Scrotal Ultrasound for Pain: Low Frequency of Absolute Surgical Indications.

OBJECTIVE: To examine the results of scrotal ultrasounds (US) conducted for scrotal or testicular pain and review the pathologic findings of orchiectomies done for lesions that were suspicious for malignancy on US. MATERIALS AND METHODS: We retrospectively reviewed the indications and findings of all scrotal US completed at our institution from 2002 to 2014. If a patient underwent an orchiectomy for an intratesticular lesion that was concerning for malignancy on US, the pathology report was also reviewed. RESULTS: There were 18,593 scrotal US performed, with 7,668 (41.2%) conducted for scrotal pain. Of the US performed for pain, 80.4% revealed benign or normal findings, and only 2.2% demonstrated a finding that is an absolute indication for surgery (intratesticular lesion suspicious for malignancy 0.8%, abscess 0.7%, torsion 0.6%, infiltrative process such as lymphoma 0.1%). For those patients undergoing an orchiectomy, 75% had malignancy on pathologic analysis. CONCLUSION: The majority of the 7668 US performed to evaluate scrotal or testicular pain reveal normal or benign findings. A low percentage demonstrates a finding that necessitates urgent or emergent surgery.

Prostate MRI: a national survey of Urologist's attitudes and perceptions.

INTRODUCTION: The use of multi-parametric (MP) MRI to diagnose prostate cancer has been the subject of intense research, with many studies showing positive results. The purpose of our study is to better understand the accessibility, role, and perceived accuracy of MP-MRI in practice by surveying practicing urologists. MATERIALS AND METHODS: Surveys were sent to 7,400 practicing American Urological Association member physicians with a current email address. The survey asked demographic information and addressed access, accuracy, cost, and role of prostate MRI in clinical practice. RESULTS: Our survey elicited 276 responses. Respondents felt that limited access and prohibitive cost of MP-MRI limits its use, 72% and 59% respectively. Academic urologists ordered more MP-MRI studies per year than those in private practice (43.3% vs. 21.1%; p<0.001). Urologists who performed more than 30 prostatectomies a year were more likely to feel that an MP-MRI would change their surgical approach (37.5% vs. 19.6%, p-value=0.002). Only 25% of respondents agreed or strongly agreed that MP-MRI should be used in active surveillance. For patients with negative biopsies and elevated PSA, 39% reported MP-MRI to be very useful. CONCLUSIONS: Our study found that MP-MRI use is most prominent among practitioners who are oncology fellowship-trained, practice at academic centers, and perform more than 30 prostatectomies per year. Limited access and prohibitive cost of MP-MRI may limit its utility in practice. Additionally, study participants perceive a lack of accuracy of MP-MRI, which is contrary to the recent literature.

Prostate MRI: a national survey of urologist's attitudes and perceptions

ABSTRACT Introduction The use of multi-parametric (MP) MRI to diagnose prostate cancer has been the subject of intense research, with many studies showing positive results. The purpose of our study is to better understand the accessibility, role, and perceived accuracy of MP-MRI in practice by surveying practicing urologists. Materials and Methods Surveys were sent to 7,400 practicing American Urological Association member physicians with a current email address. The survey asked demographic information and addressed access, accuracy, cost, and role of prostate MRI in clinical practice. Results Our survey elicited 276 responses. Respondents felt that limited access and prohibitive cost of MP-MRI limits its use, 72% and 59% respectively. Academic urologists ordered more MP-MRI studies per year than those in private practice (43.3% vs. 21.1%; p<0.001). Urologists who performed more than 30 prostatectomies a year were more likely to feel that an MP-MRI would change their surgical approach (37.5% vs. 19.6%, p-value=0.002). Only 25% of respondents agreed or strongly agreed that MP-MRI should be used in active surveillance. For patients with negative biopsies and elevated PSA, 39% reported MP-MRI to be very useful. Conclusions Our study found that MP-MRI use is most prominent among practitioners who are oncology fellowship-trained, practice at academic centers, and perform more than 30 prostatectomies per year. Limited access and prohibitive cost of MP-MRI may limit its utility in practice. Additionally, study participants perceive a lack of accuracy of MP-MRI, which is contrary to the recent literature.

