from 10 children were eligible for inclusion. Compared with before therapy initiation, total UTI episodes were significantly fewer after therapy initiation (57 vs 4; P = 0.0001). Seven (70%) were free of rUTIs during the follow-up period. Of the 8 patients with known compliance, 7 (88%) were free of rUTIs. IMPLICATIONS: Given the chronic nature of these patients' symptoms, the significant decrease in UTI after the initiation of therapy, and the increase in the interval without an infection and/or its symptoms, this treatment regimen has the potential to improve overall quality of life, decrease antibiotic courses, and decrease health care costs in children with rUTI. These results will be validated with a larger cohort of patients in a prospective, randomized trial.

Long-term Artificial Urinary Sphincter Outcomes Following a Prior Rectourethral Fistula Repair.

OBJECTIVE: To determine the long-term outcomes of artificial urinary sphincter (AUS) implantation following a successful rectourethral fistula (RUF) repair. MATERIALS AND METHODS: Between January 1, 2006 and January 1, 2012, a total of 26 patients underwent successful repair of an RUF. Stress urinary incontinence was treated in 6 patients (23%) with implantation of an AUS. Preoperative and postoperative evaluation included demographic variables, voiding diaries, 24-hour pad weight, urodynamic characteristics, operative time, estimated blood loss, complication rates, follow-up time, and cuff selection. RESULTS: All 6 patients underwent successful RUF repair using a perineal approach. Mean age was 64.3 years (range 58-74). Mean follow-up after repair was 51.5 months (range 34-64). RUF etiology included radical prostatectomy (4), brachytherapy + external beam radiotherapy (1), and cryotherapy + external beam radiotherapy (1). The median time between RUF repair and AUS placement was 12 months (range 2-41). No intraoperative complications occurred during AUS implantation. The average operative time was 61.8 minutes with an estimated blood loss of 24 mL. The initial cuff size selected was 4.0 or 4.5 cm, and no patient required transcorporal cuff placement. Pad use was reported as ≤1 pad per day in all 6 patients at the initial 3-month follow-up. Median follow-up after AUS placement was 43.5 months (5-55). No patient required revision or removal for mechanical complications, infection, or erosion. No patient had recurrence of their previously repaired RUF or new-onset fecal incontinence. CONCLUSION: Patients who require placement of an AUS after an RUF repair seem to fare just as well as patients who undergo primary AUS implantation with no increased rate of complications postoperatively.

Resolution rate of isolated low-grade hydronephrosis diagnosed within the first year of life.

OBJECTIVE: Diagnosis of low-grade hydronephrosis often occurs prenatally, during evaluation after urinary tract infection (UTI), or imaging for non-urologic reasons within the first year of life. Its significance in terms of resolution, need for antibiotic prophylaxis, or progression to surgery remains uncertain. We hypothesized that isolated low-grade hydronephrosis in this population frequently resolves, UTIs are infrequent, and progression to surgical intervention is minimal. PATIENTS AND METHODS: Children < 12 months old diagnosed hydronephrosis (Society for Fetal Urology [SFU] grade 1 or 2) between January 2004 and December 2009 were identified by ICD9 code. Patients with other urological abnormalities were excluded. Stability of hydronephrosis, UTI (≥ 100,000 CFU/mL bacterial growth) or need for surgical intervention was noted. RESULTS: Of 1496 infants with hydronephrosis, 416 (623 renal units) met inclusion criteria. Of 398 renal units with grade 1 hydronephrosis, 385 (96.7%) resolved or remained stable. Only 13 (3.3%) worsened, of which one underwent ureteroneocystostomy. Of 225 renal units with grade 2 hydronephrosis, 222 (98.7%) resolved, improved or remained stable, three (1.3%) worsened, of which one required pyeloplasty. Only 0.7% of patients in the ambulatory setting had a febrile UTI. CONCLUSIONS: Low-grade hydronephrosis diagnosed within the first year of life remains stable or improves in 97.4% of renal units. Given the low rate of recurrent UTI in the ambulatory setting, antibiotic prophylaxis has a limited role in management.

Evaluation of cold ischemia for preservation of testicular function during partial orchiectomy in the rat model.

OBJECTIVE: We hypothesized that cold ischemia during partial orchiectomy would lead to higher serum testosterone levels and preservation of testicular architecture than warm ischemia in a prepubescent rat model. MATERIALS AND METHODS: Eighteen prepubescent male Sprague-Dawley rats were randomized to three different surgical groups: sham surgery, bilateral partial orchiectomy with 30 min of cord compression with cold ischemia, or bilateral partial orchiectomy with 30 min of cord compression with warm ischemia. Animals were killed at puberty, and serum, sperm, and testicles were collected. Histological tissue injury was graded by standardized methodology. RESULTS: Mean serum testosterone levels were 1445 ± 590 pg/mL for the sham group, 449 ± 268 pg/mL for the cold ischemia group and 879 ± 631 pg/mL for the warm ischemia group (p = 0.12). Mean sperm counts were 2.1 × 10(7) for sham, 4.4 × 10(6) for cold ischemia, and 9.9 × 10(6) for the warm ischemia groups (p = 0.48). Histological evaluation revealed significant difference in tissue injury grading with more injury in the cold ischemia than in the warm ischemia group (p = 0.01). CONCLUSIONS: In our preclinical rat model, we found no benefit for cold ischemia over warm ischemia at 30 min.

