Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male

For many transgender males, "lower" or "bottom" surgery (the construction of a phallus and scrotum) is the definitive step in their surgical journey for gender affirmation. The implantation of penile and testicular prostheses is often the final anatomic addition and serves to add both functionality and aesthetics to the reconstruction. However, with markedly distinctive anatomy from cis-gender men, the implantation of prostheses designed for cis-male genitalia poses a significant surgical challenge for the reconstructive urologist. The surgical techniques for these procedures remain in their infancy. Implantation of devices originally engineered for cis-men is an imperfect solution but not insurmountable if approached with ingenuity, patience, and persistence. Urologists and patients undergoing implantation should be aware of the high complication rates associated with these procedures as well as the current uncertainty of long-term outcomes. This review provides a comprehensive overview of the perioperative considerations, adaptive surgical techniques, and unique complications of penile and testicular prosthetic implantation in transgender men.

Evaluating the Role of Postoperative Oral Antibiotic Administration in Artificial Urinary Sphincter and Inflatable Penile Prosthesis Explantation: A Nationwide Analysis

OBJECTIVE

To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown.

MATERIALS AND METHODS

We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates.

RESULTS

We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation.

CONCLUSION

Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.

Best practice policy statement on urodynamic antibiotic prophylaxis in the non-index patient

AIMS

Antibiotic prophylaxis before urodynamic testing (UDS) is widely utilized to prevent urinary tract infection (UTI) with only limited guidance. The Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) convened a Best Practice Policy Panel to formulate recommendations on the urodynamic antibiotic prophylaxis in the non-index patient.

METHODS

Recommendations are based on a literature review and the Panel's expert opinion, with all recommendations graded using the Oxford grading system.

RESULTS

All patients should be screened for symptoms of UTI and undergo dipstick urinalysis. If the clinician suspects a UTI, the UDS should be postponed until it has been treated. The first choice for prophylaxis is a single oral dose of trimethoprim-sulfamethoxazole before UDS, with alternative antibiotics chosen in case of allergy or intolerance. Individuals who do NOT require routine antibiotic prophylaxis include those without known relevant genitourinary anomalies, diabetics, those with prior genitourinary surgery, a history of recurrent UTI, post-menopausal women, recently hospitalized patients, patients with cardiac valvular disease, nutritional deficiencies or obesity. Identified risk factors that increase the potential for UTI following UDS and for which the panel recommends peri-procedure antibiotics include: known relevant neurogenic lower urinary tract dysfunction, elevated PVR, asymptomatic bacteriuria, immunosuppression, age over 70, and patients with any indwelling catheter, external urinary collection device, or performing intermittent catheterization. Patients with orthopedic implants have a separate risk stratification.

CONCLUSIONS

These recommendations can assist urodynamic providers in the appropriate use of antibiotics for UDS testing. Clinical judgment of the provider must always be considered.

Assessing variability of the 24-hour pad weight test in men with post-prostatectomy incontinence

Purpose:

Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity.

Materials and Methods:

25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used.

Results:

Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74–0.93), p<0.001). The mean difference between the minimum pad weight leakage and maximum leakage per patient was 133.4g (95% CI 80.4–186.5). The mean increase in 24-hour leakage for a one-point increase in self-reported activity level was 118.0g (95% CI 74.3–161.7, p<0.001). Pad weights also varied significantly when self-reported activity levels did not differ (mean difference 51.2g (95% CI 30.3–72.1), p<0.001).

Conclusions:

24-hour pad weight leakage may vary significantly on different days of collection. This variation is more pronounced with changes in activity level. Taking into account patient activity level may enhance the predictive value of pad weight testing.

Novel Technique for Proximal Bone Anchoring of Penile Prosthesis After Radial Forearm Free Flap Neophallus

OBJECTIVE

To describe outcomes of bone anchoring of penile implant in a neophallus with an accompanying video focusing on operative technique and salient tips for surgeons performing these procedures. Penile prosthesis insertion allows individuals with a neophallus to achieve erectile function. Lack of corporal bodies to accommodate cylinders makes anchoring of any prosthesis challenging. Anchoring the device to the pubic bone is one strategy to achieve proximal stabilization.

