PROPOSED REVISION OF THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA RENAL TRAUMA ORGAN INJURY SCALE: SECONDARY ANALYSIS OF THE MULTI-INSTITUTIONAL GENITOURINARY TRAUMA STUDY.

BACKGROUND: This study updates the American Association for Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention. METHODS: This was a secondary analysis of a multi-center retrospective study including patients with high grade renal trauma from 7 Level-1 trauma centers from 2013-2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells (PRBCs) transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the receiver-operator curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST organ injury scale. RESULTS: based on the 2018 OIS grading system, we included 549 patients with AAST Grade III-V injuries and CT scans (III: 52% (n = 284), IV: 45% (n = 249), and V: 3% (n = 16)). Among these patients, 89% experienced blunt injury (n = 491) and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC = 0.805, revised AUC = 0.883; p = 0.001) and number of units of PRBCs transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention. CONCLUSIONS: A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system. LEVEL OF EVIDENCE: II.

Retrospective Multicenter Observational Study of Immediate Voiding at End of Urinary Sphincter Surgery (REMOVE).

PURPOSE: Patients may remain catheterized after artificial urinary sphincter surgery to prevent urinary retention, despite a lack of evidence to support this practice. Our study aims to evaluate the feasibility of outpatient, catheter-free continence surgery using a multi-institutional database. We hypothesize that between catheterized controls and patients without a catheter, there would be no difference in the rate of urinary retention or postoperative complications. MATERIALS AND METHODS: We conducted a retrospective review of patients undergoing first-time artificial urinary sphincter placement from 2009-2021. Patients were stratified by postoperative catheter status into either no-catheter (leaving the procedure without a catheter) or catheter (postoperative indwelling catheter for ∼24 hours). The primary outcome, urinary retention, was defined as catheterization due to subjective voiding difficulty or documented postvoid residual over 250 mL. RESULTS: Our study identified 302 catheter and 123 no-catheter patients. Twenty (6.6%) catheter and 9 (7.3%) no-catheter patients developed urinary retention (P = .8). On multivariable analysis, controlling for age, cuff size, radiation history and surgeon, there was no statistically significant association between omitting a catheter and urinary retention (OR: 0.45, 95% CI: 0.13-1.58; P = .2). Furthermore, at 30 months follow-up, Kaplan-Meier survival analysis revealed that device survival was 70% (95% CI: 62%-76%) vs 69% (95% CI: 48%-82%) for the catheter and no-catheter group, respectively. CONCLUSIONS: In our multi-institutional cohort, overall retention rates were low (7%) in groups with a catheter and without. Obviating postoperative catheterization facilitates outpatient incontinence surgery without altering reoperation over medium-term follow-up.

Shattered Kidney After Renal Trauma: Should It Be Classified As an American Association for the Surgery of Trauma Grade V Injury?

OBJECTIVE: To study the prevalence and management of shattered kidney and to evaluate if the new description of "loss of identifiable renal anatomy" in the 2018 American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) would improve the ability to predict bleeding control interventions. METHODS: We used high-grade renal trauma data from 21 Level-1 trauma centers from 2013 to 2018. Initial CT scans were reviewed to identify shattered kidneys, defined as a kidney having ≥3 parenchymal fragments displaced by blood or fluid on cross-sectional imaging. We further categorized patients with shattered kidney in two models based on loss of identifiable renal parenchymal anatomy and presence or absence of vascular contrast extravasation (VCE). Bleeding interventions were compared between the groups. RESULTS: From 861 high-grade renal trauma patients, 41 (4.8%) had shattered kidney injury. 25 (61%) underwent a bleeding control intervention including 18 (43.9%) nephrectomies and 11 (26.8%) angioembolizations. 18 (41%) had shattered kidney with "loss of identifiable parenchymal renal anatomy" per 2018 AAST OIS (model-1). 28 (68.3%) had concurrent VCE (model-2). Model-2 had a statistically significant improvement in area under the curve over model-1 in predicting bleeding interventions (0.75 vs 0.72; P = .01). CONCLUSION: Shattered kidney is associated with high rates of active bleeding, urinary extravasation, and interventions including nephrectomy. The definition of shattered kidney is vague and subjective and our definition might be simpler and more reproducible. Loss of identifiable renal anatomy per the 2018 AAST OIS did not provide better distinction for bleeding control interventions over presence of VCE.

Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study.

PURPOSE: To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management. METHODS: We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery). RESULTS: Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found. CONCLUSION: Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

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.

Small Diameter Penile Implants: A Survey on Current Utilization and Review of Literature.

