Current urethroplasty trends in recent GURS fellowship graduates.

PURPOSE: To assess self-reported urethroplasty success rates and outcomes of recent GURS fellowship graduates and compare these data to the large body of published urethroplasty outcomes literature. METHODS: A voluntary survey was distributed from June 1 to June 30, 2023 to GURS fellowship graduates of the last 5 years. Participants were surveyed on time since graduation, operative volume, outcomes, and quoted success rates for urethroplasty. Data were then analyzed using descriptive statistics, binary logistic regression, and correlative analyses. RESULTS: We received responses from 49/101 (48.5%) GURS graduates. Five-year post-graduates were most represented (44.7%). The majority (52.2%) consider 81-90% of urethroplasty successful, without significant change with years in practice. Approximately 65% quoted excision and primary anastomosis (EPA) as > 90% successful. Over half of the respondents had performed > 60 urethroplasties since graduation. Only 31.3% of respondents reported re-intervening in > 10% of their postop patients, with a weak positive correlation between years in practice and need for re-intervention (p 0.01). Nearly 20% of respondents referred patients to an external reconstructionist. CONCLUSION: Increased length of time in practice does not result in higher reported urethroplasty success rates, counseling on successful outcomes, or rates of re-intervention and complications. Our survey highlights that the traditionally used success rates for urethroplasty may not be reflective of new graduates and lower volume reconstructive surgeons in their early career.

Adolescent and Young Adult Urogenital Outcome following Childhood Hypospadias Repair: Perfection Revisited.

PURPOSE: We assessed the long-term surgical, functional urinary and sexual outcomes of adolescent and young adult men who underwent childhood hypospadias repair. MATERIALS AND METHODS: Men born with nonsyndromic hypospadias and healthy male controls aged 16-21 years old were recruited, and their surgical, urinary, sexual functional and aesthetic outcomes assessed. Good outcome was defined as a patent and orthotopic meatus without fistulas, and straight erections (<30 degree curvature) without erectile or ejaculatory problems. Statistics included regression analyses, chi-square/Fisher exact tests and Student's t/Mann-Whitney U and Kruskal-Wallis tests. RESULTS: A total of 193 patients and 50 controls participated 16.4 years (range 8.2-21.2) after initial repair. At least 1 reintervention was performed in 39.2%. The highest reintervention rate was found in those younger than 12 months at initial repair, even when excluding proximal hypospadias cases. A disturbed urinary and/or suboptimal sexual functional outcome was seen in 52.9% of cases. Suboptimal voiding was found in 22.1%, although few had relevant residual urine. More reinterventions and proximal hypospadias cases were associated with suboptimal urinary outcome, and the latter also with impaired sexual function. Poor inter-observer agreements were found between physician and patient genital appraisal. CONCLUSIONS: In 52.9% of cases, at least 1 concern was identified that required long-term followup. Hypospadias repair below 12 months was associated with more reinterventions. Adopting a restrictive attitude toward aesthetic refinement, unless on the patient's own request, could improve urinary outcomes.

Urinary Symptom Nonresponse ("LUTS Failure") after Urethroplasty: Incidence and Associations.

