Early Post-Operative Events After Urethroplasty in Obese Patients: A Multi-Institutional Retrospective Series.

OBJECTIVE: To compare early urethroplasty outcomes in non-obese, obese and morbidly obese patients undergoing urethroplasty for urethral stricture disease. The impact of obesity on outcomes is poorly understood but will be increasingly important as obesity continues to rise. METHODS: Patients underwent urethroplasty at one of the 5 institutions between January 2016 and December 2020. Obese (BMI 30-39.9, n = 72) and morbidly obese (BMI >40, n = 49) patients were compared to normal weight (BMI <25, n = 29) and overweight (BMI 25-29.9, n = 51) patients. Demographics, comorbidities, and stricture characteristics were collected. Outcomes including complications, recurrence, and secondary interventions were compared using univariate and multivariate analysis. RESULTS: Two hundred and one patients (Mean BMI 34.1, Range 18.4-65.2) with mean age 52.2 years (SD=17.2) were analyzed. Median follow-up time was 3.71 months. Obese patients were younger (P = .008), had more anterior (P <.001), iatrogenic and LS-associated strictures (P = .036). Sixty-day complication rate was 26.3% with no differences between cohorts (P = .788). Around 9.5% of patients had extravasation at catheter removal, 18.9% reported stricture recurrence, and 7.4% required additional interventions. Obese patients had greater estimated blood loss (P = .001) and length of stay (P = .001). On multivariate analysis, smoking associated with contrast leak (OR 7.176, 95% CI 1.13-45.5) but not recurrence or need for intervention (P = .155, .927). CONCLUSION: Obese patients in our cohort had more anterior, iatrogenic, and LS-related strictures. However, obesity is not associated with complications, contrast leak, secondary interventions, or recurrence. Obese had higher blood loss and length of stay. Urethroplasty is safe and effective in obese patients.

Current devices, outcomes, and pain management considerations in penile implant surgery: an updated review of the literature.

Penile prosthesis surgery is a definitive treatment for erectile dysfunction (ED). The two categories of penile prosthesis are endorsed by professional guidelines, inflatable penile prosthesis (IPP) and malleable penile prosthesis (MPP). Each modality of penile prosthesis offers distinct advantages and incorporates specific design features, allowing for personalized device selection that aligns with individual needs and preferences. While the overall complication rate of penile implant surgery remains low, surgeons should maintain a high index of suspicion for complications in the perioperative time period. Multimodal analgesic regimens including nerve blocks and narcotic-free pathways should be administered to manage perioperative pain. Finally, the high patient satisfaction after penile prosthesis surgery underscores the success of this ED treatment option.

Decreased Opioid Use and Equivalent Pain Score Outcomes After Robotic Urologic Surgery Using a Simplified Opioid Minimization Protocol: A Safety-Net Hospital Experience.

INTRODUCTION: We aimed to implement a simplified opioid minimization (OM) protocol after robotic urologic surgery in a safety-net hospital to decrease opioid consumption without compromising patient-reported pain or satisfaction. METHODS: Robotic urologic surgery was performed in 103 consecutive patients at a safety-net hospital. An opioid control (OC) cohort was established from January to May 2021, and the OM protocol was implemented from June to October 2021. On postoperative day (POD) 2 and POD7, a validated survey was used to assess pain and satisfaction. Opioid dispensation records were queried from the Prescription Monitoring Program. Outcomes were compared by univariate methods. RESULTS: There were no demographic differences between the OM (n = 45) and OC (n = 35) cohorts. Total opioids received within 30 days of surgery decreased by 68% in the OM vs OC cohort (median [IQR] 32.5 [7.5-65] vs 100 [30-173] morphine milligram equivalents, P < .001). The median amount of opioids prescribed at discharge for the OM cohort was 0 (IQR:0-0) vs 75 morphine milligram equivalents (IQR:0-112.5) for the OC cohort (P < .001). Pain severity did not differ between cohorts on POD2 (median [IQR]: OM=3/10 [2-5], OC=3.5/10 [2-6]; P = .5) or POD7 (median [IQR]: OM=2/10 [0-3], OC=1/10 [0-3]; P = .8), and POD7 satisfaction with pain management remained high for both cohorts (P = .8). CONCLUSIONS: Our simplified OM protocol decreased total opioid use after robotic urologic surgery by 68% without compromising pain or satisfaction.