Artificial Urinary Sphincters for Treatment of Urinary Incontinence in Elderly Males.

INTRODUCTION: We sought to examine the role of advanced age (defined as >70 years), impaired cognitive function, and decreased manual dexterity in the rates of re-operation (revision or replacement) of artificial urinary sphincters (AUS). METHODS: From 1988 to 2012, 213 men underwent virgin AUS placements. Failure was defined as a revision performed for stress incontinence and replacement/exploration performed for urethral erosion/infection or mechanical failure. Kaplan-Meier curves were constructed to compare failure rates with age and Cox proportional hazard models were used to test associations. RESULTS: Advanced age was not associated with overall failure (p = 0.48), erosion/infection failure (p = 0.65), recurrent/persistent incontinence failure (p = 0.08), or mechanical failure (p = 0.36). Controlling for age, patients with cognitive dysfunction or decreased manual dexterity showed a higher rate of overall failure (p = 0.01). CONCLUSIONS: AUS placement is an excellent option to treat stress urinary incontinence in elderly men with intact cognition and good manual dexterity. AUS placement should be performed with caution in patients with impaired cognitive function or decreased manual dexterity, and additional effort should be made to identify these conditions both before and after surgery.

Anterior Urethral Stricture Disease Negatively Impacts the Quality of Life of Family Members.

Purpose. To quantify the quality of life (QoL) distress experienced by immediate family members of patients with urethral stricture via a questionnaire given prior to definitive urethroplasty. The emotional, social, and physical effects of urethral stricture disease on the QoL of family members have not been previously described. Materials and Methods. A questionnaire was administered prospectively to an immediate family member of 51 patients undergoing anterior urethroplasty by a single surgeon (SBB). The survey was comprised of twelve questions that addressed the emotional, social, and physical consequences experienced as a result of their loved one. Results. Of the 51 surveyed family members, most were female (92.2%), lived in the same household (86.3%), and slept in the same room as the patient (70.6%). Respondents experienced sleep disturbances (56.9%) and diminished social lives (43.1%). 82.4% felt stressed by the patient's surgical treatment, and 83.9% (26/31) felt that their intimacy was negatively impacted. Conclusions. Urethral stricture disease has a significant impact on the family members of those affected. These effects may last decades and include sleep disturbance, decreased social interactions, emotional stress, and impaired sexual intimacy. Treatment of urethral stricture disease should attempt to mitigate the impact of the disease on family members as well as the patient.

Epidemiology of Traumatic Adrenal Injuries Requiring Surgery.

OBJECTIVE: To analyze adrenal injuries using the National Trauma Data Bank. Adrenal trauma is rare and current literature is lacking in data from large case series. METHODS: A retrospective analysis of the National Trauma Data Bank from the years 2007-2011 was performed. Patient demographics, Injury Severity Score (ISS), mechanism of injury, type of trauma, associated injuries, and development of shock were assessed. Multivariable models were used to determine association with outcomes, such as characterization of injury, need for adrenalectomy, intensive care unit admission, and death. RESULTS: Of the 1,766,606 trauma cases recorded, 7791 involved 1 or both adrenal glands (0.44%). Common associated injuries were to the ribs (50.9%), thorax (50.0%), and liver (41.6%). Eighty adrenal injuries required surgery (80/7791, 1.0%), none of which were isolated adrenal injuries (0/120, P = .63). Higher ISS (P = .009), Black race (P = .031), penetrating injury (P < .001), and splenic (P < .001) and intestinal injuries (P = .018) were associated with need for adrenalectomy. No isolated adrenal injuries were associated with death (12% vs 0%, P < .0001). Older age (P < .001), higher ISS (P < .001), chronic kidney disease (P = .009), penetrating injuries (P < .001), and injuries to the aorta/vena cava (P = .008), peripheral vasculature (P < .0001), thorax (P = .029), brain/spinal cord (P < .001), and abdominal polytrauma (P = .005) were associated with mortality. CONCLUSIONS: Adrenal injuries are rare, comprising 0.44% of recorded traumatic injuries. Isolated adrenal injuries were not fatal and did not require surgery, and thus should be managed conservatively. Detection of adrenal injury in polytrauma patients is key, particularly penetrating trauma and concurrent splenic and/or intestinal injuries, as these patients are more likely to require adrenalectomy.

