Intraureteral indocyanine green augments ureteral identification and avoidance during complex robotic-assisted colorectal surgery

AIM

Up to 10% of patients who undergo nonurological abdominopelvic operations suffer a ureteral injury. While preoperative ureteral stenting to facilitate identification of the ureter is common, it does not reduce the incidence of intraoperative ureteral injury and is not without risk. As we continue to broaden the application of minimally invasive surgical techniques, a new form of ureteral identification and avoidance that does not rely on tactile feedback is needed. We report our initial experience with intraureteral indocyanine green (ICG) for ureteral identification and avoidance during complex robotic-assisted colorectal surgery.

METHOD

Patients undergoing adjunctive ureteral identification during robotic-assisted colorectal surgery were prospectively identified. Each patient underwent intraureteral ICG administration using rigid cystoscopy (22 Fr). A 5-Fr open-ended ureteral catheter was inserted up to 20 cm and used to inject 5 ml of 2.5 mg/ml ICG as the catheter was withdrawn to the ureteral orifice. Intraureteral ICG was then detected using near-infrared laser fluorescence technology (Firefly®).

RESULTS

Successful ICG-enhanced ureteral identification and avoidance was performed in 15 of 16 (94%) patients undergoing robotic-assisted colorectal surgery. The median ICG instillation time was 11.5 min (range 4-21 min) and the median operative time with ICG visualization was 489 min (8 h 9 min) [range 268-738 min (4 h 28 min-12 h 18 min)]. No patient experienced intraoperative ureteral injury and there were no adverse sequelae or complications associated with intraureteral ICG administration.

CONCLUSION

Intraureteral ICG is a safe and effective method of intraoperative ureteral identification and avoidance during complex robotic-assisted colorectal surgery. Precise and prolonged ureteral visualization was achieved, allowing for long operative times compatible with complex robotic-assisted operations.

Pubectomy and urinary reconstruction provides definitive treatment of urosymphyseal fistula following prostate cancer treatment

OBJECTIVE

To describe the natural history, reconstructive solutions, and functional outcomes of those men undergoing pubectomy and urinary reconstruction after prostate cancer treatment.

PATIENTS AND METHODS

This study retrospectively identified 25 patients with a diagnosis of urosymphyseal fistula (UF) following prostate cancer therapy who were treated with urinary reconstruction with pubectomy. This study describes the natural history, reconstructive solutions, and functional outcomes of this cohort.

RESULTS

All 25 patients had a history of pelvic radiotherapy for prostate cancer. The median (interquartile range [IQR]) time from prostate cancer treatment to diagnosis of UF was 11 (6, 16.5) years. The vast majority of men (24/25; 96%) presented with debilitating groin pain during ambulation. Posterior urethral stenosis was common (20/25; 80%), with 60% having repetitive endoscopic treatments. Culture of pubic bone specimens demonstrated active infection in 80%. Discordance between preoperative urine and intraoperative bone cultures was common, 21/22 (95.5%). After surgery, major 90-day complications (Clavien-Dindo Grade III and IV) occurred in eight (32%) patients. Pain was significantly improved, with resolution of pain (24/25; 96%) and restoration of function, the median (IQR) preoperative Eastern Cooperative Oncology Group Performance Status (ECOG PS) was 3 (2, 3) vs median postoperative ECOG PS score of 0 (0, 1).

CONCLUSION

Endoscopic urethral manipulation after radiation for prostate cancer is a risk factor for UF. Conservative management will not provide symptom resolution. Fistula decompression, bone resection, and urinary reconstruction effectively treats chronic infection, improves pain and ECOG PS scores.

How to perform a robotic pyeloplasty utilizing the da Vinci SP platform: tips and tricks

Robotic pyeloplasty has become more prevalent with the evolution and dissemination of robotic surgery. The da Vinci SP robotic platform is a new technology that has allowed for true single port surgery, compared to the previous multiport robotic platforms. As the SP has been utilized for an increasing number of urologic procedures, it can also be successfully used for pyeloplasty. Herein, we describe our technique and tips for performing a da Vinci SP pyeloplasty in the adult population.