Urethral Injuries: Diagnostic and Management Strategies for Critical Care and Trauma Clinicians.

Urologic trauma is a well-known cause of urethral injury with a range of management recommendations. Retrograde urethrogram remains the preferred initial diagnostic modality to evaluate a suspected urethral injury. The management thereafter varies based on mechanism of injury. Iatrogenic urethral injury is often caused by traumatic catheterization and is best managed by an attempted catheterization performed by an experienced clinician or suprapubic catheter to maximize urinary drainage. Penetrating trauma, most commonly associated with gunshot wounds, can cause either an anterior and/or posterior urethral injury and is best treated with early operative repair. Blunt trauma, most commonly associated with straddle injuries and pelvic fractures, can be treated with either early primary endoscopic realignment or delayed urethroplasty after suprapubic cystostomy. With any of the above injury patterns and treatment options, a well thought out and regimented follow-up with a urologist is of utmost importance for accurate assessment of outcomes and appropriate management of complications.

A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury.

BACKGROUND: Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI. METHODS: Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction. RESULTS: There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784). CONCLUSION: In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The Outcomes of Pelvic Fracture Urethral Injuries Stratified by Urethral Injury Severity: A Prospective Multi-institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury. METHODS: Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score. RESULTS: There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (P < 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (P < 0.001). CONCLUSION: In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed.

Opiate Prescriptions Vary among Common Urologic Procedures: A Claims Dataset Analysis.

Objectives: This study aimed to better understand differences in the total days' supply and fills of common opiates following urologic procedures. Materials and Methods: The Truven Health MarketScan® database was used to extract CPT codes from adults 18 years or older who underwent a urologic procedure with 90-day follow-up from 2012−2015 within the Austin−Round Rock, Texas metropolitan service area. A multivariate analysis and first hurdle modeling with a logistic outcome for any opiates was used to (1) assess differences in opioid prescribing patterns, (2) investigate opioid prescription outcomes, and (3) explore variability among opiate prescription patterns across seven urologic procedure categories. Results: Among the 2312 patients who met the inclusion criteria, 23.7% received an opiate, with an average total day's supply of 6.20 (range 2.61−10.59). The proportion of patients receiving opiates varied significantly by procedure type (p = 0.028). Patients that had reconstructive procedures had the highest proportion of any opiates and the highest number of mean opiate prescriptions among the seven procedure categories (42% received opiates, p = 0.028, mean opiate prescriptions were 1.0 among all patients, p = 0.026). After adjustments, the multivariate analysis demonstrated that patients undergoing reconstructive procedures filled more opiate prescriptions (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.00−3.50, p = 0.05) compared to other subcategories. Of those that received opiates, reconstructive patients had a shorter time to fills (mean −18.4 days, CI −8.40 to −28.50, p < 0.001). Conclusion: Patients undergoing reconstructive procedures are prescribed and fill more opiates compared to other common urological procedures. The standardization and implementation of postoperative pain regimens may help curtail this variability.

Current use of testosterone therapy in LGBTQ populations.

Testosterone therapy (TT) is a type of gender-affirming hormone therapy (GAHT) in lesbian, gay, bisexual, transgender, and genderqueer (LGBTQ) populations for gender dysphoria (GD), body uneasiness, and sexual dysfunction. The physical and physiological effects of TT vary widely depending on the dosing regimen and duration of treatment. An individualized approach prioritizing patient-specific desired effects in the context of pre-existing characteristics and health history is strongly recommended. Although TT is an effective treatment for many patients, there has been an increase in the illegitimate acquisition of TT in recent years. Non-judicious prescribing and lack of physician surveillance increases the risk of unintended side effects and potential serious health consequences.