Botulinum Toxin Type A Injections for the Treatment of Continent Catheterizable Ileal-colic Urinary Diversion Muscularis Overactivity.

INTRODUCTION: Continent catheterizable diversions can exhibit long-term complications such as high pressures and involuntary unit contractions within the urinary reservoir, rendering them similar to neurogenic bladders. Given the similarity of these issues to neurogenic detrusor overactivity, the use of Botox injections is a logical treatment option to explore. TECHNICAL CONSIDERATIONS: A patient with a contracted Indiana pouch continent catheterizable diversion was treated with intra-pouch Botox injections after failing maximal doses of oral anticholinergic medications. This patient underwent four consecutive percutaneous Botox pouch injections every 11-12 months under general anesthesia. Flexible cystoscope via the catch stoma was attempted first on the first two surgeries, but the scope could not reach the majority of the pouch. Thus, percutaneous access was obtained under fluoroscopic guidance, and the injections were performed through a suprapubic tube access sheath. Two hundred to four hundred units of Botox (stained with methylene blue) were visually injected in 20-40 separate injection sites. Of note, the initial dose used was 200 units and was increased to 300 units then 400 units on subsequent treatments to improve results and durability. After each round of Botox injections, the patient noted resolution of her symptoms. Postinjection urodynamic studies showed normal filling with no evidence of muscularis overactivity, even at high volumes of 600 cc. CONCLUSION: Botox injections may be an excellent long-term treatment option for contracted continent catheterizable diversions, or at least used as a temporizing measure before surgical augmentation. Further studies are needed to verify the durability, complications, and long-term outcomes of this procedure.

A Comparative Analysis of International Knee Documentation Committee Scores for Common Pediatric and Adolescent Knee Injuries.

BACKGROUND: Several different etiologies cause knee pain in the pediatric and adolescent population, including anterior knee/patellofemoral pain, patellar instability, anterior cruciate ligament (ACL) tears, meniscal tears, osteochondritis dissecans (OCD) lesions, and discoid meniscus. The purpose of the current study was to determine the relative morbidity of different causes of knee pain in children and adolescents using the International Knee Documentation Committee (IKDC) score. METHODS: We performed a retrospective review of prospectively collected data of a cohort of pediatric and adolescent patients with knee pain who presented to a single surgeon. Each patient completed an IKDC questionnaire at the time of diagnosis and patients were grouped by diagnosis for analysis. Statistical analysis was performed to compare the IKDC scores of the 7 diagnostic groups, and a P-value <0.05 was considered significant. RESULTS: The IKDC mean score for all 242 patients was 50.3±18.3. The mean IKDC score for patients with isolated meniscal tears was 41.2±16.0, combined ACL and meniscal injuries was 50.2±13.9, and isolated ACL tears was 48.1±14.1. The mean IKDC score for patients with symptomatic discoid meniscus was 46.3±13.2, anterior knee pain/patellofemoral pain was 49.0±17.4, patellar instability was 49.2±22.1, and OCD lesions was 62.2±19.5. CONCLUSIONS: The IKDC scores of most of the diagnostic groups were similar to the overall average score, with the notable exception of patients with OCD lesions exhibiting statistically significant less morbidity reflected by a higher IKDC score. Although symptoms in each individual clinical presentation may vary, knowledge of the relative morbidity of these diagnostic groups is valuable in counseling patients and their families regarding these common pediatric and adolescent sources of knee pain. LEVEL OF EVIDENCE: Level IV.