METHODS

A single-institution, retrospective chart review of 10 neophallus patients undergoing penile prosthesis placement from 2006 to 2015 was done. The pubic symphysis is exposed and corticotomy created for placement of the rear tip extender of the implant using a Stryker TPS bone drill. Anchoring sutures through the corticotomy defect, rear tip, and proximal cylinder seat the implant. The remainder of the implantation procedure mirrors that used in native tissue.

RESULTS

The overall perioperative complication rate was 20%, with a mean follow-up of 49 months. Seventy percent of the patients required reoperation, with a mean of 1.4 prosthesis revision surgeries per patient. Primary causes of revision included infection, poor fixation of the rear tip, and prosthesis failure. Despite high revision rates, 80% of the patients have fully functioning prosthesis as of last follow-up. Limitations include retrospective study design and the small patient cohort.

CONCLUSION

Penile prosthesis placement in the neophallus is feasible and effective. A bone-anchored rear tip is an option to provide proximal stabilization. Continued efforts to minimize the need for revisions are ongoing and necessary.

Lessons from 151 ureteral reimplantations for postcystectomy ureteroenteric strictures: A single-center experience over a decade

OBJECTIVES

Ureteroenteric anastomotic strictures are common after cystectomy with urinary diversion. Endoscopic treatments have poor long-term success, although ureteral reimplantation is associated with morbidity. Predictors of successful open repair are poorly defined. Our objective was to characterize outcomes of ureteral reimplantation after cystectomy and identify risk factors for stricture recurrence.

PATIENTS AND METHODS

We performed a retrospective review of 124 consecutive patients with a total of 151 open ureteral reimplantations for postcystectomy ureteroenteric strictures between January 2006 and December 2015. Baseline clinicopathologic characteristics and perioperative outcomes were examined. Predictors for stricture recurrence were assessed by univariable testing and univariate Cox proportional hazards regression.

RESULTS

Most patients underwent preoperative drainage by percutaneous nephrostomy (PCN; 43%) or percutaneous nephroureterostomy (PCNU; 44%). Major iatrogenic injuries included enterotomies requiring bowel anastomosis (3.2%) and major vascular injuries (2.4%). Overall, 60 (48%) patients suffered 90-day complications, of which 15 (12%) patients had high-grade complications. Median length of stay was 6 days [interquartile range: 5, 8] and median follow-up was 21 months [interquartile range: 5, 43]. The overall success rate per ureter was 93.4%. On univariate analysis, the only significant predictor of stricture recurrence was preoperative PCNU placement compared with PCN placement or no drainage (success rates: 85.5% vs. 98.9%, respectively, P = 0.002). Cox proportional hazards regression demonstrated that preoperative PCNU placement yielded a hazard ratio of 10.2 (95% CI: 1.27-82.6) for stricture recurrence (P<0.005). Stricture recurrence was independent of previous endoscopic interventions (P = 0.42). Stricture length was unable to be assessed.

CONCLUSIONS

Postcystectomy ureteral reimplantation was associated with relatively low rates of major iatrogenic injuries and high-grade complications. Preoperative PCN placement rather than PCNU may yield better results.

The Impact of Minimally Invasive Surgery on Major Iatrogenic Ureteral Injury and Subsequent Ureteral Repair During Hysterectomy: A National Analysis of Risk Factors and Outcomes

OBJECTIVE

To identify risk factors for ureteral injury during hysterectomy and to assess outcomes of concurrent minimally invasive vs converted to open repairs.

