Outcomes of an Algorithmic, Multidisciplinary Approach to Rectourethral Fistula Repair: A Pre- and Postintervention Quasi-Experimental Study.

BACKGROUND: Rectourethral fistulas are a rare yet severe complication of prostate surgery, pelvic irradiation therapy, or both. Multiple surgical repairs exist with widely varying success rates. OBJECTIVE: This study aimed to present our institutional multidisciplinary algorithm for rectourethral fistula repair and its outcomes. DESIGN: This was a retrospective, pre- and postintervention, quasi-experimental design, comparing the frequency of fistula healing and reversal of urinary and fecal diversion before and after implementation of our algorithm. SETTING: All patients who presented to the Duke University with rectourethral fistula between 2002 and 2019 were included. PATIENTS: This study included 79 patients treated for rectourethral fistula: 36 prealgorithm and 43 postalgorithm. INTERVENTIONS: Our multidisciplinary algorithm was implemented in 2012. Patients with fistulas <2 cm and without history of radiation therapy underwent York-Mason repair, whereas those with fistulas 2-3 cm or with prior irradiation underwent transperineal repair with gracilis flap interposition. Those with nonrepairable fistulas (>3 cm or fixed tissues) underwent pelvic exenteration. Before repair, the algorithm recommended all patients to undergo urinary and bowel diversion. MAIN OUTCOME MEASURES: The 2 primary outcomes were rectourethral fistula healing, defined as both radiographic and clinical resolutions, and reversal of urinary and fecal diversions. RESULTS: Frequency of fistula healing improved in the post- versus prealgorithm subgroups (93.1% vs 71.9%; p = 0.04). The relative risk of fistula healing pre- versus postintervention was 0.77 (0.61-0.98; p = 0.04) among the overall cohort. Eighteen patients (22.8%) underwent pelvic exenteration for nonrepairable fistulas and were not included in primary outcome measures. LIMITATIONS: Limitations include the study's retrospective nature, possible selection bias because of algorithmic patient selection, and small sample size. CONCLUSIONS: Implementation of a multidisciplinary institutional algorithm improved rectourethral fistula repair success with high rates of ostomy reversal. Proper patient selection and multidisciplinary involvement are paramount to this success. See Video Abstract at http://links.lww.com/DCR/B955 . RESULTADOS DE UN ABORDAJE ALGORTMICO Y MULTIDISCIPLINARIO PARA LA REPARACIN DE FSTULAS RECTOURETRALES UN ESTUDIO CUASIEXPERIMENTAL PREVIO Y POSTERIOR A LA INTERVENCIN: ANTECEDENTES:Las fístulas rectouretrales son una complicación rara pero grave de la cirugía de próstata, la radiación pélvica o ambas. Existen múltiples reparaciones quirúrgicas con tasas de éxito muy variables.OBJETIVO:Presentar el algoritmo multidisciplinario de nuestra institución para la reparación de fístulas rectouretrales y sus resultados.DISEÑO:Este fue un diseño retrospectivo, previo y posterior a la intervención, cuasiexperimental, que comparó la frecuencia de curación de la fístula y la reversión de la derivación urinaria y fecal antes y después de la implementación de nuestro algoritmo.ESCENARIO:Se incluyeron todos los pacientes que acudieron a Duke con fístula rectouretral entre 2002 y 2019.PACIENTES:Setenta y nueve pacientes fueron tratados por fístula rectouretral; 36 pre-algoritmo y 43 post-algoritmo.INTERVENCIONES:Nuestro algoritmo multidisciplinario se implementó en 2012. Los pacientes con fístulas <2 cm y sin antecedentes de radiación se sometieron a reparación de York-Mason, mientras que aquellos con fístulas de 2-3 cm o radiación pélvica previa se sometieron a reparación transperineal con interposición de colgajo de gracilis. Aquellos con fístulas no reparables (> 3 cm o tejidos fijos) fueron sometidos a exenteración pélvica. Antes de la reparación, el algoritmo recomomendó que todos los pacientes se sometieran a una derivación urinaria y fecal.PRINCIPALES MEDIDAS DE RESULTADO:Los dos resultados primarios fueron la curación de la fístula rectouretral, definida como la resolución radiográfica y clínica, y la reversión de las derivaciones urinaria y fecale.RESULTADOS:La frecuencia de curación de la fístula mejoró en el subgrupo post-algoritmo vs. pre-algoritmo (93.1% vs. 71.9%, p = 0.04). El riesgo relativo de curación de la fístula antes de la intervención en comparación con después de la intervención fue de 0.77 (0.61-0.98, p = 0.04) entre la cohorte general. Dieciocho pacientes (22.8%) se sometieron a exenteración pélvica por fístulas no reparables y, por lo tanto, no se incluyeron en las medidas de resultado primarias.LIMITACIONES:Las limitaciones de este estudio incluyen su naturaleza retrospectiva, posible sesgo de selección debido a la selección algorítmica de pacientes y un tamaño de muestra pequeño.CONCLUSIONES:La implementación de un algoritmo institucional multidisciplinario mejoró el éxito en la reparación de la fístula rectouretral con altas tasas de reversión de la ostomía. La selección adecuada de pacientes y la participación multidisciplinaria son fundamentales para este éxito. Consulte Video Resumen en http://links.lww.com/DCR/B955 . (Traducción-Dr. Jorge Silva Velazco ).

