Penile Paraffinoma

Penile paraffinoma is a rare cause of penile mass that can occur following injection of liquid paraffin, performed illicitly for penile augmentation. Over the past 2 yr, we have observed an increasing number of cases presenting with the complications of penile paraffinoma; three patients of central European origin have required inpatient treatment at our institution and posed a significant management dilemma. This mini-review aims to review the literature on the aetiopathogenesis, clinical features, diagnosis, and management of penile paraffinoma. A systematic search of PubMed and Scopus was performed with 10 case series and 26 case reports identified between 1956 and 2017. A total of 124 cases, with a mean age of 36.29 yr, were identified. The majority originated in Korea, and the most common injected material was liquid paraffin (80.6%). Patients presented with pain/swelling, ulceration/fistulae, and penile deformity. The majority required surgical excision of paraffinoma followed by reconstruction with a variety of procedures including split skin grafting, scrotal skin flap reconstruction, and prepuce grafting. Mean duration of follow-up was 15.8 mo. Penile paraffinoma remains a rare presentation; however, it can present management difficulties. We have had an increase in cases, with three patients presenting with complications following injection of paraffin in our unit in the past 2 yr. Definitive management includes surgical excision and reconstruction as required with early involvement of plastic surgeons. There may be a role for conservative management; however, long-term outcomes are unclear. There may be a need for targeted preventative measures through public health agencies in communities where the practice is more prevalent. PATIENT SUMMARY: Penile paraffinoma can occur following injection of liquid paraffin or similar substances, generally used by non-healthcare personnel for the purpose of penile augmentations, and can cause significant pain, ulceration, and penile deformity. Definitive management includes surgical excision with reconstruction as required. Prevention of its use through awareness and education may be required in communities where the practice is more common.

The Midurethral Fascial "Sling on a String": An Alternative to Midurethral Synthetic Tapes in the Era of Mesh Complications

BACKGROUND

Surgery for stress urinary incontinence (SUI) has been dominated recently by synthetic midurethral tapes. Increasing recognition of serious complications associated with nonabsorbable polypropylene mesh has led to resurgence in interest in alternative approaches, such as the autologous fascial sling (AFS). Despite being an efficacious and durable option in women with recurrent and complex SUI, there has been a reluctance to consider AFS in women with primary SUI due to a perception that it is only appropriate for treating patients with intrinsic sphincter deficiency (ISD) and is associated with high rates of urinary retention and de novo storage symptoms.

OBJECTIVE

The video presented demonstrates the technique for a loosely applied midurethral AFS. In contrast to AFS applied at the bladder neck, this technical modification in patients who demonstrate primary SUI without ISD avoids high rates of de novo storage symptoms and urinary retention.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of data on patients undergoing AFS at a tertiary referral unit.

SURGICAL PROCEDURE

AFS placement in a "loose" fashion using a short length of fascia suspended on a suture bilaterally at the midurethral level rather than at the bladder neck and only using more tension in patients with ISD.

MEASUREMENTS

Subjective cure rate, rates of postoperative storage symptoms, and urinary retention necessitating intermittent self-catheterisation (ISC).

RESULTS AND LIMITATIONS

A total of 106 patients underwent AFS; the mean follow-up period was 9 mo. The mean age was 52.6 (range 24-83) yr. In total, 46.2% had primary SUI, whilst all of the remaining 53.8% had undergone prior surgical intervention. Overall subjective cure occurred in 79.2% of patients; a further 15.1% described significant subjective improvement in symptoms, whilst 5.7% reported no change in symptoms. In those with primary SUI, rates of subjective cure, improvement, and nonresolution of symptoms were 87.8%, 12.2%, and 0%, respectively. In individuals with prior surgical intervention, rates of subjective cure, improvement, and nonresolution of symptoms were 72.0%, 17.5%, and 10.5%, respectively. De novo storage symptoms occurred in 8.2% of those with primary SUI compared with 14.0% of those with prior surgical intervention. Only 2.0% patients with primary SUI needed to perform ISC beyond 2 wk compared with 10.5% of those after prior surgery.