Inflammatory response to Escherichia coli urinary tract infection in the neurogenic bladder of the spinal cord injured host.

PURPOSE: Urinary tract infections cause significant morbidity in patients with spinal cord injury. An in vivo spinal cord injured rat model of experimental Escherichia coli urinary tract infection mimics human disease with enhanced susceptibility to urinary tract infection compared to controls. We hypothesized that a dysregulated inflammatory response contributes to enhanced susceptibility to urinary tract infection. MATERIALS AND METHODS: Spinal cord injured and sham injured rats were inoculated transurethrally with E. coli. Transcript levels of 84 inflammatory pathway genes were measured in bladder tissue of each group before infection, 24 hours after infection and after 5 days of antibiotic therapy. RESULTS: Before infection quantitative polymerase chain reaction array revealed greater than twofold up-regulation in the proinflammatory factor transcripts slc11a1, ccl4 and il1ß, and down-regulation of the antimicrobial peptides lcn2 and mpo in spinal cord injured vs control bladders. At 24 hours after infection spinal cord injured bladders showed an attenuated innate immune response with decreased expression of il6, slc11a1, il1ß and lcn2, and decreased il10 and slpi expression compared to controls. Despite clearance of bacteriuria with antibiotics spinal cord injured rats had delayed induction of il6 transcription and a delayed anti-inflammatory response with decreased il10 and slpi transcript levels relative to controls. CONCLUSIONS: Spinal cord injured bladders fail to mount a characteristic inflammatory response to E. coli infection and cannot suppress inflammation after infection is eliminated. This may lead to increased susceptibility to urinary tract infection and persistent chronic inflammation through neural mediated pathways, which to our knowledge remain to be defined.

Variation in definitions of urinary tract infections in spina bifida patients: a systematic review.

OBJECTIVE: Urinary tract infections (UTIs) are a common source of morbidity among children with spina bifida (SB) and are a frequently reported outcome in studies of this patient population. However, the criteria for a diagnosis of UTI are often not stated. We evaluated the literature on SB patients for the criteria that authors use to define parameters in reporting UTI outcomes. METHODS: Embase and Medline were queried with the medical subject heading terms "spinal dysraphism," "myelomeningocele," "infection,"and "urinary tract infection." A second search with the exploded term"spina bifida" and "urinary tract infection" was performed. Original research studies reporting a UTI outcome in SB patients were included and evaluated by 2 independent reviewers for the presence of a UTI definition and diagnostic criteria. RESULTS: We identified 872 publications, of which 124 met inclusion criteria. Forty-five of 124 (36.3%) studies reporting UTI as an outcome provided a definition of UTI. Of 124 studies, 28 (22.6%) were published in pediatric journals and 69 (55.6%) in urology journals. A definition of UTI was provided in 11 (39.3%) and 26 (37.7%) studies, respectively. "Fever,culture, and symptoms" defined a UTI in 17 of 45 studies. Journal category and presence of UTI definitions did not correlate (P = .71). CONCLUSIONS: Explicit definitions for UTI are heterogeneous and infrequently applied in studies of SB patients, limiting study reliability and estimates of true UTI rates in this population. Future studies will benefit from the development and application of a standard definition for UTI in this population.

The Publication Ranking Score for pediatric urology: quantifying thought leadership within the subspecialty.

OBJECTIVES: Clinical care parameters are frequently assessed by national ranking systems. However, these rankings do little to comment on institutions' academic contributions. The Publication Ranking Score (PRS) was developed to allow for objective comparisons of scientific thought-leadership at various pediatric urology institutions. METHODS: Faculty lists were compiled for each of the US News & World Report (USNWR) top-50 pediatric urology hospitals. A list of all faculty publications (2006-2011) was then compiled, after adjusting for journal impact factor, and summed to derive a Publication Ranking Score (PRS). PRS rankings were then compared to the USNWR pediatric urology top-50 hospital list. RESULTS: A total of 1811 publications were indexed. PRS rankings resulted in a mean change in rank of 12 positions, compared to USNWR ranks. Of the top-10 USNWR hospitals, only 4 were ranked in the top-10 by the PRS. There was little correlation between the USNWR and PRS ranks for either top-10 (r = 0.42, p = 0.23) or top-50 (r = 0.48, p = 0.0004) hospitals. CONCLUSIONS: PRS institutional ranking differs significantly from the USNWR top-50 hospital list in pediatric urology. While not a replacement, we believe the PRS to be a useful adjunct to the USNWR rankings of pediatric urology hospitals.

Reviewing definitions of urinary continence in the contemporary spina bifida literature: a call for clarity.