PURPOSE: An ill-defined proportion of patients undergoing urethroplasty fail to experience improvement in lower urinary tract symptoms (LUTS) despite being stricture-free. We aim to identify the incidence, associations and causes of "LUTS failure" after urethroplasty. MATERIALS AND METHODS: Patients undergoing urethroplasty over a 6-year period were offered enrollment in a prospective study examining urinary function after urethroplasty. Patients were assessed preoperatively and 6 months postoperatively using the International Prostate Symptom Score (IPSS) and cystoscopy. "LUTS failure" was defined as ≤3-point improvement in IPSS despite an anatomically successful urethroplasty. Multivariable logistic regression was utilized to evaluate the association between patient factors and "LUTS failure." RESULTS: Of 365 patients meeting inclusion criteria, mean postoperative IPSS (20.3 vs. 5.4, p <0.0001) and median urinary quality of life (UQOL; 5 vs. 1; p <0.0001) were significantly improved. Despite being stricture-free, 7.7% of patients reported "LUTS failure" and 10.1% reported UQOL nonresponse. On multivariable logistic regression, increasing age (OR 1.04, 95% CI 1.01-1.06; p=0.006) and hypospadias (OR 18.2, 95% CI 2.1-156.0; p=0.008) were associated with "LUTS failure," while stricture location (p=0.76), length (p=0.14), previous urethroplasty (p=0.96), failed endoscopic treatment (p=0.17), type of urethroplasty (p=0.93) and other etiologies were not. Qualitatively, the most likely causes of "LUTS failure" were detrusor underactivity (39.3%), overactivity (21.4%), pelvic floor dysfunction (21.4%) or benign prostatic hyperplasia (14.3%). Only increasing age was associated with UQOL nonresponse (OR 1.03, 95% CI 1.01-1.07; p=0.02). CONCLUSIONS: While many patients experience improved voiding function after urethroplasty, 7.7% experience "LUTS failure" and 10.1% report UQOL nonresponse. Both occurrences are independently associated with increasing patient age and most commonly related to detrusor underactivity.

Prostatic urethral lift (UroLift): a real-world analysis of outcomes using hospital episodes statistics.

BACKGROUND: To determine real-world outcomes of prostatic urethral lift (UroLift) procedures conducted in hospitals across England. METHODS: A retrospective observational cohort was identified from Hospital Episode Statistics data including men undergoing UroLift in hospitals in England between 2017 and 2020. Procedure uptake, patient demographics, inpatient complications, 30-day accident and emergency re-attendance rate, requirement for further treatment and catheterization were captured. Kaplan-Meier and hazard analysis were used to analyse time to re-treatment. RESULTS: 2942 index UroLift procedures from 80 hospital trusts were analysed; 85.3% conducted as day-case surgery (admitted to hospital for a planned surgical procedure and returning home on the same day). In-hospital complication rate was 3.4%. 93% of men were catheter-free at 30 days. The acute accident and emergency attendance rate within 30 days was 12.0%. Results of Kaplan Meier analysis for subsequent re-treatment (including additional UroLift and endoscopic intervention) at 1 and 2 years were 5.2% [95% CI 4.2 to 6.1] and 11.9% [10.1 to 13.6] respectively. CONCLUSIONS: This real-world analysis of UroLift shows that it can be delivered safely in a day-case setting with minimal morbidity. However, hospital resource usage for catheterization and emergency hospital attendance in the first 30 days was substantial, and 12% required re-treatment at 2 years.

Reoperation after Hypospadias Repair: Long-Term Analysis.

PURPOSE: While the true incidence of secondary hypospadias repair is unknown, the current literature cites a 3.3% to 6.7% reoperation rate after distal hypospadias repair and an association with age. We hypothesized that secondary surgery rates are associated with patient factors and have been underreported due to limited followup. MATERIALS AND METHODS: We used an academic practice plan consortium database to identify a population that underwent primary hypospadias repair in 2009 and 2010. Secondary surgeries between 2009 and 2019 were captured. The association of variables such as age, insurance type, region, surgeon volume and surgeon years in practice with all-inclusive and specific secondary surgery procedures were analyzed using mixed effects multiple logistic regression models. RESULTS: We identified 5,178 boys who had primary hypospadias repair performed by 84 pediatric urologists at 46 hospitals in 2009 and 2010. During the ensuing 9 to 10 years, distal, proximal and perineal hypospadias repair had a 12.6%, 37.9% and 46.6% rate of secondary surgery, respectively. After adjusting for all other variables in the model, patients with noncommercial insurance had a 26% (OR 1.26, p=0.04) increased odds of secondary surgery. Patient age and surgeon years in practice were not associated with all-inclusive secondary surgery except for endoscopic treatment. Surgeon volume was not associated with secondary surgery. CONCLUSIONS: This study demonstrated that secondary surgery rates are underreported if followup is limited to less than 6 years. Patient age, surgeon volume and experience did not associate with all-inclusive reoperation rates whereas insurance status was a major predictor of reoperation.

