Impact of perioperative anticoagulation on artificial urinary sphincter device survival.

OBJECTIVE: The aim of this study was to evaluate the impact of perioperative anticoagulation on artificial urinary sphincter (AUS) device outcomes. METHODS: Following institutional review board approval, patients undergoing AUS surgery from 1983 to 2014 were evaluated to assess device survival in patients with warfarin use compared to individuals without warfarin use. Hazard regression analysis was used to determine the association between warfarin use and device outcomes. RESULTS: From 1983 to 2014, there were 2125 AUS procedures at Mayo Clinic. Of these, information regarding anticoagulation use was available in 651, including 43 patients who were on warfarin and 608 who were not. On univariate analysis, the use of warfarin was associated with an increased rate of infection/erosion [hazard ratio (HR) 2.58, p = 0.02]. However, there was no increased risk of overall AUS failure (HR 1.66, p = 0.06), malfunction of AUS (HR 1.19, p = 0.74) or urethral atrophy (HR 1.09, p = 0.88). Kaplan-Meier assessment of device survival for individuals not on warfarin versus individuals on warfarin at 1 and 5 years was 91% versus 83% and 72% versus 57%, respectively (p = 0.058). On multivariate analysis, warfarin was not associated with an increased risk of infection/erosion (HR 1.37, p = 0.51). CONCLUSION: Perioperative management of AUS patients on warfarin requires expert care; however, long-term AUS device survival is not significantly affected by warfarin use. Recognition of these outcomes is important for improving preoperative patient counseling and surgical patient selection.

Outcomes of Holmium Laser Enucleation of the Prostate in the Re-Treatment Setting.

PURPOSE: Holmium laser enucleation of the prostate can also be applied in the re-treatment setting when other benign prostatic hyperplasia therapies fail. We compared outcomes in men who underwent holmium laser enucleation of the prostate in the primary vs the re-treatment setting. MATERIALS AND METHODS: We retrospectively reviewed the records of 2,242 patients who underwent holmium laser enucleation of the prostate at a total of 4 academic hospitals between 2003 and 2015. Patient demographics, and operative and perioperative outcomes were compared between re-treatment and primary holmium laser enucleation of the prostate. RESULTS: Of the 360 of 2,242 men (16%) who underwent re-treatment holmium laser enucleation of the prostate the procedure was done for residual urinary symptoms in 71%. The most common primary procedure was transurethral resection of the prostate in 42% of cases. Mean time between prior benign prostatic hyperplasia surgery and re-treatment was 68 months (range 1 to 444). There were no significant differences in age, prostate size, AUA (American Urological Association) symptom score or average flow rate between the cohorts. Perioperatively, re-treatment holmium laser enucleation of the prostate was associated with significantly shorter operative time, reduced blood loss, lower specimen weight and shorter length of stay. The AUA symptom score improved in both groups, although it remained higher in men who underwent re-treatment (6.5 vs 5.0, p <0.001). The likelihood of clot retention (4.7% vs 1.8%, p = 0.01) and urethral stricture (3.3% vs 1.5%, p = 0.043) was slightly higher in the re-treatment group. CONCLUSIONS: Immediate perioperative outcomes of holmium laser enucleation of the prostate performed in the re-treatment setting were no different from those in the primary setting. While re-treatment was associated with an increased likelihood of clot retention, urethral stricture and higher AUA symptom score, these minimal differences must be considered against the overall favorable symptom improvement across both cohorts.

Outcomes Following Radical Cystectomy for Plasmacytoid Urothelial Carcinoma: Defining the Need for Improved Local Cancer Control.