CONCLUSIONS

A midurethral AFS appears to be effective and safe both in women with primary SUI who want to avoid the placement of permanent material and its attendant risks, and in more complex cases where this is less appropriate.

PATIENT SUMMARY

A graft taken from the covering of the abdominal muscle or the outer aspect of the thigh is an alternative to a synthetic vaginal mesh in women who have stress urinary incontinence requiring surgical treatment. Placing the graft loosely at the midpoint of the urethral tube, rather than at the bladder neck, reduces the risk of postoperative voiding difficulty and overactive bladder symptoms. Long-term data have suggested an outcome at least as good as a synthetic nonabsorbable tape without the potential for sling erosion into adjacent structures, as it avoids the use of nonabsorbable material.

Contemporary outcomes of hypospadias retrieval surgery in adults

OBJECTIVE

To describe the surgical approach and outcomes in the treatment of adult patients with complications of childhood hypospadias surgery, as such patients present a significant reconstructive challenge due to the combination of anatomical and cosmetic deformity, which often results in major functional and psychosexual sequelae.

PATIENTS AND METHODS

We analysed prospectively collected data on 79 adults with complications of childhood hypospadias surgery, who were operated on between 2004 and 2016. Of the 79 patients, 48 underwent a two-stage urethroplasty using a buccal mucosa graft, and 31 underwent a one-stage distal urethroplasty.

RESULTS

Patients were followed up using flexible cystoscopy (every 6-9 months). The mean (range) follow-up was 48 (12-96) months. Of the 48 patients who underwent a two-stage repair, eight (16%) needed a revision of the first-stage graft. In total, nine of the 48 patients (16%) developed fistula requiring closure after the second stage; all but one was closed successfully on the first attempt, whilst one required two attempts before closure. Only two of the 48 patients that underwent a two-stage procedure required a re-do urethroplasty within 3 years. Of the 31 patients who underwent a one-stage repair, six (19%) needed fistula closure, all of which were successful. No patient required a further urethroplasty during follow-up.

CONCLUSIONS

Despite the significant surgical challenges found in this patient group, excellent long-term functional outcomes can be achieved. As expected there is a need for additional intervention, either for revision of the first stage or to close fistulae and less commonly for further reconstruction for stricture recurrence.

Current concepts of the acontractile bladder

The acontractile bladder (AcB) is a urodynamic-based diagnosis wherein the bladder is unable to demonstrate any contraction during a pressure flow study. Although it is often grouped with underactive bladder, it is a unique phenomenon and should be investigated independently. The purpose of the present review was to examine the current literature on AcB regarding its pathology, diagnosis, current management guidelines, and future developments. We performed a review of the PubMed database, classifying the evidence for AcB pathology, diagnosis, treatment, and potential future treatments. Over the 67 years covered in our review period, 42 studies were identified that met our criteria. Studies were largely poor quality and mainly consisted of retrospective review or animal models. The underlying pathology of AcB is variable with both neurological and myogenic aetiologies. Treatment is largely tailored for renal preservation and reduction of infection. Although future developments may allow more functional restorative treatments, current treatments mainly focus on bladder drainage. AcB is a unique and understudied bladder phenomenon. Treatment is largely based on symptoms and presentation. While cellular therapy and neuromodulation may hold promise, further research is needed into the underlying neuro-urological pathophysiology of this disease so that we may better develop future treatments.

UK medical students' perceptions, attitudes, and interest toward medical leadership and clinician managers

BACKGROUND

We aimed to determine UK medical students' perceptions and attitudes and interest toward medical leadership and clinician managers.

METHODS

A cross-sectional study was conducted during the academic year 2015-2016. An online questionnaire was distributed to 2,349 final-year students from 10 UK medical schools. Participants were asked to complete a 5-point Likert scale on their current perceptions, attitudes, and interest toward medical leadership and clinician managers. They were also asked to self-rate their leadership competences set by the Medical Leadership Competency Framework and to rate the quality of management and leadership training they received from their medical school.