Prevalence and Predictors of Climacturia and Associated Patient/Partner Bother in Patients With History of Definitive Therapy for Prostate Cancer

BACKGROUND

Climacturia is an under-reported complication of definitive therapy for prostate cancer (PCa) - that is, radical prostatectomy (RP) and/or radiation therapy (RT).

AIM

We sought to identify the prevalence and predictors of climacturia and associated patient/partner bother in patients with and without prior PCa treatment.

METHODS

We analyzed a database of patients who presented to our Men's Health clinic and filled out a questionnaire related to sexual function and pertinent medical histories. The prevalence of climacturia and associated patient/partner bother in patients with/without prior RP/RT was calculated. Univariable and multivariable logistic regressions were performed to identify predictors associated with climacturia and patient/partner bother.

OUTCOMES

The primary outcomes were the prevalence and predictors of climacturia and associated patient/partner bother in patients with/without history of definitive PCa treatment.

RESULTS

Among 1,117 patients able to achieve orgasm, 192 patients (17%) had prior history of definitive therapy for PCa (RP alone = 139 [72%]; RT alone = 22 [11%]; RP + RT = 31 [16%]). Climacturia was reported by 39%, 14%, 52%, and 2.4% of patients with history of RP alone, RT alone, RP + RT, and neither RP nor RT, respectively (P < .05 between all groups). 33 to 45 percent of patients with climacturia noted significant patient/partner bother. Factors significantly associated with climacturia were prior RP, prior RT, history of other prostate surgery, and erectile dysfunction, although erectile dysfunction was not significant on multivariable analysis. Significant reduction in climacturia prevalence was noted for patients who were ≥1 year out from RP, compared with patients who were <1 year out. Among patients with prior RP/RT, stress urinary incontinence was associated with increased risk of climacturia, whereas diabetes was associated with decreased risk. No factors were associated with patient/partner bother. Among patients with prior RP, nerve-sparing technique did not predict presence of climacturia but was associated with reduced patient/partner bother.

CLINICAL TRANSLATION

Given significant prevalence of climacturia and associated patient/partner bother, patients should be counseled on the risk of climacturia before undergoing RP/RT.

STRENGTHS AND LIMITATIONS

Strengths include the large study population and the focus on both RP and RT. Limitations include the facts that this is a single-institution study that primarily relies on patients' subjective reporting and that the study population may not represent the general population.

CONCLUSIONS

Climacturia affects a significant proportion of patients with history of RP/RT for PCa, and many patients and their partners find this bothersome. Jimbo M, Alom M, Pfeifer ZD, et al. Prevalence and Predictors of Climacturia and Associated Patient/Partner Bother in Patients With History of Definitive Therapy for Prostate Cancer. J Sex Med 2020;17:1126-1132.

Treatment outcomes of bladder neck contractures from surgical clip erosion: a matched cohort comparison

Vesicourethral anastomotic stenosis (VUS) from surgical clip erosion after radical prostatectomy (RP) is a rare scenario with potentially significant quality of life implications. The literature is limited to case series, and the impact of clip erosion on VUS prognosis is not known. Years 2001 to 2012 of our institutional RP registry were queried for patients with symptomatic VUS without prior strictures or radiotherapy. Patients with clip-associated VUS (caVUS) were identified and compared to a 1:3 matched cohort (based on age, Gleason score, and year of surgery) of non-caVUS patients using descriptive statistics and time to event analyses. At a median follow-up of 54 months after RP, 243 men with symptomatic VUS were identified of which 21 (8.6%) were caVUS. Robotic RPs had a higher rate of caVUS (0.5%) vs. open RPs (0.06%), P<0.01. Patients with caVUS had longer time to diagnosis after RP compared to a matched cohort of 63 non-caVUS patients (median 9.2 vs. 3.7 months after RP, P<0.01). Although patients with caVUS had a higher VUS recurrence rate after endoscopic treatment compared to patients with non-caVUS, the difference was not statistically significant on log-rank comparison (3-year VUS recurrence rate 56.4% vs. 39.4%, P=0.23). Majority of VUS recurrences were within 18 months of initial treatment. Clip erosion is responsible for 8.6% of VUS after RP, takes longer to present than non-caVUS, and was seen more commonly after a robotic RP. VUS recurrence rates are similar for caVUS and non-caVUS.

