Long-term Renal Preservation and Complication Profile With Ileal Ureter Creation.

OBJECTIVE: To examine long-term ileal ureter replacement results at over 32 years at our institution. Long segment or proximal ureteral strictures pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, Boari flap, buccal ureteroplasty, and autotransplantation are common reconstructive techniques. We show that ileal ureter remains a lasting option. METHODS: We performed a retrospective review of patients undergoing open ileal ureter creation from 1989-2021. Patient demographics, operative history, and complications were examined. All patients were followed for changes in renal function. Demographic data were analyzed and Cox proportional hazard models were performed. RESULTS: One hundred and fifty-eight patients were identified with median follow-up time of 40 months. Eighty-one percent had a unilateral ileal ureter creation. Fifty percent were female, median age was 53.3. Twenty-seven percent of patients had radiation-induced strictures. Preoperatively, 56.3% of patients were chronic kidney disease stage 1-2 and 43.7% were stage 3-5. Post-operatively, 54% were stage 1-2 and 46% were stage 3-5. Cox proportional hazard models demonstrated no significant correlation between worsening renal function and stricture cause, bilateral repair, complications, or sex (biologically male or female). Seventy-seven percent had no 30-day complications. Clavien complications included grade 1 (18), grade 2 (4), grade 3 (9), and grade 4 (5). Long-term complications included worsening renal function (3%), incisional hernia (8.2%), and small bowel obstruction (6.9%). Five (3.1%) patients ultimately required dialysis and 5 (3.1%) patients developed metabolic acidosis. CONCLUSION: Ileal ureteral reconstruction is often a last resort for patients with complex ureteral injuries. Clinicians can be reassured by our long-term data that ileal ureteral creation is a safe treatment with good preservation of renal function and low risk of hemodialysis and metabolic acidosis.

Female Bladder Dysfunction Following Boari Bladder Flap Ureteral Reconstruction.

OBJECTIVE: To describe our institution's experience with Boari flap ureteral reconstruction, specifically focusing on the development of postoperative lower urinary tract symptoms (LUTS). METHODS: A retrospective review of all Boari flaps performed at our institution between 2013 and 2023 was performed, excluding patients with urothelial carcinoma and males, given the frequency of LUTS from benign prostatic hyperplasia. Primary outcome was the development of new onset LUTS and subsequent treatment. Secondary outcomes included postoperative infections and ureteral stricture. RESULTS: Twenty-nine total patients were identified. Mean age was 52.2 years (standard deviation (SD) 13.1). Mean follow-up was 22.3 months (SD 25.3). Primary reasons for ureteral reconstruction were radiation damage (37.9%) and iatrogenic surgical injury (37.9%). A concurrent psoas hitch was performed in 18/29 (62%) cases, nephropexy was utilized in 1/29 (3.4%) cases, and contralateral bladder pedicles were ligated in 10/29 (34.5%) for increased bladder mobilization. Postoperatively, 8 patients (27.6%) developed new-onset LUTS, effectively managed with oral anticholinergics. Recurrent urinary tract infections occurred in 5 patients (17.2%) and pyelonephritis in 1 (3.4%) patient. Two patients (6.9%) developed ureteral strictures, one treated with ileal ureter replacement and the other with ureteral balloon dilation. CONCLUSION: Boari bladder flap ureteral reconstruction leads to moderate rates of new onset LUTS postoperatively, which is important information when counseling women on reconstructive options. Boari flap ureteral reconstruction has a high success rate, and serious complications are rare. In the setting of ureteral injury, reconstruction using Boari flaps with or without psoas hitch should be considered for definitive management.

A review of the literature and proposed algorithm for penile fracture management.

INTRODUCTION: In the management of penile fractures, immediate surgical repair has resulted in better outcomes when compared with a conservative approach; however, there is currently no consensus on the treatment of patients presenting beyond the immediate period (>24 hours) following injury. OBJECTIVES: To examine the latest literature on management strategies in penile fracture and propose an optimal algorithm for the treatment of patients with delayed presentation. METHODS: A comprehensive search was conducted following the PRISMA-P 2020 guidelines. A search was performed in several databases with the following strategy: ("Penile fracture" OR "fracture of penis" OR "rupture of corpora cavernosa" OR "rupture of tunica albuginea") AND (management OR treatment OR surgery OR "surgical reconstruction" OR "surgical repair"). This resulted in 108 relevant articles. Two independent reviewers screened these articles according to the inclusion criteria. Full-text review of 56 articles was performed, and ultimately 20 studies were selected. Measures included the use of diagnostic imaging, timing of surgical repair (immediate, <24 hours after injury; delayed, >24 hours), surgical approach, and long-term complications (ie, erectile dysfunction and penile curvature). RESULTS: The review highlighted the benefits of immediate surgical repair in penile fractures, demonstrating improved patient outcomes. Furthermore, it found that surgical repair should be considered even in cases with delayed presentation (>24 hours after injury). To better evaluate the long-term impact of delayed surgical intervention on patient outcomes, we recommend standardized postoperative follow-up, with routine assessments of erectile function and penile curvature. CONCLUSION: Contemporary literature suggests that immediate and delayed surgical repair of penile fractures leads to adequate postoperative outcomes, and patients presenting >24 hours after injury should still be considered for surgery.