Increasing Comorbidity and Frailty is Not Associated with Early Postoperative Complications among Men Undergoing Artificial Urinary Sphincter or Sling Implantation: A Real-World Application of NSQIP® Data to Reconstructive Urology.

INTRODUCTION: Urologists may be hesitant to surgically treat urinary incontinence in comorbid genitourinary cancer survivors. We assessed the relationship between comorbidities and 30-day perioperative outcomes following artificial urinary sphincter and sling implantation. METHODS: Using the National Surgical Quality Improvement Program, patients with CPT codes for artificial urinary sphincter and sling implantation were identified between 2007 and 2015. The patient's Charlson comorbidity index and Frailty Index scores were calculated based on ICD-9 codes. The primary outcome was presence of perioperative complications. The association between Charlson comorbidity index and Frailty Index and each primary outcome was investigated using multivariate logistic regression models. RESULTS: We queried 1,370 and 1,018 records with artificial urinary sphincter and sling implantation, respectively. The median Charlson comorbidity index for artificial urinary sphincter patients was 4.0 (Q1 3, Q3 5), while for sling patients it was 3.0 (Q1 3, Q3 4). In the artificial urinary sphincter cohort, 47% had 1 Frailty Index condition, whereas 25% had 2 or more Frailty Index conditions. In the sling group, 42% had 1 Frailty Index condition, while 19% had 2 or more Frailty Index conditions. The event rate for overall complications was 5.4% and 3.0% in the artificial urinary sphincter and sling cohort, respectively. After adjusting for covariates in both the artificial urinary sphincter and sling cohort Charlson comorbidity index or Frailty Index was not associated with the odds of having a complication. CONCLUSIONS: The presence of increased comorbidities or frailty is not associated with short-term postoperative complications among men undergoing artificial urinary sphincter or sling implantation.

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.

Urinary Retention in Surgical Patients.

Urinary retention is an important and potentially avoidable postoperative complication. Identifying risk factors for retention is important given expedient bladder decompression is important for long-term outcomes. Age, benign prostatic hyperplasia, and lower urinary tract symptoms are patient factors that predispose to retention. Surgery-related factors include operative time, intravenous fluid administration, type of anesthesia, and procedure type. The mainstay for treatment in the acute setting is Foley catheter placement. Starting alpha-blockers in men is also indicated as they increase voiding trial success. Long-term solutions for chronic retention include a variety of surgeries, with transurethral prostatectomy as the gold standard.

Correlation of computed tomographic signs of hypoperfusion and clinical hypoperfusion in adult blunt trauma patients.