Neurogenic bladder: management of the severely impaired patient with complete urethral destruction: ileovesicostomy, suprapubic tube drainage or urinary diversion-is one treatment modality better than another?

Background

Management of the severely impaired patient (pt) with a neurogenic bladder (NGB) and complete urethral destruction employs three therapeutic options; bladder neck closure (BNC) with ileovesicostomy, BNC with suprapubic tube (SPT) placement or in pts with an end-stage bladder, cystectomy with enteric conduit diversion. This paper was performed to test the hypothesis that pts managed with an ileovesicostomy would have the best long-term prognosis.

Methods

Patients with a NGB and complete urethral destruction managed between 1986-2018 were reviewed. Three treatment populations were assessed, pts treated with BNC with ileovesicostomy, BNC with SPT placement or cystectomy with enteric conduit diversion. A minimal follow-up interval of 2 years was necessary to be entered into the study. The number of uroseptic episodes, development of urolithiasis, the onset of new renal scars, ≥ stage 3 chronic renal failure, or need for additional surgery were recorded. Statistical evaluations used either chi-squared contingency table analysis, Fisher's exact 2-tailed tests, or Kaplan-Meier curve analysis where indicated. P values of <0.05 were considered significant.

Results

Ten pts were managed by cystectomy, and enteric conduit, 17 by BNC and ileovesicostomy and 21 by BNC and SPT placement, median follow up of 8 yrs (range, 2-30 yrs). No significant differences between the three groups regarding the development of urolithiasis (30%, 3/10 pts; 53%, 9/17 pts; 52%, 11/21 pts; respectively), new onset of renal scarring (30%, 6/20 kidneys; 41%, 14/34 kidneys; 45%, 19/42 kidneys; respectively) or stage 3 chronic renal failure (40%, 4/10 pts; 47%, 8/17 pts; 24%, 5/21 pts; respectively. However, the number of hospitalizations for uroseptic episodes significantly increased in patients managed with an ileal conduit (60%, 6/10 pts) and ileovesicostomy (82%; 14/17 pts) compared to those maintained with a SPT (29%, 6/21 pts) P=0.025 and 0.006, respectively. When evaluating the need for delayed surgical intervention due to either urolithiasis or other complications, a total of 50% (5/10 pts) of the patients managed by an ileal conduit, 88% (15/17 pts) of the ileovesicostomy and 52% (11/21 pts) of the patients with a SPT required additional operations. In essence, significantly more pts undergoing BNC and ileovesicostomy required delayed surgical interventions for complications arising from the surgery compared to patients managed with either a cystectomy and ileal conduit (P=0.0285) or BNC and SPT placement (P=0.0180).

Conclusions

In severely impaired pts with a NGB and urinary outlet destruction, BNC and ileovesicostomy are associated with a significantly increased incidence of urosepsis and late surgical complications that required operative intervention compared to alternative treatments. This finding has resulted in the abandonment of the ileovesicostomy from our surgical armamentarium.