OBJECTIVE: To evaluate oncological outcomes after radical cystectomy (RC) in patients with plasmacytoid urothelial carcinoma (UC) and to compare survival to that in patients with pure UC of the bladder. MATERIALS AND METHODS: We identified 46 patients with plasmacytoid UC and 972 with pure UC who were treated with RC between 1980 and 2009. All pathologic specimens were re-reviewed by a single GU pathologist. Patients were matched 1:2 by age, gender, Eastern Cooperative Oncology Group performance status, pathologic tumor stage, and nodal status to patients with pure UC. Survival was estimated using the Kaplan-Meier method and compared with the log rank test. RESULTS: Patients with plasmacytoid UC were more likely to have extravesical disease (≥pT3) (83% vs 43%, P < .0001) and positive margins (31% vs 2.1%, P < .0001) than patients with pure UC. Plasmacytoid UC was associated with decreased overall survival (27% vs 45% at 5 years, relative risk [RR] 1.4, P = .04), cancer-specific survival (36% vs 57% at 5 years, RR 1.7, P = .01), and local recurrence-free survival (63% vs 81% at 5 years, RR 2, P = .01). When patients with plasmacytoid UC were matched to those with pure UC, there were no significant differences in 5-year overall, cancer-specific, and local or distant recurrence-free survival. CONCLUSION: Plasmacytoid UC is associated with a high rate of locally advanced disease and positive margins at RC, as well as increased local recurrence rates. Further research is necessary to delineate adjuvant or neoadjuvant treatment strategies to improve local cancer control of this rare subtype of UC.

Outcomes of Surgical Management in Patients with Stress Urinary Incontinence and/or Neovesicovaginal Fistula after Orthotopic Neobladder Diversion.

PURPOSE: To our knowledge there are no guidelines for the evaluation and management of incontinence in women with an orthotopic neobladder. We propose a treatment algorithm based on our experience with treating this patient population. MATERIALS AND METHODS: We identified women in whom orthotopic neobladder diversion and surgery for incontinence were performed from January 1, 1995 to January 1, 2014. Charts were reviewed for management, outcomes and complications within 30 days of surgery. RESULTS: At this institution 12 women with orthotopic neobladder diversion were treated with surgery for incontinence between 1995 and 2014. Six women (50%) had an undiagnosed neovesicovaginal fistula, of whom 3 (50%) underwent successful fistula repair. A total of 12 bulking agent injections were performed in 6 women (50%). The outcomes were continued dryness after 1 injection (8%), transient improvement after 9 (75%), immediate failure after 1 (8%) and secondary fistula development after 1 (8%). Four transobturator slings and 4 pubovaginal slings were placed in a total of 6 patients (50%), of whom 1 (17%) was dry and 1 (17%) was improved. At a median followup of 22.9 months (IQR 11.1-46.4) 6 women (50%) were dry or improved and 6 (50%) had no improvement in leakage. Of the 6 (50%) women who were dry or improved 2 (17%) achieved planned intermittent catheterization after surgery and 2 (17%) underwent ileal conduit conversion. CONCLUSIONS: Bulking agents have low long-term efficacy and carry the risk of fistula formation. The efficacy of tension-free sling placement is low and continence requires an obstructing sling. Counseling should include acceptance of multiple procedures, which may be necessary to achieve continence, and consideration of conduit diversion.

Endoscopic Management of Urolithiasis in the Horseshoe Kidney.

OBJECTIVE: To assess the endourologic outcomes of patients diagnosed with a horseshoe kidney (HK) and symptomatic urolithiasis. METHODS: A retrospective review was performed of patients diagnosed with an HK who underwent endoscopic management from 2002 to present. RESULTS: We identified 45 patients with 64 stone-bearing moieties who underwent 56 procedures, of which 31 (69%) were male. Mean age was 49.4 years (23-78) and mean stone size was 1.6 cm (0.2-5.7). Of the 64 moieties, 37 (58%) underwent percutaneous nephrolithotomy (PCNL), 25 (39%) underwent ureteroscopy (URS), and 2 (3%) underwent extracorporal shockwave lithotripsy (SWL). More than one access was utilized in 2 (5.7%) moieties undergoing PCNL. Additional procedures were required in 10 (28.5%) PCNL patients, of which 7 were URS, 2 were secondary PCNL, and 1 sandwich therapy with SWL and PCNL. Stone-free rate by moiety was 81.1% for PCNL, 84% for URS, and 50% for SWL. Postoperative complications occurred in 3 patients in the PCNL group, including readmission for pain and complicated urinary tract infection. With a mean follow-up of 20.5 months (range 0-118 months), stone recurrence was noted in 7 (16%) patients with a total of 11 events. Calcium oxalate was the most common stone type and 20/24 (83%) of patients with metabolic evaluations were found to have at least one abnormality. CONCLUSION: After careful consideration of the anatomy, individuals with HK and symptomatic urolithiasis can be managed safely by a variety of endoscopic approaches with excellent outcomes; however, secondary procedures and recurrence are common.