Decisional regret and impacts on quality of life following genitourinary reconstruction for neurogenic bladder: A comparison between acquired and congenital spinal cord injury.

INTRODUCTION: Patient expectations and baseline health are important drivers of outcomes following major genitourinary reconstructive surgery for neurogenic bladder (NGB). Differences in expectations and quality of life (QoL) improvements among different populations with NGB remain insufficiently explored in the literature. OBJECTIVE: To compare decisional regret (DR) and urinary-related QoL (UrQoL) in patients undergoing urinary diversion for NGB arising from spinal cord injury of acquired (A-SCI) and congenital (C-SCI) etiologies. We hypothesize that patients with A-SCI have higher expectations of improvement in QoL following surgery when compared with C-SCI, which may lead to higher DR and decreased UrQoL, postoperatively. DESIGN: In this cross-sectional survey study, we compared A-SCI to C-SCI in terms of DR, UrQoL, and postoperative changes in self-reported physical health, mental health, and pain using validated patient-reported outcome measures. SETTING: Participants were enrolled from a quaternary care institution via mail and MyChart. PARTICIPANTS: The A-SCI group consistied of 17 patients with traumatic spinal cord injury the C-SCI group was composed of 20 patients with spina bifida. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Decisional Regret Scale, Short form- Qualiveen (SF-Qualiveen), and Patient-reported outcomes measurement Information system-10 (PROMIS-10) Global Health surveys. RESULTS: The A-SCI group displayed poorer preoperative physical health than the C-SCI cohort, but absolute postoperative changes in this score, along with mental health score and pain level, were not significant after adjusting for baseline scores and follow-up time. SF-Qualiveen scores revealed significantly worse impact of NGB in UrQoL for A-SCI than for C-SCI when adjusted for other factors. No differences in DR were seen between the groups. CONCLUSIONS: Patients with A-SCI demonstrate lower self-reported baseline physical health compared with patients with C-SCI, which may have implications in setting patient expectations when undergoing urinary diversion. In this small cohort, we found a milder self-reported postoperative impact of NGB in UrQoL in patients with C-SCI.

Urology Residency Applicant Selection: Program Directors' New Criteria.

OBJECTIVE: To evaluate the impact of the recent changes to the urology residency application process on the criteria utilized by residency program directors (PDs) for interview invitations and their perspectives concerning these changes. METHODS: One hundred thirty-seven urology residency PDs were invited to participate in an anonymous survey to explore interview selection criteria and the impact of the increase in preference signals (PS) per applicant. RESULTS: Fifty-eight PDs (42.8%) completed the survey. The highest-ranked criteria were letters of recommendation (LoR) and successful sub-internship (sub-I) at the PD's institution, without statistically significant differences between these 2. Gender, ethnicity, and medical school prestige were the lowest rated criteria, without significant differences between these 3. Compared to before the increase in the number of PS per applicant, 80.7% of PDs reported that not receiving a PS from an applicant this cycle would more negatively impact the chances of offering an interview to that applicant. Moreover, 12.2% stated they would not interview any applicants who did not send a PS. Finally, 62.1% of PDs believed recent changes worsened the process. CONCLUSION: Recent changes impacted PDs applicant evaluation, with the highest ranked criteria being LoRs and sub-I. Paradoxically, the increase in the number of PS per applicant has increased their importance as applicants are much less likely to receive interview offers from programs they have not signaled. Lastly, most PDs believe changes have worsened the evaluation process.

External Urethral Sphincter Botulinum Toxin Injection to Treat Pseudodysynergia in Patients With Cerebral Palsy.

OBJECTIVE: To evaluate urinary outcomes following cystoscopic external urinary sphincter onabotulinumtoxinA (BTX) injections in patients with cerebral palsy (CP). Adults with CP can suffer from bladder outlet obstruction and urinary retention due to a spastic external urethral sphincter ("pseudodysynergia"). We have used BTX injections into the sphincter to relieve the obstruction and allow patients to maintain spontaneous voiding rather than intermittent catheterization. METHODS: Patients were included in this retrospective cohort study if they had a diagnosis of CP, were at least 18 years of age, and underwent a urethral external sphincter BTX injection between 2016-2023. The procedure included 100 u or 200 u of BTX mixed in 4cc of saline. Primary outcomes were subjective, patient or caregiver reported changes in retention, lower urinary tract symptoms (LUTS), frequency of recurrent urinary tract infections (UTIs), and hydronephrosis or bladder stones/debris on ultrasound. RESULTS: Fifty patients were included; the majority were male (60%), lived at home with assistance (58%), and had a Gross Motor Function Classification System level of V (50%; ie, severe CP). The most common indications for BTX were retention (96%), LUTS (48%), hydronephrosis (18%), and recurrent UTIs (22%). Post-BTX improvement was seen in 67% of those with LUTS, 65% with retention, 67% with hydronephrosis, and 73% with recurrent UTIs. Most patients underwent repeat injections (60%). There were no significant complications associated with injections. CONCLUSION: External urethral sphincter BTX is a safe, effective option for treating pseudodysynergia in adults with CP.