What is the role of pre-operative blood parameters in forecasting varicocelectomy success?

BACKGROUND: We aimed to examine the effects of pre-operative blood values on varicocelectomy success. MATERIALS AND METHODS: A total of 130 patients who underwent varicocelectomy in our clinic were retrospectively analyzed. Operation success was defined as the return of all semen parameters (concentration, progressive motility, and morphology) to normal values 6 months after surgery. The patients were separated as two groups as benefiting from the treatment (Group A) and not (Group B). RESULTS: The best cut-off value for the neutrophil/lymphocyte ratio (NLR), which can predict varicocelectomy success, was assigned to be 2.27, with AUC of 0.859 (%95 CI 0.795-0.922). The highest sensitivity and specificity were 0.857 and 0.731 (p < 0.001). The best cut-off value for the mean platelet volüme (MPV) value, which can predict varicocelectomy success, was assigned to be 9.45, with AUC of 0.729 (%95 CI 0.639-0.819). The highest sensitivity and specificity were 0.655 and 0.635 (p < 0.001). Binary logistic regression analysis showed NLR ratio (odds ratio (OR): 11.2, p < 0.001) and MPV (OR: 2.65, p = 0.002) parameters as independent predictive factors in predicting varicocelectomy success. DISCUSSION AND CONCLUSION: Our study showed that low NLR ratio (≤2.27) and high MPV (≥9.45) ratio levels may be a useful pre-operative predictive tool in identifying men who benefit most from varicocelectomy in infertile patients with varicocoele.

Evaluation of Opioid Prescribing Patterns and Drivers of Variation Following Endoscopic Procedures for Benign Prostatic Hyperplasia Across an Integrated Academic Health System.

OBJECTIVES: To evaluate patient, provider, and facility factors associated with variation in opioid prescribing after endoscopic procedures for benign prostatic hyperplasia across a large academic health system to drive improvement efforts. METHODS: Opioids prescribed at discharge for patients who underwent an endoscopic prostate procedure March 2018-November 2019 were analyzed. Multivariable logistic and linear regression were used to evaluate the relationship between patient, provider, and facility factors and the receipt of any opioid prescription and the quantity prescribed. RESULTS: We included 724 patients who had surgery with one of 26 urologists across five facilities. 222 (30.7%) received an opioid prescription, and the average morphine milligram equivalents (MMEs) prescribed was 97.9±33.5. We found wide variation in the proportion of patients who received an opioid prescription across surgeons (range 0%-88.9%) and facilities (range 19.9%-66.7%) and the average MMEs prescribed (range 25-188.5). Outpatient surgery (OR 2.32; 95% confidence interval [CI] 1.22-4.40, P = .010) and preoperative opioid use (OR 15.04; CI 9.65-23.45, P < .001) were associated with higher rates of opioid prescribing, while prescribing decreased with increasing patient age (OR 0.97; CI 0.95-0.99, P = 0.016). Multivariable linear regression analysis demonstrated an association between surgery at satellite facilities, having a surgeon in practice for at least 20 years, and higher surgeon volume with increased MMEs prescribed. CONCLUSIONS: Opioid prescribing following endoscopic prostate procedures varied widely. Targeted interventions tailored to younger patients, those taking opioids preoperatively, recipients of outpatient surgery and those undergoing surgery at satellite facilities may be particularly high yield given the association between these factors and increased postoperative prescribing.

Is combined topical-local anesthesia technique adequate for visual internal urethrotomy in the treatment of traumatic posterior urethral strictures and prostatic urethral stenoses?