Persistent, long-term risk for ureteroenteric anastomotic stricture formation: the case for long term follow-up

Background

Up to one in ten patients undergoing cystectomy with urinary diversion develop a ureteroenteric stricture (UES). Despite unrecognized ureteral obstruction contributing to infection, nephrolithiasis, and/or progression of kidney disease, the long-term natural history and risk factors associated with UES remains understudied. Herein, we report our single institutional experience with the long-term incidence, clinical presentation, and risk factors associated with UES formation following urinary diversion.

Methods

We reviewed 2,285 patients who underwent RC with urinary diversion between 1980-2008. UES was defined as radiographic evidence of ureteral obstruction at the level of the ureteroenteric anastomosis. The diagnosis of benign UES was confirmed by pathology. UES-free survival was estimated using the Kaplan-Meier method. The association between clinicopathologic features and the development of a UES were assessed using multivariable models.

Results

A total of 192 (8%) patients developed a benign UES, at a median of 7 months (IQR 4-24) following RC, with 5% occurring after 10 years. Seventy seven percent of patients exhibited signs and/or symptoms of ureteral obstruction. Patients who developed a UES had a greater body mass index (BMI) (28 vs. 27), operative time (330 vs. 301 minutes) and were more likely to experience a <30-day Clavien ≥3 complication (all P<0.05). Receipt of abdominal radiation and smoking history were not significantly associated with UES stricture risk. On multivariable analysis, only greater BMI (per 1-unit increase) (OR 1.06, 95% CI: 1.02-1.09; P=0.0009) and <30-day Clavien ≥3 complication (OR 2.85, 95% CI: 1.90-4.28; P<0.0001) were associated with the development of a UES. Development of UES was associated with renal function deterioration.

Conclusions

UES was identified in 8% of patients following RC with urinary diversion, with the majority presenting with symptoms. While the majority of these occur in the first 2 years after surgery, a patients' risk for the development of this complication persists beyond 10 years. Due to the adverse sequelae of UES, long-term functional and imaging surveillance following urinary diversion is warranted, and early reconstruction should be considered.

Robotic urethral reconstruction: redefining the paradigm of posterior urethroplasty

Outlet procedures for benign prostatic hypertrophy, prostate cancer therapy, and trauma can result in stenosis of the posterior urethra, a complex reconstructive problem that often fails conservative endoscopic management, necessitating more aggressive and definitive reconstructive solutions. This is typically done with an open technique which may require a combined abdominoperineal approach, pubectomy, and/or flap interposition. Implementation of a robot-assisted platform affords several potential advantages including smaller incisions, magnified field of vision, near-infrared fluorescence (NIRF) imaging to characterize tissue integrity, enhanced dexterity within the deep and narrow confines of the male pelvis, sparing of the perineal planes, and shorter convalescence. Herein, we describe important surgical considerations for robotic posterior urethral reconstruction.

Pelvic fracture urethral injuries associated with rectal injury: a review of acute and definitive urologic and bowel management with long term outcomes

Background

Pelvic fracture urethral injuries (PFUI) with simultaneous rectal lacerations are unique rarely reported injuries. This paper serves to define our management, outcomes and make recommendations to improve the care of these patients.

Methods

We retrospectively reviewed all patients with a PFUI and concurrent rectal injury treated from 1990-2018, initial surgical treatments, along with definitive surgical repair were reviewed. Statistical analysis considered P values <0.05 as significant.