Preoperative and intraoperative factors predictive of complications and stricture recurrence following multiple urethroplasty techniques.

Objectives: To investigate factors predictive of postoperative recurrence and complications in patients undergoing urethroplasty for stricture repair at a single center. Patients and methods: We retrospectively reviewed the records of 108 men who underwent urethroplasty for urethral stricture disease (USD) at a single center from 2016 to 2020. Demographic data, comorbidities, stricture history including etiology and prior treatments, patient-reported symptoms, and outcomes data were collected for analysis. Data were analyzed in aggregate, then, stratified by type of urethroplasty performed. Descriptive statistics, univariate analysis, multivariate logistic regression, and intergroup comparisons were completed using STATA, with an alpha value of 0.05 and a confidence interval of 95%. Results: The median age of our patients was 58 years (interquartile range: 42-69; range: 29-83), with a median stricture length of 2.0 cm (interquartile range: 1.0-4.5; range: 0.5-10). The most common stricture etiology was iatrogenic (n = 33, 31%) and the most common urethroplasty was anterior anastomotic urethroplasty (n = 38, 35%), followed by buccal mucosal graft (BMG) urethroplasty (n = 35, 32%). Twenty-four patients (22%) had stricture recurrence. Within the aggregate data, recurrence was significantly predicted by obesity (BMI > 30) (Odds Ratio [OR] 3.2, 95% Confidence Interval [CI]: 1.06-10), and the presence of postoperative complications (OR 6.3, CI: 1.9-21). The presence of any postoperative complications within 90 days was significantly predicted by stricture length ≥ 5 cm (OR 3.5, CI 1.09-12) and recurrence (OR 6.0, CI 1.7-21). Conclusion: Despite serving as the most definitive treatment for urethral stricture management, stricture recurrence and postoperative complications are not uncommon after urethroplasty. Obesity and stricture length negatively impact outcomes while a penile stricture location is associated with a lower recurrence rate, though this is not statistically significant.

Value-based care for the treatment and evaluation of benign prostatic hyperplasia: an analysis of a metropolitan service area claims database.

PURPOSE: With an aging population, cost containment and improved outcomes will be crucial for a sustainable healthcare ecosystem. Current data demonstrate great variation in payments for procedures and diagnostic workup of benign prostatic hyperplasia (BPH). To help determine the best financial value in BPH care, we sought to analyze the major drivers of total payments in BPH. MATERIALS AND METHODS: Commercial and Medicare claims from the Truven Health Analytics Markestscan® database for the Austin, Texas Metropolitan Service Area from 2012 to 2014 were queried for encounters with diagnosis and procedural codes related to BPH. Linear regression was utilized to assess factors related to BPH-related payments. Payments were then compared between surgical patients and patients managed with medication alone. RESULTS: Major drivers of total payments in BPH care were operative, namely transurethral resection of prostate (TURP) [$2778, 95% CI ($2385-$3171), p < 0.001) and photoselective vaporization (PVP) ($3315, 95% CI ($2781-$3849) p < 0.001). Most office procedures were also associated with significantly higher payments, including cystoscopy [$708, 95% CI ($417-$999), p < 0.001], uroflometry [$446, 95% CI ($225-668), p < 0.001], urinalysis [$167, 95% CI ($32-$302), p = 0.02], postvoid residual (PVR) [$245, 95% CI ($83-$407), p < 0.001], and urodynamics [$1251, 95% CI ($405-2097), p < 0.001]. Patients who had surgery had lower payments for their medications compared to patients who had no surgery [$120 (IQR: $0, $550) vs. $532 (IQR: $231, $1852), respectively, p < 0.001]. CONCLUSION: Surgery and office-based procedures are associated with increased payments for BPH treatment. Although payments for surgery were more in total, surgical patients paid significantly less for BPH medications.

Concomitant bladder and rectal injuries: Results from the American Association for the Surgery of Trauma Multicenter Rectal Injury Study Group.