BACKGROUND: To compare the effectiveness of spinal anesthesia (SA) and the combination of intraurethral topical instillation of 2% lidocaine + intraurethral local visual injection anesthesia (T + LIA) for visual internal urethrotomy (VIU) in the treatment of traumatic posterior urethral strictures and prostatic urethral stenoses. METHODS: In this study, the results of 178 patients who underwent visual internal urethrotomy for posterior urethral strictures and prostatic urethral stenoses secondary to trauma in our clinic between October 2018 and January 2020 were analyzed retrospectively. Patients were divided into two groups as combined T + LIA (n=146, 82.08%) group and SA (n=32, 17.97%) group according to the type of anesthesia used. The preoperative clinical data and postoperative results of the patients were analyzed and compared between the groups. RESULTS: The mean age of the patients was 67.99±10.87 years and the mean follow-up was 5.32±3.27 months. The median age of the patients in the T + LIA group was significantly higher than that of the patients in the SA group (p=0.033). There was no statistically significant difference between the groups regarding preoperative Q-max value (p=0.931). Similarly, the rate of postoperative improvement in the Q-max values of the patients was similar between the groups (p=0.572). The presence of postoperative complications and recurrence rates were similar between the groups (p=0.879 and p=0.904, respectively). CONCLUSION: Compared to spinal anesthesia, T + LIA anesthesia is a safe and effective technique for visual internal urethrotomy in treating traumatic posterior urethral strictures and prostatic urethral stenoses, with a high rate of success and acceptable rate of complications.

Long-term outcomes after plaque incision and grafting for Peyronie's disease: comparison of porcine dermal and bovine pericardium grafts.

BACKGROUND: Plaque incision and grafting (PEG) is one of the mainstays in surgical therapy for severe penile curvature in Peyronie's disease (PD). Different kinds of grafts are available for covering albugineal defects during PEG, both allografts and xenografts. However, to date, none of these proved superior to others. OBJECTIVES: To compare two different types of xenograft, porcine dermal matrix and bovine pericardium matrix in PEG for PD. MATERIALS AND METHODS: From 2010 to 2019, 63 patients with PD underwent PEG, using porcine dermal (n = 25; Group 1) and bovine pericardium (n = 38; Group 2) grafts. Long-term outcomes were evaluated through multi-disciplinary questionnaires administration by phone interview. The following items were considered: correction of penile bending, quality of erection, intercourse ability, penile shortening, and sensitiveness. Overall satisfaction and impact of surgery on sexual activity and quality of life were also investigated. RESULTS: Plaque median (IQR) size was 29 (22-33) mm and was smaller in Group 1 (27.5 vs. 31 mm; P = .03). Complete follow-up data were available for 53 patients (84%). Considering post-operative outcomes, no differences were found when considering ED rates, penile shortening, sensitiveness, complications, and penile straightening (all P > .1). Patients in Group 2 were more likely to have palpable penile nodules at follow-up (20.6 vs. 0%; P = .03). However, patient's post-operative sexual life satisfaction was consistent between the two groups, with just 1 (5.3) and 8 (23.5) patients in Group 1 and 2 respectively referring a worsening in sexual life satisfaction (P = 0.2). At follow-up, 84.9% of patients that would still undergo surgery for PD, with no statistical difference between the two groups (P = .4). CONCLUSIONS: Corporoplasty with PEG is an effective treatment for men with PD. Porcine dermal and bovine pericardium xenografts seem to have similar long-term outcomes.

Overview of the italian experience in surgical management of bladder cancer during first month of COVID-19 pandemic.

OBJECTIVE: Overview of bladder cancer (BC) management in Italy during the first month of the COVID-19 pandemic (March 2020) with head to head comparison of the data from March 2019, considered "usual activity" period. The aim is to analyze performance of different Italian Centers in North, Center and South, with a special eye for Lombardy (the Italian epicenter). PATIENTS AND METHODS: During April 2020, a survey containing 14 multiple-choice questions focused on general staffing and surgical activity related to BC during the months of March 2019 and March 2020 was sent to 32 Italian Centers. Statistical analysis was performed using IBM SPSS Statistics (v26) software. A Medline search was performed, in order to attempt a comparative analysis with published papers. RESULTS: 28 Centers answered, for a response rate of 87.5%. Most of the urology staff in the Lombardy region were employed in COVID wards (p = 0.003), with a statistically significant reduction in the number of radical cystectomies (RC) performed during that time (p = 0.036). The total amount of RC across Italy remained the same between 2019 and 2020, however there was an increase in the number of surgeries performed in the Southern region. This was most likely due to travel restrictions limiting travel the North. The number of Trans-Urethral Resection of Bladder Tumors (TURBT) (p = 0.046) was higher in Academic Centers (AC) in 2020 (p = 0.037). CONCLUSIONS: The data of our survey, although limited, represents a snap shot of the management of BC during the first month of the COVD-19 pandemic, which posed a major challenge for cancer centers seeking to provide care during an extremely dynamic clinical and political situation which requires maximum flexibility to be appropriately managed.