Gracilis muscle interposition flap repair of urinary fistulae: pelvic radiation is associated with persistent urinary incontinence and decreased quality of life.

PURPOSE: The primary goal of urinary fistulae repair is to improve continence and quality of life. Irradiated patients are predisposed to development of bladder outlet dysfunction (BOD), defined as bladder neck contracture or stress urinary incontinence. Here, we review our experience with gracilis flap repairs for rectourinary fistulae (RUF) and urinary cutaneous fistulae (UCF) in patients who underwent pelvic radiation. METHODS: Twenty-seven patients underwent repair of a RUF/UCF with gracilis flap between 2003 and 2013. Patients were assessed for postoperative fistula closure and BOD, and quality of life was assessed with the Expanded Prostate Index Composite (EPIC) questionnaire administered via telephone at the time of final follow-up. RESULTS: Mean age was 60 years (50-73) with median follow-up of 28.7 months (1.0-128). Flap failure was noted in 5/20 radiated patients versus 3/7 non-radiated patients (p = 0.63). Of the 8 flap failures, 7 underwent secondary repair: repeat gracilis flap (2), coloanal pull-through (2), rectal advancement flap (1), sliding flap (1), and omental flap (1). Median time to revision was 7.2 months (3.5-24.9). In irradiated patients, 18/20 (90 %) developed BOD compared with 1/7 (14 %) who were not radiated (p = 0.0006). Radiation was associated with worse scores on the urinary incontinence domain of the EPIC questionnaire compared with non-radiated patients (p = 0.0458). CONCLUSIONS: Urinary fistula repairs in radiated patients should be undertaken with caution. Even if the fistula is successfully repaired, patients may still have bladder outlet dysfunction and decreased quality of life. Consequently, patients should be counseled about all possible procedures, including permanent urinary diversion as primary therapy.

Hemorrhagic Cystitis Requiring Bladder Irrigation is Associated with Poor Mortality in Hospitalized Stem Cell Transplant Patients

Purpose: To evaluate the overall prognosis of post-stem cell transplant inpatients who required continuous bladder irrigation (CBI) for hematuria. Materials and Methods: We performed a retrospective analysis of adult stem cell transplant recipients who received CBI for de novo hemorrhagic cystitis as inpatients on the bone marrow transplant service at Washington University from 2011-2013. Patients who had a history of genitourinary malignancy and/or recent surgical urologic intervention were excluded. Multiple variables were examined for association with death. Results: Thirty-three patients met our inclusion criteria, with a mean age of 48 years (23-65). Common malignancies included acute myelogenous leukemia (17/33, 57%), acute lymphocytic leukemia (3/33, 10%), and peripheral T cell lymphoma (3/33, 10%). Median time from stem cell transplant to need for CBI was 2.5 months (0 days-6.6 years). All patients had previously undergone chemotherapy (33/33, 100%) and 14 had undergone prior radiation therapy (14/33, 42%). Twenty-eight patients had an infectious disease (28/33, 85%), most commonly BK viremia (19/33, 58%), cytomegalovirus viremia (17/33, 51%), and bacterial urinary tract infection (8/33, 24%). Twenty-two patients expired during the same admission as CBI treatment (22/33 or 67% of total patients, 22/28 or 79% of deaths), with a 30-day mortality of 52% and a 90-day mortality of 73% from the start of CBI. Conclusions: Hemorrhagic cystitis requiring CBI is a symptom of severe systemic disease in stem cell transplant patients. The need for CBI administration may be a marker for mortality risk from a variety of systemic insults, rather than directly attributable to the hematuria.

Testicular Interposition Flap for Repair of Perineal Urinary Fistulae: A Novel Surgical Technique.