BACKGROUND: Combined traumatic injuries to the rectum and bladder are rare. We hypothesized that the combination of bladder and rectal injures would have worse outcomes than rectal injury alone. METHODS: This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004 to 2015 traumatic rectal injury patients who were admitted to one of 22 participating centers. Demographics, mechanism, and management of rectal injury were collected. Patients who sustained a rectal injury alone were compared with patients who sustained a combined injury to the bladder and rectum. Multivariable logistic regression was used to determine if abdominal complications, mortality, and length of stay were impacted by a concomitant bladder injury after adjusting for cofounders. RESULTS: There were 424 patients who sustained a traumatic rectal injury, of which 117 (28%) had a combined injury to the bladder. When comparing the patients with a combined bladder/rectal injury to the rectal alone group, there was no difference in admission demographics admission physiology, or Injury Severity Score. There were also no differences in management of the rectal injury and no difference in abdominal complications (13% vs. 16%, p = 0.38), mortality (3% vs. 2%, p = 0.68), or length of stay (17 days vs. 21 days, p = 0.10). When looking at only the 117 patients with a combined injury, the addition of a colostomy did not significantly decrease the rate of abdominal complications (14% vs. 8%, p = 0.42), mortality (3% vs. 0%, p = 0.99), or length of stay (17 days vs. 17 days, p = 0.94). After adjusting for cofounders (AAST rectal injury grade, sex, damage-control surgery, diverting colostomy, and length of stay) the presence of a bladder injury did not impact outcomes. CONCLUSION: For patients with traumatic rectal injury, a concomitant bladder injury does not increase the rates of abdominal complications, mortality, or length of stay. Furthermore, the addition of a diverting colostomy for management of traumatic bladder and rectal injury does not change outcomes. LEVEL OF EVIDENCE: Level IV; prognostic/therapeutic.

Occupational traumatic injuries rarely affect genitourinary organs: a retrospective, comparative study.

PURPOSE: To determine the mechanisms of injury associated with occupational injuries (OI) to genitourinary (GU) organs and compare GU OIs with GU non-OIs. METHODS: A single institution, retrospective study was conducted at a level 1 trauma center between 2010 and 2016 of all patients with GU injuries. OI was defined as any traumatic event that occurred in the workplace requiring hospital admission. Types of occupations were recorded in addition to the location of injury, mechanisms of injury, concomitant injuries, operative interventions, total cost, and mortality. GU OI patients were then compared to GU non-OI patients. RESULTS: 623 patients suffered a GU injury, of which 39 (6.3%) had a GU OI. Fall (43%) was the most common mechanism of injury; followed by motor vehicle collision/motorcycle crash (31%), crush injury (18%), and pedestrian struck (8%). The adrenal gland (38%) and kidney (38%) were the most commonly injured organs. There was no difference in mortality (13% GU OI vs. 15% GU non-OI, p = 0.70) or total direct cost ($21,192 ± 28,543 GU OI vs. $28,215 ± 32,332 GU non-OI, p = 0.45). Total costs were decreased with mortality from a GU injury (odds ratio (OR) 0.3, CI 0.26-0.59; p = < 0.001) and increased with higher injury severity scores (OR 1.1, CI 1.09-1.2; p = < 0.0001). Total costs were not affected by OI status. CONCLUSIONS: Occupational GU trauma presents with similar patterns of injury, hospital course, and direct cost as GU trauma that occurs in non-occupational settings.

Enterorenal Fistula as an Unusual Complication from Ureteroscopic Lithotripsy: A Case Report.