Learning curve of various type of male urethroplasty.

PURPOSE: To determine the number of cases required to achieve a specified recurrence-free rate (>80%) among urethroplasty types. MATERIALS AND METHODS: A retrospective analysis of consecutive patients, who underwent urethroplasty performed by a single surgeon between April 2013 and January 2019, was conducted. Urethroplasty subtypes were divided according to stricture location: penile, bulbar, and posterior. If there was no recurrence for >6 months after surgery, the surgery was considered to be a success. The average success rates among quintile groups were compared to determine the learning curve for each type. RESULTS: Of 150 patients who underwent urethroplasty, 112 were included in this study. The overall success rate was 89.7% in penile, 97.8% in bulbar, and 74.1% in posterior urethroplasty. Bulbar urethroplasty reached the target success rate in the first quintile group (1-9 cases). Penile urethroplasty also achieved the target success rate in the first quintile group (1-8 cases), and the success rate gradually increased until the fifth quintile group (32-39 cases). In posterior urethroplasty, the target success rate was achieved in the fifth quintile group (20-27 cases). CONCLUSIONS: Bulbar urethroplasty had the fastest learning curve, and posterior urethroplasty the slowest.

Competency in Tubularized Incised Plate Repair for Distal Hypospadias: Cumulative Sum Learning Curve Analysis of a Single Surgeon Experience.

PURPOSE: We sought to determine the number of cases to achieve competency and proficiency in tubularized incised plate technique for distal hypospadias repair using cumulative sum analysis. MATERIALS AND METHODS: From 2001 to 2015 we reviewed all distal tubularized incised plate repairs performed by a single surgeon since independent practice. Data for 450 consecutive cases included age, meatal location, presence of curvature, operative time, occurrence of complications and followup duration. A cumulative sum analysis cohort chart was used to determine trends in complication rate and operative time during the evaluation period. In order to account for surgical experience with time, the highest peak, plateau, and down trends in operative time and complication rate were identified on the plot and set as the transition points between learning (phase 1), competence (phase 2) and proficiency (phase 3). RESULTS: Based on the cumulative sum analysis learning curve, the competence phase with plateau of operative time and complication rate commences beyond the 127th case, and the proficiency phase with notable decline in operative time and complication rate was noted beyond the 234th case. When comparing case characteristics and surgical outcomes between phases and learning curve, the proficiency phase involved younger patients and more severe degree of distal hypospadias being repaired using the tubularized incised plate approach with fewer complications related to meatal stenosis and fewer cosmetic complications. CONCLUSIONS: In our study competency in distal hypospadias tubularized incised plate repair was reached beyond the 127th case, while proficiency was attained beyond the 234th case.

Using Artificial Intelligence to Predict Surgical Shunts in Men with Ischemic Priapism.