Percutaneous Cystolitholapaxy Is Safe and Effective in Adult Patients With Lower Urinary Tract Reconstruction Utilizing Bowel.

OBJECTIVE: To investigate the safety, efficacy, and surgical approach of percutaneous bladder calculi removal in adult patients with prior lower urinary tract reconstruction utilizing bowel using a single-institution database. METHODS: Twenty patients with prior history of lower urinary tract reconstruction (continent cutaneous urinary reservoir, augmentation enterocystoplasty with catheterizable channel, or ileal neobladder) who underwent percutaneous cystolitholapaxy from 2014 to 2020 were identified from an IRB-approved database. Analysis of patient demographics, operative details, stone composition, stone-free rates, recurrence, and associated complications was performed. RESULTS: Percutaneous access and either ultrasonic lithotripter or laser lithotripsy were utilized to remove bladder stones. Over half of the patients also underwent concomitant renal stone removal via percutaneous removal or retrograde ureteroscopy. Postoperative computed tomography imaging revealed complete bladder stone clearance in 90% of patients. There were no notable complications from percutaneous bladder stone removal and most patients were discharged either the same day or within 24hours. Urine and stone analysis revealed infection was present in the majority of patients. Bladder stones recurred in 45% of patients after more than 2years of follow-up, on average. CONCLUSION: Percutaneous cystolitholapaxy is a safe and effective approach for the removal of moderate-sized bladder calculi in adults with prior lower urinary tract reconstruction utilizing bowel. Its efficacy and minimally invasive nature make it the approach of choice at our institution.

Ileal Ureter Utilization in Patients With Previous Urinary Diversions.

OBJECTIVE: To evaluate a subset of patients who develop strictures requiring Ileal Ureter (IU) in the setting of prior urinary diversion or augmentation (ileal conduits, neobladders, continent urinary diversions). To our knowledge, there are no prior studies on patients with IU substitution into established lower urinary tract reconstructions. METHODS: A retrospective review of patients (18 years) undergoing IU creation from 1989 to 2021 was performed. A total of 160 patients were identified. In total, 19 (12%) patients had IUs into diversions. We examined demographics, stricture cause, diversion type, renal function, and postoperative complications. RESULTS: Nineteen patients were identified. Sixteen were male. Mean age was 57.7(SD 17.0) years. Diversions included continent urinary reservoirs (4), neobladders (5), ileal conduits (7), and bladder augmentations with Monti channels (3). Fifteen had unilateral surgery, and 4 had bilateral "reverse 7" IU creation. Average length of stay was 7.6 days (SD 2.9). Average follow-up was 32.9 months (SD 27). Mean preoperative creatinine was 1.5 (SD 0.4); mean postoperative creatinine at most recent follow-up was 1.6 (SD 0.7). There was no significant difference between pre- and postoperative creatinine (P = .18). One patient had a ventriculoperitoneal Shunt infection resulting ventriculoperitoneal shunt externalization, 1 had Clostridium difficile infection potentially causing an entero-neobladder fistula, 2 with ileus, 1 urine leak, and 1 wound infection. None required renal replacement therapy. CONCLUSION: Patients with urinary diversions and prior bowel reconstructive surgeries with subsequent ureteral strictures are a challenging cohort of patients. In properly selected patients, ureteral reconstruction with ileum is feasible and preserves renal function with minimal long-term complications.

Impact of American Society of Anesthesiologists score on postoperative holmium enucleation of the prostate outcomes and complications.