Posterior Urethral Reconstruction at the Time of Rectourethral Fistula Repair: Technique and Outcomes.

OBJECTIVE: To assess the impact of posterior urethral stenosis or defect on outcomes following rectourethral fistula (RUF) repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair. METHODS: We identified 130 men who underwent RUF repair at our institution between 2003 and 2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months preoperatively), and 20 men suprapubic catheter placement (median, 5.5 months preoperatively). RESULTS: RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intraoperatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%). At a median follow-up of 55.7 months (interquartile range (IQR), 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation. CONCLUSION: Posterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis or defect.

Surgical Management and Oncologic Outcomes of Renal Cell Carcinoma and Inferior Vena Caval Thrombi With Aggressive Histologic Variants.

OBJECTIVE: To characterize the surgical management, perioperative, and cancer-specific outcomes, and the influence of aggressive histologic variants (AHV) on operative management among patients with renal cell carcinoma (RCC) and inferior vena cava (IVC) thrombus. RCC with rhabdoid and/or sarcomatoid differentiation, which we defined as AHV, portends a worse prognosis. AHV can be associated with a desmoplastic reaction which may complicate resection. METHODS: We reviewed patients undergoing radical nephrectomy and IVC thrombectomy between 1990 and 2020. Comparative statistics were employed as appropriate. Survival analysis was performed according to the Kaplan-Meier method, and intergroup analysis performed with log-rank statistics. Multivariable cox proportional hazards regression was used to assess the effect of AHV, age, thrombus level, vena cavectomy, metastases, and medical comorbidities on recurrence and overall survival (OS). RESULTS: Ninety-four of 403 (23.3%) patients had AHV, including 43 (46%) rhabdoid, 39 (41%) sarcomatoid, and 12 (13%) with both. AHV were more likely to present with advanced disease; however, increased perioperative complications or decreased OS were not observed. Median (IQR) survival was 16.7 (4.8-47) months without AHV and 12.6 (4-29) months with AHV (P = .157). Sarcomatoid differentiation was independently associated with worse OS (HR = 2.016, CI 1.38-2.95, P <.001), whereas rhabdoid alone or with sarcomatoid demonstrated similar OS (P = 0.063). CONCLUSION: RCC and IVC thrombus with AHV are more likely to present with metastatic disease, and sarcomatoid differentiation is associated with a worse OS. Resection of tumors with and without AHV have similar perioperative complications, suggesting that surgery can be safely accomplished in patients with RCC and IVC thrombus with AHV.

Impact of Virtual Care on Outpatient Urinary Tract Infection Management.

OBJECTIVE: To examine the effect of virtual care on urine testing, antibiotic prescription patterns, and outcomes of care in urinary tract infection (UTI) management. METHODS: We conducted retrospective analysis of adults treated for UTI in an ambulatory setting across a large health system from March 2020-2021. Outcomes included urine testing, antibiotic prescription, and retreatment or hospitalization, stratified by in-person vs virtual visit. Multivariable logistic regression was performed to examine factors contributing to outcomes. RESULTS: Significantly fewer patients seen virtually had urine testing as compared to those seen in-person (19% vs 69%, P <.001). On multivariable logistic regression analysis, virtual visit was the most significant predictor of urine testing, associated with an 86% reduction in the odds of urine testing (odds ratio (OR) 0.14, P <.001). Having a complicated UTI did not affect the likelihood of urine testing (OR 1.0, P = .95). Patients seen virtually were more likely to have a subsequent repeat ambulatory UTI visit (OR 1.16) or repeat antibiotic prescription (1.06) more than 2 weeks after the index encounter, though no more likely to be hospitalized for UTI (OR 1.00). CONCLUSION: Virtual care for UTI is associated with a significant reduction in urine testing and an increase in repeat UTI encounters and additional antibiotics among patients with complicated and uncomplicated UTIs.

Complex ureteral stricture from chronic schistosomiasis requiring ileal ureter interposition: a case report.