METHODS

We queried the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2013 to identify abdominal hysterectomy (AH), minimally invasive hysterectomy (MIH), or vaginal hysterectomy. Ureteral injury was identified based on intraoperative or delayed management. Multivariate logistic regression was performed to assess the effect of hysterectomy approach on risk of ureteral injury while controlling for covariates. For patients with ureteral injury during MIH, we compared 30-day outcomes following minimally invasive vs converted open repairs.

RESULTS

There were 302 iatrogenic ureteral injuries from 96,538 hysterectomies, with 0.18%, 0.48%, and 0.04% from AH, MIH, and vaginal hysterectomy, respectively. Patients who underwent MIH were younger and had decreased comorbidities compared to patients who underwent AH (all P < .001). MIH resulted in lower overall complications (6.6% vs 14.8%, P < .001) but higher ureteral injury rate (0.48% vs 0.18%, P < .001) compared to AH. On multivariate analysis, the minimally invasive approach was associated with increased risk of ureteral injury (odds ratio 4.2, P < .001). Patients undergoing minimally invasive ureteral repairs (89%) during MIH had shorter operating room time and length of stay but similar overall perioperative complications compared to those with converted open repairs (11%).

CONCLUSION

Using a large national series, we show that the minimally invasive approach for hysterectomy is an independent risk factor for iatrogenic ureteral injuries. During MIH, concurrent minimally invasive ureteral repairs resulted in comparable 30-day outcomes compared to converted to open repairs.

Iatrogenic Bladder Injury: National Analysis of 30-Day Outcomes

OBJECTIVE

To examine the risk factors and outcomes of BI, a rare complication of abdominopelvic surgery.

METHODS

We queried the National Surgical Quality Improvement Program database to identify intraoperative bladder injury (BI) defined by the Current Procedural Terminology code for cystorrhaphy from 2005 to 2013. Propensity-score matching balanced the differences between patients with BI and the controls. The factors matched included age, body mass index, race, modified frailty index, and procedure category.

RESULTS

There were 1685 cases of BI in 1,541,736 surgeries (0.11%). Although 49.5% of surgeries were performed in an open fashion, this approach accounted for 69.3% of BI (P < .001). Prior to matching, mortality rates and morbidity were increased for the BI group (P < .001). Moreover, age, recent chemotherapy or radiation or steroid history, and smoking were among the risk factors for BI (all P < .05). Resident involvement increased the odds of BI and complications after BI, but decreased the risk of readmission (all P < .05). After matching, 30-day mortality was no longer increased for patients with BI (P < .001). Patients with BI requiring repair did have increased median length of stay (6 days [interquartile range {IQR}: 3-11] vs 5 [IQR: 2-9]; P < .001) and operative time (203 min [IQR: 140-278] vs 134 [IQR: 86-199]; P < .001). BI patients were more likely to undergo reoperation (7.7% vs 5.3%; P = .005). Urine infection, sepsis, and bleeding were more likely in the BI group compared with the matched controls (all P < .001). Delayed repair was rare.

CONCLUSION

We present the largest national series assessing iatrogenic BI and subsequent repair. BI increases 30-day complications, reoperation, and length of stay but does not increase 30-day mortality compared with matched controls. More complex surgical cases and increased baseline comorbidity were risk factors for BI.

National Patterns of Urethral Evaluation and Risk Factors for Urethral Injury in Patients With Penile Fracture

OBJECTIVE

To examine the epidemiology and timing of penile fracture, patterns of urethral evaluation, and risk factors for concomitant urethral injury.

MATERIALS AND METHODS

The National Inpatient Sample (2003-2011) was used to identify patients with penile fractures. Clinical data included age, race, comorbidity, insurance, hospital factors, timing, hematuria, and urinary symptoms. Rates of formal urethral evaluation (cystoscopy or urethrogram) and urethral injury were calculated. Multivariate logistic regression was used to identify predictors of urethral evaluation and risk factors for urethral injury.