BACKGROUND: Urinary continence is a common goal for children with spina bifida and their physicians. However, definitions of urinary continence vary widely across published studies. We systematically assessed the utilization of common definitions of urinary continence in the spina bifida literature. METHODS: We searched library databases for reports (2000-2012) describing urinary continence outcomes in children with spina bifida. We assessed various patient-level factors such as age, lesion level, surgical history, and use of additional therapies, as well as study-level factors such as study design, country of origin, continence definition(s), and method of data collection. RESULTS: Of 473 identified articles, 105 met inclusion criteria, comprising a total of 3209 patients. Of these, 1791 patients (56%) were deemed continent by the study authors. Only 60 studies (57%) clearly defined what they considered to be "continent". The most common definition, used in 24% of all reports, was "always dry". There was no association between journal of publication (p = 0.13), publication year (p = 0.86), study size (p = 0.26), or study country (p = 0.43) and likelihood of a continence definition being included in the manuscript. CONCLUSIONS: The most frequent definition of urinary continence in the spina bifida literature is "always dry". However, definitions were highly variable, and many authors did not define continence at all. Clinicians and researchers alike would be better able to apply research findings toward improving patient care if continence definitions were more explicitly reported and less variable.

Partial orchiectomy for bilateral synchronous testicular masses in a prepubescent boy: a case report.

Testicular masses in prepubescent children are typically benign. Most masses are mature teratomas, epidermoid cysts, and stromal tumors. Synchronous bilateral testicular masses in children are rare. The etiology of these includes synchronous primary testicular masses, lymphoma, leukemia, and adrenocortical rest hyperplasia. Partial orchiectomy, or testis-sparing surgery, is now preferred in the management of testicular masses deemed to be benign. We present a case of benign bilateral testicular masses managed with testis-sparing surgery. Six-month follow-up revealed no residual tumor, normal contour of the testes, and no evidence of atrophy.

Cross-sectional evaluation of parental decision making factors for vesicoureteral reflux management in children.

PURPOSE: Parental decision making in children with vesicoureteral reflux has potentially become more complex with the evolution of ethnic diversity in the United States, the Internet, the publication of contradictory clinical data and the emergence of minimally invasive surgery. We performed a cross-sectional study of parental management for pediatric vesicoureteral reflux. MATERIALS AND METHODS: We administered a 26-item questionnaire to parents of children with vesicoureteral reflux seen at Texas Children's Hospital urology offices or undergoing antireflux surgery at that institution. Univariate and multivariate analysis was done on patient disease characteristics, demographics, predicted reflux duration, surgery success rate, antibiotic cessation, complication risk, financial considerations, urologist recommendations, Internet information, friend recommendations, and postoperative voiding cystourethrography, renal ultrasound and recovery. RESULTS: Enrolled in the study were 15 boys and 49 girls with a mean age of 3.5 years and a mean reflux grade of 2.8. Of the cases 37 were bilateral. Parents chose endoscopic treatment in 38 children, open ureteroneocystostomy in 9, antibiotic prophylaxis in 14 and observation without antibiotics in 3. Univariate analysis suggested that Hispanic parents rated ultrasound and financial considerations as more important than white parents (p <0.05). Multivariate analysis revealed that differences seen on univariate analysis may have been due to an association between race and income. Finally, 93.6% of parents rated urologist opinion as very or extremely important. CONCLUSIONS: Data indicate that the parents of our patients highly value the opinion of the pediatric urologist when choosing treatment for their children with vesicoureteral reflux. Despite social changes the physician-parental relationship remains critical. Differences in parental decision making may be linked to associations between race and income.

Factors associated with delayed treatment of acute testicular torsion-do demographics or interhospital transfer matter?

PURPOSE: Testicular torsion is a true urological emergency. We determined whether a delay in treatment due to hospital transfer or socioeconomic factors would impact the orchiectomy rate in children with this condition. MATERIALS AND METHODS: We retrospectively evaluated the records of boys seen at a single institution emergency department who proceeded to surgery for a diagnosis of acute testicular torsion from 2003 to 2008. Charts were reviewed for transfer status, symptom duration, race, insurance presence or absence and distance from the hospital. Orchiectomy specimens were evaluated for histological confirmation of nonviability. RESULTS: We reviewed 97 records. The orchiectomy rate in patients who were vs were not transferred to the emergency department was 47.8% vs 68.9%, respectively (p = 0.07). Symptom duration was greater in the orchiectomy group with a mean difference of 47.9 hours (p <0.01). The mean transfer delay was 1 hour 15 minutes longer in the orchiectomy group (p = 0.01). Boys who underwent orchiectomy were 2.2 years younger than those who avoided orchiectomy (p = 0.01). Multivariate analysis showed that symptom duration and distance from the hospital were the strongest predictors of orchiectomy. CONCLUSIONS: Data suggest that torsion is a time dependent event and factors that delay time to treatment lead to poorer outcomes. These factors include distance from the hospital and the time delay associated with hospital transfer.