INTRODUCTIONS: The American Society of Anesthesiologists Physical Status Classification System (ASA) is a validated risk stratification method for patients undergoing surgery. There is an increased prevalence of benign prostatic hyperplasia and comorbidities in our aging population. The role of ASA related to postoperative complications in patients undergoing holmium laser enucleation of the prostate (HoLEP) has not been described. METHODS: A review of our database was performed for patients who underwent HoLEP from July 2018 to December 2020. Patients were stratified based on ASA score. Preoperative, perioperative, and complication data were analyzed using SAS analytics software. RESULTS: Of 472 patients undergoing HoLEP, 320 (67.8%) were ASA 3-4 patients. There was a statistically significant difference found in age (72.3 ± 9.8 vs. 69.1 ± 9.0 years, p < 0.001), body mass index (BMI) (29.0 ± 5.9 vs. 27.3 ± 4.2, p = 0.004), and use of antiplatelet/anticoagulant medications (14.6% vs. 2.6%, p < 0.001) in the ASA 3-4 group. There was no significant difference between prostate volume (p = 0.158) or catheter-dependent urinary retention (p = 0.376). No difference was found in enucleation time (52.76 ± 24.8 vs. 54.16 ± 23.7 min, p = 0.587), OR specimen weight (70.24 ± 58.5 vs. 81.53 ± 65.9, p = 0.094). or intraoperative complications (2.8% vs. 1.3%, p = 0.330). There were higher postoperative complications in the ASA 3-4 group (12.8% vs. 7.9%, p = 0.03), but no difference in Clavien ≥3 complications (p = 0.068). ASA 3-4 patients had similar postoperative international prostate symptom score (p = 0.159). CONCLUSION: HoLEP is feasible and effective in patients who are ASA 3-4. The high-risk cohort had an increased rate of low-grade complications. Patients with an ASA score of 3-4 should be counseled regarding a higher rate of low-grade complications.

The role of urethral ligation after AUS failure and end stage urethra.

PURPOSE: To provide our single-center experience with an approach to refractory stress urinary incontinence (SUI) with permanent urethral ligation (PUL) and suprapubic tube (SPT) placement, in hopes of contributing to the limited body of research surrounding this surgical treatment option for patients with end-stage urethra (ESU). METHODS: All patients undergoing PUL with SPT placement from 01/01/2018 to 04/30/2022 were identified from an institutional database. Institutional Review Board exempt status was granted for the conduct of this study. Patients were seen postoperatively at 1 month and 1 year. If there were any concerns of incontinence, an antegrade urethrogram via the SPT was performed. Descriptive statistics were used to evaluate patients. RESULTS: Seven patients underwent PUL with SPT in our timeframe and were included in the study. All patients previously had an AUS placed, and two patients had a urethral sling previously placed. The median follow-up time was 21 months, ranging between 2 and 48 months. Complications included bladder spasms (43%) and continued leakage per urethra (14%). Of the 7 patients, 6 have reported continence through their urethra at their most recent follow-up. CONCLUSION: This initial data suggest that PUL with SPT placement may be a viable surgical approach to treating refractory SUI, especially for patients with ESU who wish to avoid the morbidity associated with more formal supravesical diversion. Further study of this technique and longer follow-up is required to determine its long-term efficacy and tolerability for patients.

Comparison of Perioperative Outcomes and Clinical Characteristics of Calcium, Matrix and Struvite Stones From a Single Institution.

OBJECTIVE: To define risk factors and perioperative outcomes for matrix stones and compare these outcomes with struvite and calcium stone cohorts. METHODS: A retrospective cohort study comparing matrix stones (n=32), struvite stones (n=23) and a matched, calcium stone control group (n=32) was performed. Two-way ANOVA was used to compare the groups for continuous variables. Chi-square tests were used to compare categorical variables. Significance was set at P <.05. All statistical tests were performed using R (v1.73). RESULTS: We identified no differences in age, gender, or BMI between the three groups. Matrix and struvite stones were more likely to have a history of prior stone surgery and recurrent UTIs compared to calcium stones (P=.027 and P <.001, respectively). Struvite stones were more likely to present as staghorn calculi compared to matrix or calcium stones (56.5% vs 21.7% vs 18.8%, P=.006). There were no significant differences in postoperative stone free rates (P=.378). No significant differences in postoperative infectious complications were identified. Matrix stones were more likely to have Candida on stone culture compared to the struvite or calcium stones (P <.0001). CONCLUSION: Matrix and struvite stones were more likely have a history of stone surgery and preoperative recurrent UTIs. Struvite stones were more likely to present as staghorn calculi. Matrix stones were more likely to have Candida present in stone cultures. However, no difference in postoperative infectious outcomes or stone free rates were identified. Further study with larger cohorts is necessary to distinguish matrix stone postoperative outcomes from struvite and calcium stones.