Rectourinary fistulae and urinary-cutaneous fistulae are a rare yet devastating complication. Current options for tissue interposition include rectus, gracilis, or gluteal muscle, omentum, or intestine for use in coloanal pull-through procedures. In elderly patients, testicular interposition flaps may be an excellent tissue option to use when vitalized tissue is necessary to supplement fistula repair. Elderly patients frequently have increased spermatic cord length, potentially offering a longer flap reach than use of a muscle flap. Additionally, mobilizing one of the testicles and developing it through the external inguinal ring may be a less morbid and less costly procedure than harvesting and tunneling a muscle flap. Longer follow-up and further studies are needed to determine the outcomes of this novel technique.

Outcomes of Iatrogenic Genitourinary Injuries During Colorectal Surgery.

OBJECTIVE: To describe, categorize, and determine the outcomes of repairs of genitourinary (GU) injuries that occur during colorectal surgery. Presently, little is known regarding these injuries or the long-term outcomes of their repair. METHODS: We performed a retrospective review of patients undergoing colorectal surgery between 2003 and 2013 who experienced iatrogenic GU injuries requiring surgical repair. GU repair failures were defined as development of urine leak, urinary fistula, or anastomotic stricture requiring secondary GU intervention. Possible risk factors associated with repair failures were examined and included age, American Society of Anesthesiology score, comorbidities, type of colorectal surgery, radiation, and chemotherapy. RESULTS: Of 42,570 colorectal surgeries performed, 75 GU injuries were identified (0.18%). Mean age was 57.5 years (range, 22-91), and median follow-up was 19.5 months (range, 1-128). Fifty-nine (59/75, 79%) patients required a single GU repair whereas 16 of 75 (21%) patients experienced repair failure requiring additional GU intervention. The most common GU injuries were cystotomy (26/75, 35%), incomplete ureteral transection (22/75, 29%), complete proximal and distal ureteral injuries (13/75, 17%; 11/75, 15%), urethral injury (2/75, 3%), and injury to a pre-existing ileal conduit (1/75, 1). Twenty-seven patients (36%) had prior radiation and 35 patients (47%) had prior chemotherapy. Preoperative radiation and chemotherapy were both associated with failure of the GU repair (P = .003; P = .013). Delayed repair of the GU injury was also associated with repair failure (P = .001). CONCLUSION: Iatrogenic GU injuries during colorectal surgery are rare, affecting only 0.18% of colorectal procedures. Preoperative external beam radiation therapy/chemotherapy and delayed GU repair are associated with worse outcomes of repairs of these injuries.

Urinary-cutaneous Fistulae in Patients With Neurogenic Bladder.

OBJECTIVE: To review our experience with neurogenic bladder (NGB) patients who developed urinary-cutaneous fistulae (UCF). Patients with NGB can form UCF of multiple etiologies; however, little is known about the characteristics or long-term outcomes of these defects. MATERIALS AND METHODS: We reviewed 21 patients with NGB who developed UCF between 1998 and 2013. The clinical end points of the study were development of UCF, fistula repair failure, and need for permanent urinary diversion. Possible risk factors associated with repair failures were examined. RESULTS: We evaluated 21 patients with a mean age of 39.5 years (23-76) and median follow-up of 67 months (1-179). Causes of UCF included decubitus ulcers (7), wound infections or abscess formation (5), condom catheter complications (4), traumatic catheterization (4), and pelvic trauma (1). Thirteen patients had their fistulae repaired surgically, with 9 patients eventually requiring urinary diversion with a suprapubic (SP) tube (7) or ileal conduit (2) (9 of 13, 69%). Eight patients had their urine diverted upon presentation, with ileal conduit (5 of 8, 63%), SP tube (2 of 8, 25%), or perineal urethrostomy (1 of 8, 12%). In total, 17 eventually required permanent surgical or SP tube urinary diversion (81%), of which 9 were with an SP tube (53%), 4 with an ileal conduit (23%), 3 with a conduit catheter (18%), and 1 with a perineal urethrostomy (6%). CONCLUSION: UCF repairs in patients with NGB are a challenge to manage. Patients who undergo surgical repair of their fistula are likely to require repeat repairs with eventual need for a permanent urinary diversion.