Results

Eighteen patients were identified; median follow-up post injury is 4 years, range 1-12 years. Injuries that impacted urologic care included concurrent bladder neck lacerations (BNL) in 50% (9/18) and concurrent neurologic injuries in 28% (5/18). In the nine patients with a simultaneous BNL, 44% (4/9) underwent a primary sutured anastomotic repair of the BNL and urethra, 33% (3/9) underwent primary closure of the bladder neck and SPT drainage and 23% (2/9) had primary repair of BNL with urethral realignment. Continued urinary extravasation through the BN despite the initial surgery resulted in life threating pelvic sepsis in 56% (5/9) versus 0% (0/9) in the patients without a bladder neck laceration, P=0.012. Long term follow up revealed, 22% (2/9) are currently voiding per urethra, neither are continent, one with chronic diaper dependent incontinence, one with stress incontinence. Urinary continence was eventually obtained in 44% (4/9) with either closure of the bladder neck and creation of a continent catheterizable stoma (3 pts) or with cystectomy and creation of an Indiana pouch (1 pt), 33% (3/9) were managed with eventual cystectomy and an enteric urinary conduit. In the nine patients with no concurrent bladder neck injury all were managed with a suprapubic tube placement and consideration for a delayed urethral reconstruction. Delayed end to end urethroplasties were performed in 67% (6/9). Eighty-three percent (5/6) are continent, 50% (3/6) are voiding per urethra without sequale, 33% (2/6) developed recurrent urethral strictures, one was treated with a single DVIU and has retrained urethral patency, at four years post treatment, one is on daily intermittent catheterization to maintain patency. Stress incontinence is noted in 17% (1/6). Due to concurrent neurologic injuries 33% (3/9) of these pts did not undergo further attempt at repair and have been managed with a long-term suprapubic tube.

Conclusions

PFUI with simultaneous rectal lacerations have significant comorbid injuries, especially, concurrent bladder neck lacerations and neurologic injuries that affect the urologic prognosis. In patients with a concurrent BNL we recommend initial intervention include primary lower urinary tract reconstruction with simultaneous proximal urinary diversion to help prevent the complication of persistent urinary extravasation with resultant pelvic sepsis.

Balloon dilation performs poorly as a salvage management strategy for recurrent bulbar urethral strictures following failed urethroplasty

BACKGROUND

The optimal management strategy for recurrent urethral stricture disease (USD) following urethroplasty remains undefined. We aim to evaluate the role and efficacy of endoscopic urethral balloon dilation in temporizing recurrent USD after failed urethroplasty.

METHODS

Between 2007-2018 at our institution, 80 patients underwent balloon dilation procedures for bulbomembranous urethral strictures. Balloon dilation was performed with an 8-cm, 24-French UroMax Ultra™ balloon dilator, under direct vision, guided by a 16-French flexible cystoscope. Patients who underwent concomitant open or endoscopic urethral procedures were excluded. Treatment failure was defined as the need for subsequent surgical intervention for stricture recurrence. Stricture characteristics including etiology, length, location, severity stage, and prior surgical procedures were compared between patients with and without treatment failure.

RESULTS

Failure cases were more likely to have strictures following urethroplasty (21/27, 78%) [vs. the no-failure group (27/53, 51%)]. Among the 27/80 (33.8%) failures with a median follow-up of 8.4 months (IQR, 3.9-22.5 months), median time to recurrence was 4 months (IQR, 2-12 months). These patients had a greater incidence of prior stricture intervention in general (P=0.01) and prior urethroplasty specifically (P=0.03). On multivariable analysis, the number of prior treatments specifically independently remained associated with treatment failure. Complications of balloon dilation were uncommon (6/80, 7.5%) and minor in nature.

CONCLUSIONS

Endoscopic balloon dilation performs poorly as a salvage strategy after failed open urethral reconstruction in addition to prior urethral dilations.

Enhanced ambulatory male urethral surgery: a pathway to successful outpatient urethroplasty

Background

Length of stay following anterior urethroplasty (AU) surgery has progressively shortened over the past two decades with most patients discharging the day of surgery or following overnight observation. We sought to assess overall analgesia and patient satisfaction with same-day discharge after AU surgery.

Methods

Our prospectively maintained anterior urethroplasty database was reviewed. Men were identified who underwent anterior urethroplasty surgery by a single surgeon (B.R.V.) with the Enhanced Ambulatory Male Urethral Surgery (EAMUS) protocol followed by same-day discharge. Patients were contacted within 3 weeks of surgery and completed validated assessment tools to characterize satisfaction with the outpatient experience and with analgesia management. A statistical analysis was performed to assess predictors of overall satisfaction with same-day discharge following AU surgery.