BACKGROUND: Inflatable penile prostheses (IPPs) with smaller diameter cylinders have been in use for over 30 years, yet the literature is sparse on their utilization patterns amongst prosthetic surgeons. AIM: To understand current usage of small diameter penile implants (SDPI) among prosthetic surgeons. METHODS: IRB approval was obtained to conduct a survey of prosthetic surgeons. A 23-question online survey was distributed via email to physician members of the Sexual Medicine Society of North America (SMSNA) and Society of Urologic Prosthesis Surgeons (SUPS). The survey included questions regarding surgeon experience and volume, frequency of SDPI utilization, indications for SDPI, surgical strategy in the setting of SDPI (approach, use of concordant modeling/grafting), reservoir and pump management, and perceived infection risk and patient satisfaction. MAIN OUTCOME MEASURE: SDPI were utilized by the vast majority of respondents in certain clinical situations such as corporal fibrosis or anatomically small corpora, and surgeons have had a favorable experience with these as a final destination implant or as a place-holder until reimplantation with a normal diameter device. RESULTS: Fifty individuals responded to the survey, 48 of whom routinely utilized SDPI. The most common indication for SDPI placement was corporal fibrosis from prior infection, followed by anatomically small corpora and priapism. The most common maximal dilation diameter was 10 mm (47%), an additional 23% of respondents utilized SDPI with 11 mm dilation. 75.4% of respondents sometimes or always intended to upsize to standard diameter cylinders in the future. 68.8% of surgeons routinely counseled patients on the possibility of reduced grith and rigidity with SDPI. Patient satisfaction was perceived to be comparable to standard diameter cylinders in 56.3% of respondents, while the remaining 43.6% believed it to be lower than traditional cylinders. Utilization of SDPI can be an important tool for prosthetic surgeons faced with difficult cases due to corporal fibrosis or small corpora. This survey provides new insight into patterns of SDPI utilization by surgeons. A limitation of the study is that patient satisfaction is indirectly addressed through surgeons' perception and experience, further research will be necessary to include patient questionnaires regarding device satisfaction. CONCLUSION: SDPI are necessary in certain scenarios that preclude the use of normal diameter cylinders. These implants may offer satisfactory erections, but can also be upsized to standard diameter cylinders in the future. Campbell SP, Kim CJ, Allkanjari A et al. Small Diameter Penile Implants: A Survey on Current Utilization and Review of Literature. Sex Med 2022;10:100458.

Nephrectomy After High-Grade Renal Trauma is Associated With Higher Mortality: Results From the Multi-Institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates. METHODS: We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS). RESULTS: A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P <.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55). CONCLUSION: Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage.

External validation of a nomogram predicting risk of bleeding control interventions after high-grade renal trauma: The Multi-institutional Genito-Urinary Trauma Study.

BACKGROUND: Renal trauma grading has a limited ability to distinguish patients who will need intervention after high-grade renal trauma (HGRT). A nomogram incorporating both clinical and radiologic factors has been previously developed to predict bleeding control interventions after HGRT. We aimed to externally validate this nomogram using multicenter data from level 1 trauma centers. METHODS: We gathered data from seven level 1 trauma centers. Patients with available initial computed tomography (CT) scans were included. Each CT scan was reviewed by two radiologists blinded to the intervention data. Nomogram variables included trauma mechanism, hypotension/shock, concomitant injuries, vascular contrast extravasation (VCE), pararenal hematoma extension, and hematoma rim distance (HRD). Mixed-effect logistic regression was used to assess the associations between the predictors and bleeding intervention. The prediction accuracy of the nomogram was assessed using the area under the receiver operating characteristic curve and its 95% confidence interval (CI). RESULTS: Overall, 569 HGRT patients were included for external validation. Injury mechanism was blunt in 89%. Using initial CT scans, 14% had VCE and median HRD was 1.7 (0.9-2.6) cm. Overall, 12% underwent bleeding control interventions including 34 angioembolizations and 24 nephrectomies. In the multivariable analysis, presence of VCE was associated with a threefold increase in the odds of bleeding interventions (odds ratio, 3.06; 95% CI, 1.44-6.50). Every centimeter increase in HRD was associated with 66% increase in odds of bleeding interventions. External validation of the model provided excellent discrimination in predicting bleeding interventions with an area under the curve of 0.88 (95% CI, 0.84-0.92). CONCLUSION: Our results reinforce the importance of radiologic findings such as VCE and hematoma characteristics in predicting bleeding control interventions after renal trauma. The prediction accuracy of the proposed nomogram remains high using external data. These variables can help to better risk stratify high-grade renal injuries. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

The American Association for the Surgery of Trauma Renal Grading System-Should Segmental Kidney Infarction be Classified as a Grade IV Injury?