Background: Schistosomiasis is most notably associated with squamous cell carcinoma of the bladder, and it is estimated that approximately 10% of people infected will develop a urologic complication. Ureteral pathology is rare and has only been described in a handful of case reports. Increasing awareness of this condition is needed given a recent increase in sub-Saharan immigrant population in the United States (US), as prompt recognition is key to providing optimal care. Case Description: A 40-year-old Kenyan immigrant presented to the emergency department with left-sided flank pain and was found to have left hydronephrosis and three mid-ureteral calcifications. He underwent ureteroscopy where the left ureter appeared blind-ending just proximal to the iliac vessels. A percutaneous nephrostomy tube was placed, and renal pelvis urine was analyzed for mycobacterium tuberculosis and acid fast bacilli which were negative. Antegrade ureteroscopy demonstrated a second, proximal ureteral stricture with a pinpoint lumen. Antegrade and retrograde pyelography revealed a 3 cm mid-ureteral stricture with no contrast passage. Given the stricture length, multifocality, and unclear pathology, we opted to perform ureterectomy with ileal interposition. Final pathology revealed schistosomiasis with calcifications. The patient received two doses of Praizquantel and his stent was removed 6 weeks postoperatively. He is doing well without complications. Conclusions: There is a wide range of urologic complications caused by schistosomiasis infection, and this case highlights an extreme case. Although many patients will present with a fixed urologic complaint, they remain at risk for additional urologic pathology in the future without antihelminthic therapy. This highlights the need for an accurate diagnosis and a high index of suspicion for at-risk populations.

Diversity Attracts Diversity: 2023 AUA Match Results.

OBJECTIVE: To assess the rationale behind the choice of programs for preference signaling (PS) and subinternships by urology applicants in the 2023 cycle. METHODS: We emailed an anonymous, multiple-choice survey to the 403 prospective candidates who applied to our institution for the 2023 Urology Residency Match. RESULTS: 121 applicants (30.0%) responded to the survey. 81.8% were in favor of the continuation of PS, with 4.1% against it. When choosing where to PS or subinternship, geographic location and perceived quality of clinical training were the highest-ranked criteria. Racial/ethnic diversity of the residents influenced PS or subinternship choice for 77.8% of Black, 72.7% of Asian, 57.1% of Latinos, and 46.5% of White respondents (P < .05 for Black and Asian vs White). Institutional statements on diversity influenced PS or subinternship choice for 88.9% of Black, 55% of Asian, 64.3% of Latino, and 25.4% of White respondents (P < .05 for Black, Asian and Latino vs White). Females had an increased likelihood of PS or choosing subinternship programs with gender diversity of residents (81.6% vs 33.8, P = .002). A program with PS was associated with a 2.74 increase in likelihood of obtaining an interview compared to programs that were not PS. Of 107 matched applicants, 47.5% matched at a program where they completed a subinternship, and 25.7% matched at a signaled program. CONCLUSION: PS plays a major role in the match process. When choosing where to PS, applicants prioritize geographic location and perceived quality of training. Diversity of residents plays a major role in recruiting diverse applicants.

Outcomes of Inflatable Penile Prosthesis following Radical Cystectomy: A Matched Cohort Analysis.

OBJECTIVE: To evaluate outcomes of inflatable-penile-prosthesis (IPP) implantation after radical-cystectomy compared to other etiologies of erectile dysfunction. MATERIALS AND METHODS: All IPPs within the past 20 years in a large regional health system were reviewed, and erectile dysfunction (ED) etiology was determined as radical-cystectomy, radical-prostatectomy, or organic/other ED. Cohorts were generated by 1:3 propensity score match using age, body mass index, and diabetes status. Baseline demographics and relevant comorbidities were evaluated. Clavien-Dindo complications, grade, and reoperation were assessed. Multivariable logarithmic regression was used to identify the predictors of 90-day complications following IPP implantation. Log-rank analysis was used to assess the time-to-reoperation after IPP implantation in patients with a history of cystectomy compared with noncystectomy etiologies. RESULTS: Of 2600 patients, 231 subjects were included in the study. Comparing patients undergoing IPP for cystectomy vs pooled noncystectomy indications, those who underwent radical-cystectomy had a higher overall complication rate (24% vs 9%, p = 0.02). Clavien-Dindo complication grades did not differ across groups. Reoperation was significantly more common following cystectomy (cystectomy: 21% vs noncystectomy: 7%, p = 0.01), however time to reoperation did not differ significantly by indication (cystectomy: 8 years vs noncystectomy: 10 years,p = 0.09). Among cystectomy patients, 85% of reoperations were due to mechanical failure. CONCLUSION: Compared to other erectile dysfunction etiologies, patients undergoing IPP with a history of cystectomy have an increased risk of complications within 90-days of implantation and need for surgical device revision, but no greater risk for high-grade complications. Overall IPP remains a valid treatment option after cystectomy.