RESULTS

In total, we received 114 complete responses. Only 7.9% of respondents were in agreement (strongly agree or agree) when asked whether they felt they were well informed about what a managerial position in medicine entails. When asked whether clinicians should influence managerial decisions within a clinical setting, 94.7% of respondents were in agreement with the statement. About 85% of respondents were in agreement that it is important for clinicians to have managerial or leadership responsibilities, with 63.2% of students in agreement that they would have liked more management or leadership training during medical school. Over half the respondents rated their management and leadership training they received during medical school as "very poor" or "poor" (54.4%).

CONCLUSION

Our study suggests that UK medical students have an appetite for management and leadership training and appreciate its importance but feel that the training they are receiving is poor. This suggests that there is a gap between the demand for management and leadership training and the quality of training supplied by UK medical schools.

Botulinum Toxin Versus Neural Stimulation

Botulinum toxin and nerve stimulation are viable options for overactive bladder refractory to pharmacotherapy. Treatment choice depends on multiple factors including associated symptoms, bladder function, and health economics. Decision-making should be individualised to the particular situation taking into account patient preference.

Application of Tissue Engineering to Pelvic Organ Prolapse and Stress Urinary Incontinence

Synthetic or biological materials can be used for the surgical repair of pelvic organ prolapse (POP) or stress urinary incontinence (SUI). While non-degradable synthetic mesh has a low failure rate, it is prone to complications such as infection and erosion, particularly in the urological/gynecological setting when subject to chronic influences of gravity and intermittent, repetitive strain. Biological materials have lower complication rates, although allografts and xenografts have a high risk of failure and the theoretical risk of infection. Autografts are used successfully for the treatment of SUI and are not associated with erosion; however, can lead to morbidity at the donor site. Tissue engineering has thus become the focus of interest in recent years as researchers seek an ideal tissue remodeling material for urogynecological repair. Herein, we review the directions of current and future research in this exciting field. Electrospun poly-L-lactic acid (PLA) and porcine small intestine submucosa (SIS) are two promising scaffold material candidates. Adipose-derived stem cells (ADSCs) appear to be a suitable cell type for scaffold seeding, and cells grown on scaffolds when subjected to repetitive biaxial strain show more appropriate biomechanical properties for clinical implantation. After implantation, an appropriate level of acute inflammation is important to precipitate moderate fibrosis and encourage tissue strength. New research directions include the use of bioactive materials containing compounds that may help facilitate integration of the new tissue. More research with longer follow-up is needed to ascertain the most successful and safe methods and materials for pelvic organ repair and SUI treatment.

The Aetiology, Treatment, and Outcome of Urogenital Fistulae Managed in Well- and Low-resourced Countries: A Systematic Review

CONTEXT

Urogenital fistula is a global healthcare problem, predominantly associated with obstetric complications in low-resourced countries and iatrogenic injury in well-resourced countries. Currently, the published evidence is of relatively low quality, mainly consisting retrospective case series.

OBJECTIVE

We evaluated the available evidence for aetiology, intervention, and outcomes of urogenital fistulae worldwide.

EVIDENCE ACQUISITION

We performed a systematic review of the PubMed and Scopus databases, classifying the evidence for fistula aetiology, repair techniques, and outcomes of surgery. Comparisons were made between fistulae treated in well-resourced countries and those in low-resourced countries.

EVIDENCE SYNTHESIS

Over a 35-yr period, 49 articles were identified using our search criteria, which were included in the qualitative analysis. In well-resourced countries, 1710/2055 (83.2%) of fistulae occurred following surgery, whereas in low-resourced countries, 9902/10398 (95.2%) were associated with childbirth. Spontaneous closure can occur in up to 15% of cases using catheter drainage and conservative approaches are more likely to be successful for nonradiotherapy fistulae. Of patients undergoing repairs in well-resourced countries, the median overall closure rate was 94.6%, while in low-resourced countries, this was 87.0%. Closure was significantly more likely to be achieved using a transvaginal approach then a transabdominal technique (90.8% success vs 83.9%, Fisher's exact test; p=0.0176).

CONCLUSIONS

It is difficult to conclude whether any specific route of surgery has advantage over any other, given the selection of patients to a particular procedure is based upon individual fistula characteristics. However, surgical repair should be carried out by experienced fistula surgeons, well versed in all techniques as the primary attempt at repair is likely to be the most successful.