Results

Fifty-seven patients with median age 52.2 years underwent same-day AU surgery between August 2017 and October 2018. In total, 46 patients (80.7%) responded to post-discharge surveys assessing overall outpatient satisfaction and satisfaction with analgesia. Median satisfaction with outpatient experience (scale 1-5) was 5 (IQR 4, 5) with 93.4% of patients indicating they were satisfied to very satisfied (4 or 5). Median patient satisfaction with analgesia (scale 1-6) was 6 (IQR 5, 6) with 93.4% of patients indicating a satisfaction with analgesia score of ≥5 (satisfied to very satisfied). Median number of 5 mg oxycodone tablets used following discharge was 3 (IQR 0.75, 5). Postoperative complications occurred in 14 patients (25%) with 12 (86%) being low grade complications (Clavien-Dindo Classification ≤ II).

Conclusions

With appropriate preoperative education and peri-operative analgesia, anterior urethroplasty surgery can be performed with same-day discharge with comparable postoperative complication rates while maintaining excellent patient satisfaction. Additional high volume, prospectively collected studies are necessary to verify short-term satisfaction rates while confirming long-term urethroplasty success rates remain comparable to AU surgery performed with next day discharge.

Evaluating the impact of radiation therapy on patient quality of life following primary artificial urinary sphincter placement

Background

The impact of prior radiation therapy on patient satisfaction following primary artificial urinary sphincter (AUS) placement is not well described, therefore our aim was to evaluate the effect of radiation on patient satisfaction among men undergoing primary AUS with and without a history of prior radiation.

Methods

From 1983-2011, 1,082 men underwent primary AUS placement at our institution. Of these, 467 were alive, with an intact primary AUS and invited to participate in a mailed survey assessing AUS status, patient satisfaction, and urinary control. Clinical subjective outcomes were assessed via reported change in urinary control from pre-operative to post-AUS placement.

Results

In total, 229/467 (49%) of men with an intact primary AUS completed the survey, with a median follow-up of 8.4 years [interquartile range (IQR) 5.8-11.4]. Of these, 64 men (28%) had a prior history of radiation therapy. Both men with and without history of radiation, reported a high likelihood of electing to have AUS surgery again, 87% vs. 91% respectively (P=0.87), and of recommending AUS surgery to a family member, 86% vs. 93% respectively (P=0.18). There were no significant differences between those with and without prior radiation with regard to rates of reported: substantial improvement in urinary control following surgery (72% vs. 78%, P=0.30), minimal bothersome leakage (57.1% vs. 66%, P=0.31), and pad use ≤1 pad/day (49% vs. 59%, P=0.06).

Conclusions

In a large cohort of primary AUS implants with and without prior radiation therapy we noted a high-level of satisfaction and though many patients still utilized 1 or more pads/day with long-term follow-up. Importantly, there was no significant difference in quality of life (QoL) outcomes compared between those with and without prior radiation therapy.

Initial Experience with da Vinci Single-port Robot-assisted Radical Prostatectomies

BACKGROUND

Single-port robotic surgery is being adopted for various surgical procedures. There have been interest in and clinical use of single-port robot-assisted radical prostatectomy (spRARP), but little reported data on feasibility and early outcomes.

OBJECTIVE

To describe our institution's initial experience with spRARP utilizing the da Vinci single-port (SP) robotic system.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of the initial experience of three high-volume robotic prostate surgeons performing an spRARP utilizing the da Vinci SP robotic system was carried out.

SURGICAL PROCEDURE

An spRARP using the da Vinci SP robotic system was performed following the traditional retropubic or Retzius-sparing approach.

MEASUREMENTS

Patient demographics, operative time, blood loss, postoperative hospital stay, complications, and catheter duration were obtained and analyzed.