Cancer risk in bladder diverticula: a large institutional analysis of risk and management.

PURPOSE: Bladder diverticula (BD) are usually asymptomatic, but may increase the risk of infections, stones, or malignancy, likely due to urinary stasis within the BD. We aim to characterize the risk of bladder cancer (BC) within diverticula. METHODS: Retrospective review was conducted of patients diagnosed with BD between 1994 and 2021 at a single institution. Cancer risk was characterized using descriptive statistics and multivariable logistic regression as appropriate. RESULTS: We identified 764 patients with mean age 68 years, the majority of whom were male (87%) and Caucasian (86%). Of this total, 13.3% (102/764) had a diagnosis of BC and 35.3% of this subset (36/102) had definitive cancer within the BD. Diverticulectomy or partial cystectomy was performed in 13.6% (104/764), 76% of whom were preoperatively presumed to have benign disease. Surgical patients were younger and had larger BD. Of the 79 patients who underwent diverticulectomy without preoperative suspicion for cancer, 5 were incidentally diagnosed with BC on final pathology. On multivariable logistic regression, male gender [odds ratio (OR) = 2.6, p = 0.03] and increasing age (OR = 1.02, p = 0.03) were independent risk factors for BC diagnosis. Indwelling catheter, recurrent urinary tract infections (UTIs), and bladder stones did not affect the risk of BC. CONCLUSIONS: The majority of patients with BD are not managed with surgery. BC is identified in a small but considerable proportion of patients with BD, with an even lower rate of incidentally diagnosed cancer among those undergoing BD surgery. Male gender and increasing age increased the risk of BC diagnosis.

Sacral Insufficiency Fractures After Total Pubectomy for Osteomyelitis: A Case Series.

OBJECTIVE: To document the incidence, risk factors, and prevalence of sacral insufficiency fractures (SIF) among patients who have undergone total pubectomy for osteomyelitis. METHODS: A retrospective chart review was performed of patients undergoing total pubectomy for osteomyelitis at a single institution from 2016 to 2021. Descriptive statistics and univariate analysis were performed using the Wilcoxon rank-sum test and Fisher exact test as appropriate. RESULTS: Sixteen patients underwent total pubectomy for osteomyelitis. The median age was 68 years. 12 of 16 (75%) had previously received pelvic radiotherapy. The median BMI was 27.8 kg/m2. Eleven (68.75%) had postoperative pelvic imaging, of which 3 (27.3%) had a new SIF. One other patient had a SIF 3 days before pubectomy. Three SIFs were detected via MRI and 1 by CT scan. The median BMI of patients with SIF was significantly lower than those without SIF (22.4 vs 30.5, P = .004). All patients with SIF presented with new pelvic or perineal pain without radiculopathy. Symptoms resolved for three patients with non-opioid analgesics, physical therapy, and/or a brief trial of opioids. CONCLUSION: Sacral insufficiency fracture is a rare sequela of total pubectomy for osteomyelitis. Lower BMI is significantly associated with SIF perhaps due to reduced muscle mass or poor bone condition and, as a result, baseline pelvic instability. Medical management should be first-line therapy.

Long-term Follow-up of Patients With Cerebral Palsy Undergoing Catheterizable Channel Creation Without Concurrent Bladder Augmentation.

OBJECTIVE: To characterize long-term outcomes for adults with cerebral palsy who have undergone catheterizable channel creation without concurrent bladder augmentation. METHODS: Retrospective review was conducted of patients who underwent catheterizable channel creation without augmentation by the senior author. Variables of interest included development of de novo neurogenic detrusor overactivity, change in continence, escalation in therapy, and upper tract changes. Descriptive statistics were conducted using t-tests and chi-squared tests as appropriate. RESULTS: Nine patients were followed for an average of 70 months. Prior to surgery two patients were on regular clean intermittent catheterization (CIC), six were not on CIC, and one was on occasional CIC. Patients not on CIC preoperatively were more likely to develop de novo neurogenic detrusor overactivity (83% vs 0%, P = .02), and have statistically significant decreases in average compliance (P = .04 vs P = .31). They were also more likely to require escalation in bladder therapy (83% vs 50%) and have worsening of incontinence (67% vs 0%), though these did not reach statistical significance (P = .34, 0.1). Five patients underwent repeat urodynamics an average of 46 months after initial postoperative study because of persistent urgency - 4 of 5 had stable urodynamic findings and one demonstrated >50% reduction in compliance and capacity. CONCLUSION: Adults with cerebral palsy who are not on CIC prior to creation of a catheterizable channel are at high risk for development of de novo neurogenic detrusor overactivity and decrease in bladder compliance. Prophylactic augmentation should be considered in this group.