Patient Characteristics and Perioperative Outcomes of Female Urethral Diverticulectomy: Analysis of a Multi-Institutional Prospective Database.

OBJECTIVE: To assess the patient and perioperative characteristics of urethral diverticulectomy using a large multi-institutional prospectively collected database. MATERIALS AND METHODS: Female patients were identified using the American College of Surgeons National Surgical Quality Improvement Program participant user files (2007-2012) and current procedural terminology codes for urethral diverticulectomy (53,230). Preoperative variables and 30-day complications were examined. RESULTS: Urethral diverticulectomies were performed on 122 females during the study period. The cohort was relatively healthy; 80% of patients had an American Society of Anesthesiologists score of 1 or 2. The majority of procedures were performed in an outpatient setting (82%). The median procedure length was 77.5 minutes (interquartile range: 50.5-112.5), and the median length of stay was 0 days (interquartile range: 0-1). The overall 30-day complication rate was 3.3% (n = 4): 3 patients developed urinary tract infections (UTIs) and 1 patient developed both a UTI and a superficial wound infection. CONCLUSION: To our knowledge, our study represents the largest multi-institutional cohort of patients having undergone urethral diverticulectomy. The patients requiring this intervention were relatively healthy, and the procedure itself was short, allowing most patients to be discharged within 24 hours. The 30-day complication rate was very low, with UTI being the most common complication. Thus, patients can continue to be confidently counseled that urethral diverticulectomy is a safe procedure with very few perioperative complications.

Pelvic radiation is associated with urinary fistulae repair failure and need for permanent urinary diversion.

OBJECTIVE: To review our experience with nonmuscle flap repairs of enterourinary fistulae (EUF) and urinary cutaneous fistulae (UCF). EUF and UCF can be treated either with temporary urinary diversion allowing for healing by secondary intention or primary closure of the defect using an interposing omental, sliding, or muscle flap. Even after successful fistula repair, permanent urinary diversion can be required because of persistent urinary incontinence. MATERIALS AND METHODS: We reviewed 86 patients who underwent treatment of EUF or UCF at Washington University between the years 1998 and 2013. Of these, 39 patients underwent fistula repair, whereas 47 patients underwent either surgical or nonsurgical urinary diversion. Outcomes measured included postoperative fistula closure, need for permanent urinary diversion, and urinary incontinence. RESULTS: The mean age in our series was 59 years (21-87 years) at the time of surgery, with median follow-up of 20 months (1-137 months). Among patients who underwent surgical repair, radiation was associated with higher rates of repair failure (P = .0002), postsurgical incontinence (P <.0001), and the need for permanent urinary diversion (P = .0076). At the time of final follow-up, 32 of the 44 radiated patients had required permanent diversion (72%) compared with 3 of the 42 nonradiated patients (7%; P <.0001). CONCLUSION: Patients who undergo pelvic radiation before EUF and UCF repairs are at higher risk for developing repair failure and postsurgical incontinence. Many patients eventually require permanent urinary diversion. Therefore, EUF and UCF repairs in radiated patients should be undertaken with caution, and patients should be counseled about the possibility of urinary diversion as primary therapy.

Seminoma presenting as renal mass, inferior vena caval thrombus, and regressed testicular mass.

Testicular cancer is the most common malignancy of men aged 15-40. Metastatic spread classically begins with involvement of the retroperitoneal lymph nodes, with metastases to the liver, lung, bone, and brain representing advancing disease. Treatment is based on pathologic analysis of the excised testicle and presence of elevated tumor markers. We report a case of a 34-year-old male presenting with back pain who was found to have a right renal mass with tumor extension into the inferior vena cava. Subsequent biopsy was consistent with seminoma. We review this rare case and discuss the literature regarding its diagnosis and management.