Background: This case highlights an enterorenal fistula as a rare complication from ureteroscopic lithotripsy. Case Presentation: A 56-year-old woman with significant obesity, decompensated cirrhotic and ascitic liver disease, hypertension, type 2 diabetes mellitus, and nephrolithiasis treated with five prior ureteroscopic lithotripsies for a partial left staghorn stone presented to the emergency department (ED) with worsening left flank pain and sepsis. A CT scan of the abdomen and pelvis with contrast showed a large left perinephric hematoma. She underwent drain placement and during fluoroscopic imaging, there was a fistula from the left subcapsular hematoma/abscess to the proximal descending colon. The patient wished to proceed with a surgical course involving nephrectomy with hemicolectomy despite extensive counseling regarding her high mortality risk. However, because of worsening nutritional status as well as several other high-risk comorbidities, a shared decision was made with the patient to postpone the procedure. The patient was discharged to a skilled nursing facility for nutritional optimization and prehabilitation; however, she continued to decline with recurrent sepsis and cirrhosis-related complications and unfortunately passed away. Conclusion: A subscapular hematoma evolving into a perinephric abscess is a rare but known complication of ureteroscopic lithotripsy; however, this patient developed an enterorenal fistula that has yet to be reported after repeated ureteroscopy.

International and Multi-institutional Assessment of Factors Associated With Performance and Quality of Lymph Node Dissection During Radical Nephrectomy.

OBJECTIVE: To determine factors associated with performance and quality of lymph node dissection during radical nephrectomy. MATERIALS AND METHODS: Using an International Data Registry, we performed multilevel logistic regression to determine the association of surgical approach (open surgery vs minimally invasive surgery), institutional experience (low, moderate, and high tertiles), and institutional preference (minimally invasive surgery, balanced, and open surgery tertiles) with the performance of lymph node dissection in subgroups by clinical stage and nodal status. RESULTS: Among 1,742 patients undergoing radical nephrectomy, 312 (18%) underwent lymph node dissection, which was associated with stage (28% for ≥cT2 vs 9.3% for cT1), and nodal status (68% for ≥cN1 vs 13% for cN0). Open surgery was significantly associated with performing lymph node dissection in all subgroups. Institutional experience and institutional preference had no association with performing lymph node dissection in the ≥cN1 group. The number of nodes removed was greater for open surgery (mean 5.9) vs minimally invasive surgery (mean 3.4); this held true even when stratified by stage and nodal status. CONCLUSION: In this large dataset, open surgical radical nephrectomy is associated with more frequent performance and higher quality of lymph node dissection, which may owe to selection bias but also could reflect technical concerns. In the patient population in whom lymph node dissection is recommended (≥cN1), this is not explained by institutional experience or preference. Lymph node dissection may be under-utilized for ≥cN1 disease and over-utilized for cN0 disease, at least according to practice guidelines.

Does routine repeat imaging change management in high-grade renal trauma? Results from three level 1 trauma centers.

PURPOSE: Guidelines call for routine reimaging of Grade 4-5 renal injuries at 48-72 h. The aim of the current study is to evaluate the clinical utility of computed tomography (CT) reimaging in high-grade renal injuries. MATERIALS AND METHODS: We assembled data on 216 trauma patients with high-grade renal trauma at three level 1 trauma centers over a 19-year span between 1999 and 2017 in retrospectively collected trauma database. Demographic, radiographic, and clinical characteristics of patients were retrospectively reviewed. RESULTS: In total, 151 cases were Grade 4 renal injuries, and 65 were Grade 5 renal injuries. 53.6% (81) Grade 4 and 15.4% (10) Grade 5 renal injuries were initially managed conservatively. Of the 6 asymptomatic cases where repeat imaging resulted in intervention, 100% had collecting system injuries at initial imaging. Collecting system injuries were only present in 42.9% of cases where routine repeat imaging did not trigger surgical intervention. Collecting system injury at the time of initial imaging was a statistically significant predictor of routine repeat imaging triggering surgical intervention (p = 0.022). Trauma grade and the presence of vascular injury were not significant predictors of intervention after repeat imaging in asymptomatic patients. CONCLUSION: In asymptomatic patients with high-grade renal trauma, the number needed to image is approximately one in eight (12.5%) to identify need for surgical intervention. There is potentially room to improve criteria for routine renal imaging in high-grade renal trauma based on the more predictive imaging finding of collecting system injury.