PURPOSE: In 2018 the American Association for the Surgery of Trauma revised renal injury grading. One change was inclusion of segmental kidney infarction under grade IV injuries. We aimed to assess how segmental kidney infarction will change the scope of grade IV injuries and compare bleeding control interventions in those with and without isolated segmental kidney infarction. METHODS: We used high grade renal trauma data from 7 level 1 trauma centers from 2013 to 2018 as part of the Multi-institutional Genito-Urinary Trauma Study. Initial computerized tomography scans were reviewed to regrade the injuries. Injuries were categorized as isolated segmental kidney infarction if segmental parenchymal infarction was the only reason for inclusion under grade IV injury. All other grade IV injuries (including combined injury patterns) were categorized as without isolated segmental kidney infarction. Bleeding interventions were compared between those with and without isolated segmental kidney infarction. RESULTS: From 550 patients with high grade renal trauma and available computerized tomography, 250 (45%) were grade IV according to the 2018 American Association for the Surgery of Trauma grading system. Of these, 121 (48%) had isolated segmental kidney infarction. The majority of patients with isolated segmental kidney infarction (88%) would have been assigned a lower grade using the original 1989 grading system. Rate of bleeding control interventions was lower in isolated segmental kidney infarction compared to other grade IV injuries (7% vs 21%, p=0.002). Downgrading all patients with isolated segmental kidney infarction to grade III did not change the grading system's associations with bleeding interventions. CONCLUSIONS: Approximately half of the 2018 American Association for the Surgery of Trauma grade IV injuries have isolated segmental kidney infarction. Including isolated segmental kidney infarction in grade IV injuries increases the heterogeneity of these injuries without increasing the grading system's ability to predict bleeding interventions. In future iterations of the American Association for the Surgery of Trauma renal trauma grading isolated segmental kidney infarction could be reclassified as grade III injury.

The Male Urethra: Imaging and Surgical Approach for Common Pathologies.

Urethral pathology is common in clinical practice and important to recognize. It is essential to recognize urethral pathology on imaging and to understand how to best image the urethra. In this way, the radiologist can provide the urologist with the necessary information prior to intervention. Basic knowledge of commonly performed urethral surgeries can help the radiologist understand the expected appearance of the post-treatment urethra and common postoperative complications.

Clinical and Radiographic Factors Associated With Failed Renal Angioembolization: Results From the Multi-institutional Genitourinary Trauma Study (Mi-GUTS).

OBJECTIVE: To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma. MATERIAL AND METHODS: Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy. RESULTS: A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan. CONCLUSION: Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization.

Current Management of Extraperitoneal Bladder Injuries: Results from the Multi-Institutional Genito-Urinary Trauma Study (MiGUTS).

PURPOSE: We studied the current management trends for extraperitoneal bladder injuries and evaluated the use of operative repair versus catheter drainage, and the associated complications with each approach. MATERIALS AND METHODS: We prospectively collected data on bladder trauma from 20 level 1 trauma centers across the United States from 2013 to 2018. We excluded patients with intraperitoneal bladder injury and those who died within 24 hours of hospital arrival. We separated patients with extraperitoneal bladder injuries into 2 groups (catheter drainage vs operative repair) based on their initial management within the first 4 days and compared the rates of bladder injury related complications among them. Regression analyses were used to identify potential predictors of complications. RESULTS: From 323 bladder injuries we included 157 patients with extraperitoneal bladder injuries. Concomitant injuries occurred in 139 (88%) patients with pelvic fracture seen in 79%. Sixty-seven patients (43%) initially underwent operative repair for their extraperitoneal bladder injuries. The 3 most common reasons for operative repair were severity of injury or bladder neck injury (40%), injury found during laparotomy (39%) and concern for pelvic hardware contamination (28%). Significant complications were identified in 23% and 19% of the catheter drainage and operative repair groups, respectively (p=0.55). The only statistically significant predictor for complications was bladder neck or urethral injury (RR 2.69, 95% 1.21-5.97, p=0.01). CONCLUSIONS: In this large multi-institutional cohort, 43% of patients underwent surgical repair for initial management of extraperitoneal bladder injuries. We found no significant difference in complications between the initial management strategies of catheter drainage and operative repair. The most significant predictor for complications was concomitant urethral or bladder neck injury.