Improving resident learning on vasectomy: a national survey on urology resident vasectomy training.

INTRODUCTION: Resident training in vasectomy, especially in the office setting on the awake patient, may be limited. The aim of this study is to understand resident exposure to vasectomy and to identify barriers to learning. MATERIALS AND METHODS: An anonymous 18-question survey was distributed to urology residents of the 135 ACGME-accredited urology residencies in the United States. Residents were asked to specify the total number of vasectomies they had performed and in what environment (operating room versus office), their comfort performing vasectomy independently, and any barriers to learning the procedure. RESULTS: In total, 119 residents responded to the survey, representing a 10% response rate. Vasectomy case volumes were variable, with 36.7% of residents logging ≤ 20 vasectomies by their final year of training. Total of 23.4% indicated they did not receive training in perioperative counseling for patients considering vasectomy. Only 64.7% of all residents felt comfortable in the office setting versus 89.1% who felt comfortable in the operating room (p < 0.001). This difference persisted throughout training, and 16.7% of residents in their final year of residency were uncomfortable performing office vasectomy. Total of 60.5% of respondents cited one or more barriers to training, with lack of surgical volume (38.7%), lack of vasectomies in the resident clinic (29.4%), and lack of autonomy when performing the procedure (22.7%) being the most common. CONCLUSIONS: Residents are significantly less comfortable performing vasectomy in the office setting versus in the operating room, including in their graduating year. Residents describe low volume and lack of autonomy as barriers to vasectomy training.

Robotic Sacral Colpopexy Using Autologous Fascia Lata Compared with Mesh.

Objective: The objective is to compare robotic sacral colpopexy (RSC) utilizing autologous fascia lata with RSC with synthetic mesh in the treatment of pelvic organ prolapse (POP). Methods: We performed a prospective nonrandomized case comparison trial at a single institution. We compared RSC utilizing either synthetic mesh or autologous fascia lata in women with symptomatic POP, stages II through IV. The primary outcome was anatomic prolapse recurrence determined by the Pelvic Organ Prolapse Quantification (POP-Q) examination. Secondary outcomes included patient-reported outcomes such as the Urogenital Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7). Complications were also recorded and categorized using the Clavien-Dindo (CD) system. The hypothesis is that autologous fascia lata would provide equivalent anatomic and patient-reported outcomes compared with mesh while eliminating mesh-related complications. Results: Sixty-four women underwent RSC with 19 (29.7%) receiving fascia lata graft. The overall operative time was greater in the fascia lata group with mean fascia lata harvest time of 24.8 ± 7.4 minutes. Intragroup comparisons of the fascia and mesh groups demonstrated significant improvement in pelvic measurements as well as patient-reported outcomes. Intergroup comparison demonstrated equivalent success rates at 12.1 ± 8.7 months follow-up. There was one apical failure in the fascia lata RSC group; however, the difference was not statistically significant (p = 0.30). Significant complications in the fascia lata harvest group included two CD-II and one CD-IIIb. In the mesh group there was one mesh erosion requiring surgical excision (CD-IIIb). Conclusion: This is the first comparison between RSC with autologous fascia lata and mesh. Short-term anatomic outcomes were similar with autologous fascia lata use without the risk of mesh erosion. Morbidity from graft harvest site was not trivial. These results emphasize the need for a randomized controlled trial.

Adjuvant Aromatase Inhibitors in Early Breast Cancer May Not Increase the Risk of Falls.

BACKGROUND: Falling increases the risk for fracture. The impact of adjuvant aromatase inhibitors (AI) on the risk of falls is undefined. METHODS: A retrospective case control study was performed examining women with early stage breast cancer on adjuvant AI and matched controls without cancer. Fall and fracture data were abstracted from the medical record. RESULTS: Matched pairs of 332 women were identified (total N = 664). There was no statistically significant difference in the odds of a fall between cases and controls, p = 0.86. Similarly, the odds of a fracture between cases and controls was not significantly different, p = 1.0. There were 35 pairs in which the case fractured but the control did not and equal number of pairs where the control fractured but the case did not. For pairs in which control fractured but case did not, the median age at fracture was significant higher than that for pairs in which case fractured but the control did not (71 vs. 63 years p = 0.0003). CONCLUSION: This study did not identify a difference in the incidence of falls or fractures in women on adjuvant AI compared to their age matched controls without breast cancer. Prospective studies of falls and fracture in women on adjuvant AI therapy compared to age match controls would aid in the identification of fracture risk.