PURPOSE: Ischemic priapism is a urological emergency that requires prompt intervention to preserve erectile function. Characteristics that influence escalation to surgical intervention remain unclear. We identified factors and developed machine learning models to predict which men presenting with ischemic priapism will require shunting. MATERIALS AND METHODS: We identified men with ischemic priapism admitted to the emergency department of our large county hospital between January 2010 and June 2019. We collected patient demographics, etiology, duration of priapism prior to intervention, interventions attempted and escalation to shunting. Machine learning models were trained and tested using R to predict which patients require surgical shunting. RESULTS: A total of 334 encounters of ischemic priapism were identified. The majority resolved with intracavernosal phenylephrine injection and/or cavernous aspiration (78%). Shunting was required in 10% of men. Median duration of priapism before intervention was longer for men requiring shunting than for men who did not (48 vs 7 hours, p=0.030). Patients with sickle cell disease as the etiology were less likely to require shunting compared to all other etiologies (2.2% vs 15.2%, p=0.035). CONCLUSIONS: Men with longer duration of priapism before treatment more often underwent shunting. However, phenylephrine injection and aspiration remained effective for priapism lasting more than 36 hours. Having sickle cell disease as the etiology of priapism was protective against requiring shunting. We developed artificial intelligence models that performed with 87.2% accuracy and created an online probability calculator to determine which patients with ischemic priapism may require shunting.

Non-Transecting Anastomotic Bulbar Urethroplasty For Urethral Stricture Disease-Experience From A Highvolume Specialist Centre.

BACKGROUND: Urethral stricture disease has significant economic impact throughout world. The bulbar urethra is the commonest site for urethral strictures (Approx 50%) followed by penile urethra in most of the published literature. In developing countries trauma (road traffic accident and iatrogenic) is the leading cause of urethral stricture disease. Younger patients have usually idiopathic type as compare to old age group, which present more frequently with iatrogenic and trauma related urethral strictures. METHODS: This Qausi Experimental study was conducted from May2012-June2016 of duration at Liaquat National Hospital Karachi. All the patients diagnosed with short urethral strictures related to bulbar urethra were included in this study. All the patients underwent non transecting bulbar urethroplasty. All patients were assessed preoperatively, peri-operatively and postoperatively and on follow-up visits as; on 2nd, 8th and 24th week. All the data regarding outcome was recorded on the Performa and analyzed on SPSS V20. RESULTS: Total of 179patients were included, mean age was 38±SD15.3years (range 20- 65years). Anatomically bulbar urethra was affected in 52% of the cases followed by bulbopenile, bulbomembranous region. Etiologically idiopathic type was found in 40% cases, while trauma 21%, iatrogenic injury 26% and UTI 13% were also reasons. Stricture length was mean1.1±SD 1.4 cm (range 0.5-2.5cm). Preoperative Uroflowmetry revealed mean Qmax of 10.5±SD 5.3 ml/sec. Mean operative time was 35±SD 4.6 minutes, 7 patients had conversion to other procedures (3.91%), Postoperative complications were minimal. Mean follow up was 12±SD 21 months (range 6 months to 3 years). On initial follow up at 8th week and 24th week, Qmax was significantly improved. Only 3 patients required DVIU after the 24th week. Initial success rate after 24th week was 98.3% and eventually 100% at the long-term follow-up. CONCLUSIONS: non-transecting anastomotic bulbar urethroplasty (NTABU) is a new standard of care for the short bulbar urethral stricture up to 2.5cm. Idiopathic aetiology, iatrogenic and posttraumatic urethral strictures in selective patients can safely be operated with this technique.

Oncological and Functional Outcomes After Organ-Sparing Plastic Reconstructive Surgery for Penile Cancer.

OBJECTIVE: To describe oncological and functional outcomes in patients treated with reconstructive organ-sparing surgery (OSS) for squamous cell carcinoma of the penis. Plastic reconstructive OSS of the penis with a split thickness skin graft has been proposed as a treatment option for penile cancer, with the objective being preservation of physiological voiding and sexual function without comprising oncological control. MATERIALS AND METHODS: Multicenter study reporting clinicopathological data of 57 patients with malignant lesions of the penis treated with OSS and plastic reconstructive surgery with split thickness skin graft from 2007 to 2019. Health related quality of life (HRQoL) was assessed with EuroQoL-5D-3L, urinary symptoms with the International Consultation on Incontinence Modular Questionnaire for Male Lower Urinary Tract Symptoms, and erectile function with the International Index of erectile function (IIEF)-5. RESULTS: Fifty-seven patients underwent OSS reconstructive surgery. Twenty underwent glans resurfacing, 23 partial penectomy, and 14 glansectomy. Median age was 55.1 years (interquartile range [IQR] 29-90), median follow-up 55.7 months (3-149). At the time of data analysis, 6 patients had died of Squamous Cell Carcinoma (SCC) (12.5%) and 10 (17.8%) had progressed. Kaplan-Meier estimates showed a 5-year survival rate of 87.5% and a 5-year progression-free survival of 83%. We assessed HRQoL and functional outcomes in 32 patients. EuroQol 5D-3L showed a mean health status of 82.5%, median Voiding score of the ICIQ-MLTUS was 4 (IQR 1-15), and median IIEF-5 19 (IQR 10.75-25). CONCLUSION: OSS of the penis remains a safe and viable option for the treatment of SCC, ensuring a favorable appearance of the penis, preserving urinary and sexual function, with good HRQoL and without comprising oncological safety in selected cases.