PATIENT SUMMARY

Urogenital fistulae are a common problem worldwide; however, the available evidence on fistula management is poor in quality. We searched the current literature and identified that 95% of fistulae occur following childbirth in low-resourced countries, whereas 80% of fistulae are associated with surgery in well-resourced countries, where successful repair is also more likely to be achieved. The first attempt at repair is often the most successful and therefore fistula surgery should be centralised to hospitals with the most experience.

Evaluation and Classification of Stress Urinary Incontinence: Current Concepts and Future Directions

CONTEXT

Stress urinary incontinence (SUI) is a common and bothersome problem that frequently requires operative management. Over the past two decades, novel techniques have been introduced into clinical practice. With the greater variety of surgical options now available, there is an increasing focus on selecting the appropriate procedure for the individual patient based on the likely underlying pathophysiologic mechanism.

OBJECTIVE

To review the methods used in the evaluation of SUI and the proposed classification systems.

EVIDENCE ACQUISITION

A search of the PubMed database for the relevant search terms was conducted, and selected articles were retrieved and reviewed.

EVIDENCE SYNTHESIS

Standardised terminology for the description of SUI has been produced by the International Continence Society describing the problem in terms of symptoms, clinical signs, and urodynamic observations. The two major pathophysiologic theories that have emerged over the past 50 yr, urethral hypermobility and intrinsic sphincteric deficiency, have influenced the development and adoption of surgical techniques. It is now recognised that these two entities are not dichotomous but often coexist. The primary aim of the evaluation of the patient presenting with SUI is to confirm the diagnosis and assess symptom severity before instituting conservative treatments. Secondary evaluation consists of more sophisticated techniques that assess anatomy of the bladder neck and urethra under rest and stress (eg, videourodynamics, ultrasound) or direct or indirect physiologic measures of the integrity of the sphincter mechanism.

CONCLUSIONS

Classification of patients with SUI into distinct groups based on probable pathophysiologic mechanism could help guide the choice of surgical procedure, but current systems are likely too simplistic, and methods of assessment lack standardisation in techniques and sensitivity.

PATIENT SUMMARY

Urinary leakage on exertion, termed stress incontinence, is a common problem that affects many women. There is a need to develop better ways of categorising the underlying causes of leakage to ensure that patients receive the optimal treatments.

Crystallizing the Definition of Underactive Bladder Syndrome, a Common but Under-recognized Clinical Entity

Detrusor underactivity (DU) is an important contributor to lower urinary tract symptoms (LUTS). While DU has been defined in the literature in urodynamic terms, current definitions lack specific parameters. In addition, the clinical syndrome associated with and manifesting itself as DU, underactive bladder (UAB), has not been well defined in the literature. In the absence of a precise definition of UAB, it is difficult to appreciate the true nature and burden of this condition. We review the evidence regarding the epidemiology, pathogenesis, diagnosis, and treatment of DU and UAB and discuss the challenges in gathering data in the absence of precise definitions. DU may be idiopathic or caused by ageing, medications, or a number of causes of neurogenic, myogenic, or iatrogenic origin. Treatments are largely palliative due to a lack of curative options, and include watchful waiting, catheterization, medications, and surgical interventions. In light of the evidence available in the literature, we propose that a new symptom-based definition of UAB syndrome should be developed as a first step in furthering more standardized research. Further discussion on this proposed definition to reach expert consensus will enable researchers to gather more robust data, allowing greater insights into DU and UAB diagnosis and treatment.

Delayed repair of pelvic fracture urethral injuries: Preoperative decision-making

Pelvic fracture urethral injuries comprise one of the most challenging reconstructive procedures in urology. The obliterated or stenosed urethra can usually be effectively repaired by an end-to-end anastomosis (bulbomembranous anastomosis). To achieve this, a progression of surgical steps can be used to make a tension-free anastomosis. Before undertaking surgery it is important to comprehensively assess the patient to define their anatomical defects, in particular the site of the stenosis, the length of the distraction injury and the integrity of the bladder neck, and thus guide preoperative decision-making. Contemporary reports suggest that most pelvic fracture urethral distraction defects (PFUDD) can be adequately managed by a perineal approach. Nevertheless it is essential that all surgeons treating these injuries are familiar with the whole spectrum of operative steps that are necessary to repair PFUDD.