Feasibility of Intracorporeal Robotic-Assisted Laparoscopic Appendiceal Interposition for Ureteral Stricture Disease: A Case Report.

OBJECTIVE: To describe a robotic-assisted laparoscopic (RAL) technique for using the appendix to repair ureteral stricture disease MATERIALS AND METHODS: A case of a patient presenting with a 5-cm obliterative right ureteral stricture was reviewed, and surgical technique, complications, and outcomes were reported. RESULTS: Our patient developed a right-sided 5-cm obliterative ureteral stricture secondary to recurrent stone disease and pyelonephritis. He underwent an uncomplicated RAL repair of his stricture with interposition of the appendix between the 2 segments of ureter. Operative time was just over 6 hours, blood loss was minimal, and there were no complications. A 10-month follow-up showed resolution of hydronephrosis with no flank pain. CONCLUSION: We report our initial experience with this procedure and believe that RAL appendiceal interposition for ureteral stricture disease presents an excellent option for reconstruction.

Combined Aortic Valve Replacement and Renal Cell Carcinoma Thrombectomy.

Although nephrectomy for renal cell carcinoma with inferior vena cava invasion is a common procedure, it is rare to have level IV invasion necessitating cardiopulmonary bypass (CPB). Furthermore, it is exceptionally rare to perform cardiac surgery concomitantly with this resection. We report a case in which an aortic valve replacement was done in the same surgical setting as a level IV thrombectomy. We have demonstrated that although it can be difficult to manage the coagulopathy post-CPB, this can be successfully accomplished with adequate prior preparation and a coordinated team effort.

The contemporary management of urethral strictures in men resulting from lichen sclerosus.

Lichen sclerosus (LS) is a chronic, inflammatory disease primarily involving the genital skin and urethra in males. Historically, the treatment of this common condition was a challenge due to its uncertain etiology, variable response to therapy, and predilection to recur. The etiology of LS is still debated and has been linked to autoimmune disease, infection, trauma, and genetics. Today, topical steroids are a mainstay of therapy for patients, even in the presence of advanced disease, and can induce regression of the disease. In advanced cases, surgery may be required and range from circumcision, meatoplasty, or, in the case of advanced stricture disease, urethroplasty or perineal urethrostomy. When urethroplasty is required, the use of genital skin as a graft or flap is to be avoided due to the predilection for recurrence. Surgical management should be approached only after failure of more conservative measures due to the high risk of recurrence of LS in the repaired site despite the use of buccal grafting. LS may be associated with the development of squamous cell carcinoma and for this reason, patients should undergo biopsy when LS is suspected and long-term surveillance is recommended.

Metabolic syndrome as a predictor for postoperative complications after urologic surgery.

OBJECTIVE: To elucidate whether metabolic syndrome (MS) has an effect on outcomes after nephrectomy, prostatectomy, or cystectomy. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program's database, patients undergoing cystectomy, nephrectomy, or prostatectomy between 2005 and 2011 were reviewed to assess for the presence of MS and a variety of perioperative complications. RESULTS: The overall complication rate for cystectomy, nephrectomy, and prostatectomy was 52.4%, 20.2%, and 8.7%, respectively. On multivariate analysis controlling for age, sex, body mass index, cardiac comorbidity, functional status, surgical approach (prostatectomy and nephrectomy), and surgery within 30 days, MS was not associated with perioperative complications in patients undergoing cystectomy (odds ratio [OR], 0.760; 95% confidence interval [CI], 0.476-1.213). On multivariate analysis, the presence of MS was a significant predictor of perioperative complications after radical nephrectomy (adjusted OR, 1.489; 95% CI, 1.146-1.934). With regards to prostatectomy, MS was not a significant predictor of complications (OR, 1.065; 95% CI, 0.739-1.535). CONCLUSION: Patients in this cohort with MS undergoing cystectomy or prostatectomy did not experience a higher rate of complications compared with patients without MS, although patients with MS undergoing nephrectomy had a higher complication rate. It may be warranted to preoperatively counsel patients with MS undergoing nephrectomy that complication rates may be higher.

Penile prosthesis infection: approaches to prevention and treatment.

Epidemiologic studies have estimated that more than 50% of men ages 40 to 70 have some form of erectile dysfunction. Penile prosthesis implantation remains a mainstay for treatment of erectile dysfunction unresponsive to other less-invasive methods. Improvements in penile prosthesis design have extended the long-term survival of implants. As the improved design of prostheses has led to their increased mechanical survival, other complications, such as infection, have emerged as the leading causes of implant failure. This article focuses on approaches to prevention and treatment of penile prosthesis infection.