Neurogenic Bladder:: Assessment and Operative Management.

We present a phenotype-based approach to neurogenic bladder (NGB) by describing prototypical patients with spinal cord injury (SCI), spina bifida (SB), cerebral palsy (CP), and multiple sclerosis (MS). Surgical management is categorized by failure to store and failure to empty, with a focus on catheterizable channels, bladder augmentation, and bladder outlet procedures. Mitigation and management of common complications are reviewed. Specific attention is paid to social support, body habitus, and extremity function, as we believe a holistic approach is necessary for appropriate surgical selection.

A Novel Metric for Hospital Quality in Kidney Cancer Surgery: A Veterans Affairs National Health System Validation of Concept.

INTRODUCTION: We aimed to develop and validate a Compound Quality Score (CQS) as a metric for hospital-level quality of surgical care in kidney cancer at the Veterans Affairs National Health System. METHODS: A retrospective review of 8,965 patients with kidney cancer treated at Veterans Affairs (2005-2015) was performed. Two previously validated process quality indicators (QIs) were explored: the proportion of patients with 1) T1a tumors undergoing partial nephrectomy and 2) T1-T2 tumors undergoing minimally invasive radical nephrectomy. Demographics/comorbidity/tumor characteristics/treatment year were used for case mix adjustments at hospital level. The predicted versus observed ratio of cases was calculated per hospital to generate QI scores using indirect standardization and multivariable regression models. CQS represents the sum of both scores. A total of 96 hospitals were grouped by CQS, and short-term patient-level outcomes were regressed on CQS levels to assess for length of stay (LOS), 30-day complications/readmission, 90-day mortality and total cost of surgical admission. RESULTS: CQS identified 25/33/38 hospitals with higher/lower/average performance, respectively. High performance hospitals had higher nephrectomy volumes (p <0.01). Total CQS independently associated with LOS (ß=-0.04, p <0.01, predicted LOS 0.84 days shorter for CQS=2 versus CQS=-2), 30-day surgical complications (OR=0.88, p <0.01) or 30-day medical complications (OR=0.93, p <0.01) and total cost of surgical admission (ß =-0.014, p <0.01, predicted 12% lower cost for CQS=2 versus CQS=-2). No association was found between CQS and 30-day readmissions or 90-day mortality (all p >0.05), although low event rates were observed (8.9% and 1.7%, respectively). CONCLUSIONS: Variability in quality of surgical care at hospital level can be captured with the CQS among patients with kidney cancer. CQS is associated with relevant short-term perioperative outcomes and surgical cost. QIs should be used to identify, audit and implement quality improvement strategies across health systems.

Stones and Moans: Higher Number of Nephrolithiasis Related Encounters Increases the Odds of Opioid Misuse.

OBJECTIVE: To evaluate the association between kidney stones and risk of subsequent opioid misuse. METHODS: The Healthcare Cost and Utilization Project's (HCUP) inpatient, ambulatory, and emergency department databases from 4 states were queried to identify associations with a primary diagnosis code related to kidney stones followed by a diagnosis of opioid abuse, dependence, or overdose between 2005, and 2015. Logistic regression was performed to determine the strength and significance of the relationship between number of primary kidney stone episodes and subsequent diagnosis of opioid misuse. RESULTS: The final cohort included 783,929 patients across 4 states. On multivariable analysis the number of primary stone encounters (PSE) was strongly associated with the risk of developing an opioid-related disorder (ORD) when adjusting for relevant covariates (odds ratio 1.3). Patients seen in the emergency department (OR 1.4) and those treated in Iowa (OR 2.9) were at higher risk for ORD than those seen in different contexts or states. Younger age increased the strength of this association. Higher income (OR 0.7) and non-white race (OR 0.7) reduced the risk of ORD, while a diagnosis of chronic pain (OR 3.5) increased risk. CONCLUSION: Risk of subsequent diagnosis of ORD is increased in patients who have multiple episodes of care related to kidney stones.