Flexible cystourethroscopy in the follow-up of posturethroplasty patients and characterisation of recurrences

BACKGROUND

Urethral strictures can be difficult to diagnose at an early stage because the urinary flow rate does not diminish until the urethral calibre is ≤3mm. In the past, posturethral surgery follow-up has relied upon flow rates and contrast imaging.

OBJECTIVE

To evaluate the role of flexible urethroscopy in the follow-up of patients undergoing urethroplasty.

DESIGN, SETTING, AND PARTICIPANTS

Prospective flexible urethroscopy follow-up of 144 male patients who underwent urethroplasty by a single surgeon over a 10-yr period at a tertiary referral centre.

INTERVENTION

Flexible urethroscopy at 3, 6, and 12 mo postoperatively, and annually thereafter.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Type of recurrence, based on urethroscopy findings, and further interventions were measured. Actuarial analysis was performed using Kaplan-Meier curves and a log-rank test.

RESULTS AND LIMITATIONS

All 144 patients underwent flexible urethroscopy follow-up over a median postoperative follow-up of 22 mo (range: 1-96 mo). No further intervention was required for 117 patients (81.25%); 27 (18.75%) developed recurrences that required further treatment. Recurrences included diaphragms (13 patients) or significant restenosis (14 patients). Diaphragms were treated by urethrotomy, gentle dilatation, or a short course of intermittent self-dilatation. Restenosis required repeated simple procedures or surgical revision. Most recurrences (26 of 27, 96%) were detected within the first year. Urinary peak flow-rate data were available for 11 of 27 of these recurrences; 7 patients had flow rates >15ml/s. Anastomotic procedures had greater success than augmentation urethroplasty (p=0.0136); there was no significant difference in outcomes between redo and non-redo surgery (p=0.2093) CONCLUSIONS: Endoscopic follow-up of patients after urethroplasty enables earlier identification and treatment of recurrences compared to the use of urinary flow rates alone. It also enables the identification of two different morphologic recurrence patterns that require different types of intervention.

PATIENT SUMMARY

Endoscopy detects most stricture recurrences within 1 yr after urethroplasty and is more sensitive than using urinary flow rates alone.

Biomaterials for pelvic floor reconstructive surgery: how can we do better?

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are major health issues that detrimentally impact the quality of life of millions of women worldwide. Surgical repair is an effective and durable treatment for both conditions. Over the past two decades there has been a trend to enforce or reinforce repairs with synthetic and biological materials. The determinants of surgical outcome are many, encompassing the physical and mechanical properties of the material used, and individual immune responses, as well surgical and constitutional factors. Of the current biomaterials in use none represents an ideal. Biomaterials that induce limited inflammatory response followed by constructive remodelling appear to have more long term success than biomaterials that induce chronic inflammation, fibrosis and encapsulation. In this review we draw upon published animal and human studies to characterize the changes biomaterials undergo after implantation and the typical host responses, placing these in the context of clinical outcomes.

Tissue engineered buccal mucosa for urethroplasty: progress and future directions

PURPOSE

Autologous buccal mucosa is commonly utilized in the surgical treatment of urethral strictures. Extensive strictures require a larger quantity of tissue, which may lead to donor site morbidity. This review assesses progress in producing tissue engineered buccal mucosa as an alternative graft material.

RESULTS

Few clinical studies have introduced cells onto biological or synthetic scaffolds and implanted resulting constructs in patients. The available studies show that buccal mucosa cells on acellular human dermis or on collagen matrix lead to good acute stage tissue integration. Urothelial cells on a synthetic substrate also perform well. However while some patients do well many years post-grafting, others develop stricture recurrence. Acellular biomaterials used to treat long urethral defects in animals commonly lead to fibrosis.