Decisional Conflict and Knowledge Among Patients With Varicocele Seeking Treatment for Infertility.

OBJECTIVE: To study disease-specific knowledge and decisional quality in men with varicocele being counseled for infertility. MATERIALS AND METHODS: An instrument designed to measure decisional quality by evaluating disease-specific knowledge, decisional conflict, and the impression that shared decision-making was administered to 92 men identified to have a varicocele seeking their initial infertility consultation. Mean scores on disease-specific knowledge questionnaire, prevalence of decisional conflict, and impact of consultation on preferred infertility treatment were analyzed. RESULTS: Fifty-five percent of patients were found to have decisional conflict. Compared to those with decisional conflict, men without decisional conflict scored higher on the infertility knowledge assessment (63% vs 53% correct) and were more likely to feel that they discussed treatment options with their physician in detail (98% vs 82%) (all P <0.01). Prior to consultation, 28% of all patients preferred assisted reproductive technologies and 2% preferred varicocelectomy as the primary treatment for infertility. Following consultation, 12% and 17% preferred assisted reproductive technologies and varicocelectomy, respectively. The increase in preference for varicocelectomy was greater in men without decisional conflict (5%-31%) than those with conflict (0%-8%) (P = 0.03). CONCLUSION: Infertile men with varicocele have limited knowledge of their disease and high rates of decisional conflict. Before consultation, men with varicoceles showed preference for assisted reproductive technology over varicocele surgery; this trend reversed after consultation. Men with decisional conflict were less likely to prefer varicocelectomy, even after consultation.

Risk calculator for prediction of treatment-related urethroplasty failure in patients with penile urethral strictures.

PURPOSE: To design a dedicated risk calculator for patients with penile urethra stricture who are scheduled to urethroplasty that might be used to counsel patients according to their pre-operative risk of failure. METHODS: Patients treated with penile urethroplasty at our center (1994-2018) were included in the study. Patients received 1-stage or staged penile urethroplasty. Patients with failed hypospadias repair, lichen sclerosus or incomplete clinical records were excluded. Treatment failure was defined as any required postoperative instrumentation, including dilation. Univariable Cox regression identified predictors of post-operative treatment failure and Kaplan-Meier analysis plotted the failure-free survival rates according to such predictors. Multivariable Cox regression-based risk calculator was generated to predict the risk of treatment failure at 10 years after surgery. RESULTS: 261 patients met the inclusion criteria. Median follow-up was 113 months. Out of 216 patients, 201 (77%) were classified as success and 60 (23%) failures. Former smoker (hazard ratio [HR] 2.12, p = 0.025), instrumentation-derived stricture (HR 2.55, p = 0.006), and use of grafts (HR 1.83, p = 0.037) were predictors of treatment failure. Model-derived probabilities showed that the 10-year risk of treatment failure varied from 5.8 to 41.1% according to patient's characteristics. CONCLUSIONS: Long-term prognosis in patients who underwent penile urethroplasty is uncertain. To date, our risk-calculator represents the first tool that might help physicians to predict the risk of treatment failure at 10 years. According to our model, such risk is largely influenced by the etiology of the stricture, the use of graft, and patient's smoking habits.

Making surgery safer by centralization of care: impact of case load in penile cancer.