BACKGROUND: The computed tomographic signs of hypoperfusion (CTSHs) have been reported in radiology literature as preceding the onset of clinical shock in children, but its correlation with tenuous hemodynamic status in adult blunt trauma patients has not been well studied. We hypothesized that these CT findings represent a clinically hypoperfused state and predict patient outcomes. METHODS: We retrospectively reviewed 52 adult blunt trauma patients who presented to our Level I trauma center with an Injury Severity Score (ISS) greater than 15 and a systolic blood pressure less than 90 mm Hg and who underwent torso CT scans during a period of 5.5 years. Patient's demographics and clinical data were recorded. All CT scans were assessed by our radiologist (J.M.) for 25 CTSHs. RESULTS: Seventy-nine percent of the patients studied exhibited CTSH. The mean number of signs identified per patient was 4. Patient with the most common CTSH, that is, free peritoneal fluid, small bowel enhancement, flattened inferior vena cava (IVC), and flattened renal veins, had a significantly higher intensive care unit admission rate than those without (all p < 0.05). Patient with signs of small bowel abnormal enhancement/dilation, flattened IVC/renal vein had worse acidosis (all p < 0.05). A significantly lower admission hemoglobin and an increased need for red blood cell transfusion were found in patient with flattened IVC (p < 0.05), flattened renal vein (p < 0.01), and active contrast extravasation (p < 0.01). Univariate analysis identified small bowel dilatation and splenic injury as factors associated with mortality and laparotomy, respectively. Logistic regression model revealed that splenic injury is a significant independent predictor of laparotomy (odd ratio, 7.50; 95% confidence interval, 1.67-33.71; p < 0.01). CONCLUSION: CTSH correlates with clinical hypoperfusion in blunt trauma patients and has important prognostic and therapeutic implications. The presence of CTSH in blunt trauma patients should draw immediate attention and require prompt intervention. Trauma surgeons should be familiar with these signs and include them in the clinical decision-making paradigms to improve outcomes in blunt trauma. LEVEL OF EVIDENCE: Diagnostic study, level III.

A preliminary study comparing methadone and buprenorphine in patients with chronic pain and coexistent opioid addiction.

Patients with opioid addiction who receive prescription opioids for treatment of nonmalignant chronic pain present a therapeutic challenge. Fifty-four participants with chronic pain and opioid addiction were randomized to receive methadone or buprenorphine/naloxone. At the 6-month follow-up examination, 26 (48.1%) participants who remained in the study noted a 12.75% reduction in pain (P = 0.043), and no participants in the methadone group compared to 5 in the buprenorphine group reported illicit opioid use (P = 0.039). Other differences between the two conditions were not found. Long-term, low-dose methadone or buprenorphine/naloxone treatment produced analgesia in participants with chronic pain and opioid addiction.

Glioblastoma stem-like cells give rise to tumour endothelium.

Glioblastoma (GBM) is among the most aggressive of human cancers. A key feature of GBMs is the extensive network of abnormal vasculature characterized by glomeruloid structures and endothelial hyperplasia. Yet the mechanisms of angiogenesis and the origin of tumour endothelial cells remain poorly defined. Here we demonstrate that a subpopulation of endothelial cells within glioblastomas harbour the same somatic mutations identified within tumour cells, such as amplification of EGFR and chromosome 7. We additionally demonstrate that the stem-cell-like CD133(+) fraction includes a subset of vascular endothelial-cadherin (CD144)-expressing cells that show characteristics of endothelial progenitors capable of maturation into endothelial cells. Extensive in vitro and in vivo lineage analyses, including single cell clonal studies, further show that a subpopulation of the CD133(+) stem-like cell fraction is multipotent and capable of differentiation along tumour and endothelial lineages, possibly via an intermediate CD133(+)/CD144(+) progenitor cell. The findings are supported by genetic studies of specific exons selected from The Cancer Genome Atlas, quantitative FISH and comparative genomic hybridization data that demonstrate identical genomic profiles in the CD133(+) tumour cells, their endothelial progenitor derivatives and mature endothelium. Exposure to the clinical anti-angiogenesis agent bevacizumab or to a γ-secretase inhibitor as well as knockdown shRNA studies demonstrate that blocking VEGF or silencing VEGFR2 inhibits the maturation of tumour endothelial progenitors into endothelium but not the differentiation of CD133(+) cells into endothelial progenitors, whereas γ-secretase inhibition or NOTCH1 silencing blocks the transition into endothelial progenitors. These data may provide new perspectives on the mechanisms of failure of anti-angiogenesis inhibitors currently in use. The lineage plasticity and capacity to generate tumour vasculature of the putative cancer stem cells within glioblastoma are novel findings that provide new insight into the biology of gliomas and the definition of cancer stemness, as well as the mechanisms of tumour neo-angiogenesis.