CONCLUSIONS

Tissue engineered buccal mucosa shows promise as a substitute for native tissue. The fibrosis which occurs months post-implantation may reflect the underlying disease process recurring in these patients.

Contemporary concepts in the aetiopathogenesis of detrusor underactivity

Detrusor underactivity (DUA) is a poorly understood, yet common, bladder dysfunction, referred to as underactive bladder, which is observed in both men and women undergoing urodynamic studies. Despite its prevalence, no effective therapeutic approaches exist for DUA. Exactly how the contractile function of the detrusor muscle changes with ageing is unclear. Data from physiological studies in animal and human bladders are contradictory, as are the results of the limited number of clinical studies assessing changes in urodynamic parameters with ageing. The prevalence of DUA in different patient groups suggests that multiple aetiologies are involved in DUA pathogenesis. Traditional concepts focused on either efferent innervation or myogenic dysfunction. By contrast, contemporary views emphasize the importance of the neural control mechanisms, particularly the afferent system, which can fail to potentiate detrusor contraction, leading to premature termination of the voiding reflex. In conclusion, the contemporary understanding of the aetiology and pathophysiology of DUA is limited. Further elucidation of the underlying mechanisms is needed to enable the development of new and effective treatment approaches.

The effect of ascorbic acid and fluid flow stimulation on the mechanical properties of a tissue engineered pelvic floor repair material

Synthetic non-degradable meshes used in pelvic floor surgery can cause serious complications such as tissue erosion. A repair material composed of an autologous oral fibroblast seeded degradable polylactic acid scaffold may be a viable alternative. The aims of this study were to investigate the effects of media supplementation with additives (ascorbic acid-2-phosphate, glycolic acid and 17-β-oestradiol) on the mechanical properties of these scaffolds. Oral fibroblasts were isolated from buccal mucosa. The effects of the three additives were initially compared in two-dimensional culture to select the most promising collagen stimulating additive. Sterile electrospun scaffolds were seeded with 500,000 oral fibroblasts and fixed in 6-well plates and subjected to ascorbic acid-2-phosphate (the best performing additive) and/or mechanical stimulation. Mechanical stimulation by fluid shear stress was induced by rocking scaffolds on a platform shaker for 1 h/day for 10 of 14 days of culture. In two-dimensional culture, ascorbic acid-2-phosphate (concentrations from 0.02 mM to 0.04 M) and glycolic acid (10 µM) led to significantly greater total collagen production, but ascorbic acid-2-phosphate at 0.03 mM produced the greatest stimulation (of the order of >100%). In three-dimensional culture, mechanical stimulation alone gave non-significant increases in stiffness and strength. Ascorbic acid-2-phosphate (0.03 mM) significantly increased collagen production in the order 280% in both static and mechanically stimulated scaffolds (p < 0.0001). There was no additional effect of mechanical stimulation. Dense collagen I fibres were observed with ascorbic acid-2-phosphate supplementation. Uniaxial tensiometry showed that strength (p < 0.01) and stiffness (p <0.05) both improved significantly. A combination of ascorbic acid-2-phosphate and mechanical stimulation led to further non-signficant increases in strength and stiffness. In conclusion, a pelvic floor repair material with improved mechanical properties can be developed by supplementing culture media with ascorbic acid-2-phosphate to increase collagen I production. Future studies will assess the change in mechanical properties after implantation in an animal model.

Assessment of BPH/BOO

The assessment of men with bladder outflow obstruction relies on an adequate history and examination. Uroflowmetry and post-void residue estimation are very revealing and may be sufficient in the majority of men. The prostate-specific antigen test may be used to select men who are at a high risk of progression. In specific situations, cystometry may be required. We discuss the use of cystometry and the newer less-invasive methods of assessment that have emerged over the last few years, including ultrasound estimation of intravesical prostatic protrusion, prostatic urethra angle, detrusor wall thickness, ultrasound-estimated bladder weight, near-infrared spectroscopy and the condom catheter and penile cuff tests. Although these techniques show promise, they still require further modifications, standardization and testing in larger populations. In addition, they should be used in men where only specific questions need to be answered.