PURPOSE: Penile cancer is a rare but aggressive disease, often requiring a rapid and extensive surgical treatment of the primary tumor and staging or treatment of the inguinal lymph node basins. Current management and guidelines of the disease are mainly based on retrospective data, as there is a lack of controlled trials or large series. The purpose of this work is to review contemporary data on the impact of centralization and formation of rare disease networks on penile cancer care and outcomes. METHODS: This narrative, non-systematic review is based on publications retrieved by a PubMed and EMBASE search and on the current guidelines of the European Association of Urology, the National Institute for Health and Care Excellence, and the National Comprehensive Cancer network. RESULTS: The low case load, particularly in non-specialized centres, combined with limited evidence regularly results in a disparity between the treatment strategy and the guidelines. The suboptimal guideline adherence is specifically the case for organ-sparing surgery and surgical staging of the groin areas in selected cases. Treatment of the disease in high-volume referral centres has been shown to improve the use of organ-sparing surgery, the utilization of invasive lymph node staging in high-risk patients, and finally has resulted in increased survival rates. CONCLUSIONS: The management of penile cancer in disease networks and in countries where centralized healthcare is offered positively influences functional and oncological outcomes. We propose that governments and health care providers should be encouraged to centralize healthcare for rare tumors such as penile cancer.

The Top 100 Cited Articles in Urethral Reconstruction.

OBJECTIVE: To examine the most cited literature in urethral reconstruction, review types of work published, and observe research trends. METHODS: The Web of Sciences Sci-Expanded Index was used to conduct a search for urethral reconstruction. References were assessed for relevance to urethral reconstruction by 2 independent reviewers and a final list of the top 100 articles ranked by citation count was obtained. For each article, citation count, publication date, corresponding author, origin institution, origin country, topic area, study design, level of evidence, and origin journal were collected. RESULTS: The mean citation count per publication was 108 (median = 94.5; range = 69-366, SD = 43) with a total of 10,874 citations for all papers since 1970. The top 100 articles were published between 1973 and 2011, came from 19 different countries and 16 different journals. Nearly half were case series and most studies were Level III evidence or lower. The United States was the largest contributor to the top 100 with 56 publications, followed by Italy (14), England (12), and Egypt (7). "Outcomes of surgical treatment for urethral stricture disease" was the most prevalent topic area comprising 55 articles in the top 100, with most articles including descriptions or outcomes of novel surgical techniques. CONCLUSION: In this study, we discovered that the most cited literature in the field of urethral reconstruction is singularly focused and lacking in high levels of evidence. The top 100 cited articles originate primarily from the United States, focus on short-term outcomes after surgical treatment for urethral stricture disease, and are predominantly case series.

Profil des patients suivis pour affections urologiques chirurgicales aux Cliniques universitaires de Kisangani-RDC

Introduction. Les pathologies urologiques regroupent un ensemble des pathologies multiples et variées.Ces pathologies comme toutes celles chirurgicales constituent l'une des causes de mortalité en chirurgie curative surtout dans les pays en voie de développement. Le but de notre étude était donc de ressortir le profil des patientes avec pathologies chirurgicales urologiques rencontrées aux Cliniques Universitaires de Kisangani. Méthodologie.Etude transversale, descriptiveportant sur tous les cas despathologies urologiques chirurgicalesdiagnostiquées et traitéesaux cliniques universitaires de Kisangani durantla période du1er janvier 2013 au31 décembre 2017.Résultats.Les affections urologiques chirurgicales représentaient 9,7% des cas, concernant essentiellement les hypertrophies prostatiques avec 57,3% des cas. La plupart des patients avec affection urologique chirurgicale étaient de sexe masculin (98,7%), âgés de 61 ans et plus (58,7%) avec une moyenne d'âge de 55,7 ans et des extrêmes allant de 2 à 81ans, mariés (74,6%) et agents de l'état (46,7 %).Conclusion.Les pathologies urologiques chirurgicales dominées par les hypertrophies de la prostate sont fréquentes aux Cliniques universitaires de Kisangani