RESULTS AND LIMITATIONS

In a cohort of 49 patients undergoing spRARP, median age was 62yr and prostate-specific antigen 6.4. Of the patients, 35 (71%) had cT1c disease on presentation, 92% had Gleason grade group ≥2 disease, and 85% were pT2 on final pathology. Median operative time was 161min. Median blood loss was 200ml. Seven Retzius-sparing cases were performed. Four Clavien 2 complications occurred (complication rate 8.1%). Median hospital stay was 1d and median catheter duration 7d. Operative time was <200min for all three surgeons by their third case.

CONCLUSIONS

The da Vinci SP system spRARP is safe and feasible, with acceptable operative time and blood loss. Further research is needed to establish noninferiority to the da Vinci Xi and Si systems, and impact of spRARP on patient-assessed cosmesis and pain.

PATIENT SUMMARY

Robotic prostatectomy using a purpose-built da Vinci single-port robotic system is safe and feasible, and warrants further study to determine whether it can improve patient outcomes.

Sarcopenia and Response to Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer

INTRODUCTION

The objective of the study was to determine whether sarcopenia is associated with pathologic and survival outcomes for patients with muscle-invasive bladder cancer (MIBC) treated with neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC).

PATIENTS AND METHODS

We identified MIBC patients treated with cisplatin-based NAC in our cystectomy registry from 2000 to 2016. Pre- and post-NAC computed tomography images were analyzed with BodyCompSlicer, a validated body composition assessment tool. Sarcopenia was defined as a skeletal muscle index (SMI) below sex-specific international consensus values. Associations of clinical features with pathologic downstaging (<ypT2), major (Clavien III-V) complications, and cancer-specific mortality (CSM) were modeled using multivariable logistic and Cox proportional hazard regression models.

RESULTS

A total of 183 patients were identified. Median follow-up was 3.0 years (interquartile range, 1.8-5.0), during which time 79 patients died, including 62 of bladder cancer. SMI declined by a median of 8.4% during NAC treatment. In multivariable logistic regression, neither pretreatment sarcopenia nor the amount of muscle mass loss during NAC was associated with downstaging to <ypT2 disease (P > .05). Meanwhile, only post-NAC sarcopenia (hazard ratio, 1.90; 95% confidence interval, 1.02-3.56; P = .04) was independently associated with an increased risk of CSM.

CONCLUSION

Sarcopenia after NAC and before RC appeared to be prognostic. Although skeletal muscle mass declined significantly during NAC, neither the degree of muscle loss nor pretreatment SMI were significantly associated with downstaging after NAC and RC. These data do not support the use of sarcopenia as a risk stratification tool for selection of patients for or monitoring response to NAC.

Risk factors for subsequent urethral atrophy in patients undergoing artificial urinary sphincter placement

OBJECTIVE

Artificial urinary sphincter (AUS) device failure or revision can be due to multiple etiologies including erosion, infection, mechanical malfunction, and urethral atrophy. However, few studies have evaluated factors that predispose patients to urethral atrophy. Here, we sought to identify preoperative and perioperative risk factors associated with urethral atrophy in men undergoing primary artificial urinary sphincter (AUS) placement for stress urinary incontinence.

MATERIAL AND METHODS

From 1987 to 2013, 1829 AUS procedures were performed at our institution. A total of 1068 patients underwent primary AUS placement and were the focus of our study. Multiple clinical and surgical variables were evaluated for a potential association with revision for atrophy. Those found to be associated with atrophy and relevant competing risks were further evaluated on multivariable analysis.

RESULTS

With a median follow-up of 4.2 years (IQR 1.3-8.1), 89 men (8.3%) had urethral atrophy requiring reoperation. Median time to revision was 4.5 years (IQR 1.9-7.6). On univariable analysis, only smaller cuff size (4.0-cm versus 4.5-cm; HR 3.1, p=0.04) was associated with an increased rate of urethral atrophy. Notably, patient age at the time of surgery (p=0.62), body mass index (0.22), and smoking status (p=1.00) were not associated with a risk of atrophy. On multivariable analysis smaller urethral cuff size remained significant (HR 2.8, 95% CI 1.1-7.1; p=0.01).

CONCLUSION

Revision surgery for urethral atrophy was performed in approximately 8% of men undergoing primary AUS placement. Utilization of a smaller AUS cuff size appears to be an independent factor associated with increased rate of urethral atrophy.

Physical activity monitors can be successfully implemented to assess perioperative activity in urologic surgery

BACKGROUND

Mobile health and physical activity monitors (PAMs) are emerging technologies allowing patients to track multiple health parameters. These parameters could be useful in monitoring and modifying the perioperative health of urology patients. We performed a pilot study and describe a model for which to implement mHealth applications in a urology population.

METHODS

Patients undergoing robotic assisted retropubic prostatectomy were screened for inclusion and provided with Fitbit® Charge HRTM (Boston, MA, USA) devices. Patients were fitted with the device during the preoperative visit and instructed to wear before and after surgery. Biophysical data was collected and patient acceptance was assessed with a Mobile Physical Activity Monitor Questionnaire (MPAMQ).

RESULTS

Forty-six patients met inclusion criteria. Median duration of PAM usage was one and seven days preoperatively and postoperatively. Postoperatively, there was a reduction in median daily steps compared to preoperatively (2,782 vs. 3,907, P=0.024), but no statistically significant difference in minutes slept or nighttime awakenings. Obese (BMI ≥30) and older men (≥65 years) had a greater reduction in steps after surgery (P<0.001 and P=0.055), whereas there was no difference in non-obese and men age <65. Patients with BMI ≥30 took 35% fewer steps postoperatively than BMI <30 (P=0.017). The majority of patients (82%) reported a medical benefit and 95% were satisfied with using PAM technology in the perioperative period.

CONCLUSIONS

PAM effectively captures perioperative biophysical parameters and is associated with high patient satisfaction. Clinically, obese and elderly men appear to have significantly reduced activity following prostatectomy.

Excision and Primary Anastomosis Reconstruction for Traumatic Strictures of the Pendulous Urethra

OBJECTIVES

To present a multi-institutional experience with functional and patient-reported outcomes among men undergoing excision and primary anastomosis (EPA) urethroplasty for pendulous urethral strictures.

METHODS

We describe the technique and present our experience with EPA for focal penile strictures. Patients undergoing urethroplasty (2004-2017) at 2 tertiary referral centers were reviewed, of whom 14 (0.7%) underwent EPA of radiographically confirmed pendulous urethral strictures. Validated questionnaires were utilized to evaluate overall improvement (Patient Global Impression of Improvement), urinary bother (International Prostate Symptom Score), and sexual function (International Index of Erectile Function-5). Treatment success was defined as urethral patency without need for subsequent reconstruction.

RESULTS

Among 14 men undergoing penile EPA, 13/14 (93%) had durable treatment success over a median follow-up of 43 months. No patient reported penile curvature postoperatively. Stricture etiology in most cases was posttraumatic (12/14), of which 4 had a history of urethral disruption secondary to penile fracture and 8 iatrogenic trauma. Median age was 51 years (IQR 30-60) and stricture length 1.0 cm (IQR 1.0-1.4). Erectile function was normal in 8/14 patients preoperatively, and postoperative median International Index of Erectile Function was 21. Most men reported significant global improvement in condition (median Patient Global Impression of Improvement 2, IQR 1-3) and most had only mild urinary bother (median International Prostate Symptom Score 4, quality of life 1). The single treatment failure had a history of hypospadias with multiple prior urethral procedures.

CONCLUSION

For men with short strictures of the pendulous urethra, EPA has a high success rate, without adverse sequelae such as erectile function or penile curvature.