RESULTS

A weighted population of 3883 patients with penile fracture was identified. Presentations during weekends (37%) and summers (30%) were overrepresented (both P <.001). Urethral evaluation was performed in 882 patients (23%). Urethral injury was diagnosed in 813 patients (21%) with penile fracture. There was an increased odds of urethral evaluation with hematuria (odds ratio [OR] = 2.99; 95% confidence interval [CI], 1.03-8.73; P = .045) and a decrease for Hispanics (OR = 0.42; 95% CI, 0.22-0.82; P = .011). Older age (32-41 years: OR = 1.84; 95% CI, 1.07-3.16; P = .027; >41 years: OR = 2.25; 95% CI, 1.25-4.05; P = .007), black race (OR = 1.93; 95% CI, 1.12-3.34; P = .018), and hematuria (OR = 17.03; 95% CI, 3.20-90.54; P = .001) were independent risk factors for urethral injury.

CONCLUSION

Penile fractures, which occur disproportionately during summer and weekends, were associated with a 21% risk of urethral injury. Urethral evaluations were performed in a minority of patients. Even in patients with hematuria, 55% of patients underwent formal urethral evaluation. On multivariate analysis of patients with penile fracture, hematuria as well as older age and black race were independently associated with concomitant urethral injury.

Rhabdomyolysis After Major Urologic Surgery: Epidemiology, Risk Factors, and Outcomes

OBJECTIVE

To study the epidemiology, risk factors, and outcomes of rhabdomyolysis (RM) after major urologic surgery.

MATERIALS AND METHODS

The National Inpatient Sample (2003-2011) was used to identify patients who underwent radical prostatectomy, radical or partial nephrectomy, or radical cystectomy. Demographics included age, sex, race, and comorbidities. Factors examined included bleeding, hospital teaching status, minimally invasive technique, and development of RM. Multivariate logistic regression was used to identify independent risk factors of RM. Outcomes of mortality, acute kidney injury (AKI), length of stay, and charges in patients with RM were compared with those of controls.

RESULTS

A weighted population of 1,016,074 patients was identified with 870 (0.1%) developing RM, which was significantly more likely for radical or partial nephrectomy and radical cystectomy patients compared with radical prostatectomy patients. On multivariate analysis, independent risk factors for RM included younger age, male sex, diabetes, chronic kidney disease, obesity, and bleeding. Race, minimally invasive technique, and teaching status were not associated with RM when controlling for other factors. Patients with RM experienced increases in mortality, AKI, length of stay, and hospital charges.

CONCLUSION

Rhabdomyolysis is a rare complication after urologic surgery. Risk factors include male sex, younger age, diabetes, chronic kidney disease, obesity, and perioperative bleeding. Patients who develop RM have a higher risk of AKI, mortality, prolonged hospital stay, and increased charges.

Outcomes of the Endoscopic Treatment of Bladder Neck Contractures in the Orthotopic Neobladder

OBJECTIVE

To examine the outcomes of endoscopic procedures for bladder neck contracture (BNC) in the orthotopic neobladder (ONB) after radical cystectomy focusing on success rates for patients who require multiple treatments.

MATERIALS AND METHODS

Patients who underwent treatment for cystoscopically confirmed BNC in an ONB from 2007 to 2014 were studied. Treatment information included procedure type, use of adjuvant clean intermittent catheterization (CIC), and follow-up procedures. Procedures followed by additional interventions were categorized as failures. Success was defined as no additional surgical procedure with at least 1 year of follow-up. Procedures were classified by a number of prior endoscopic treatments.

RESULTS

Seventy-one patients underwent 155 individual endoscopic procedures (146 urethrotomy, 3 dilation, and 6 transurethral resection of bladder neck). All patients were male without prior radiation. Median follow-up after initial endoscopic treatment was 26.8 months (interquartile range: 16.6-51.7), and time to recurrence was 3.5 months (1.6-6.3). Success was experienced for 50 of 136 individual procedures (37%) after excluding 19 procedures for inadequate follow-up. Success rates remained 25%-43% even after multiple prior interventions. Adjuvant CIC was associated with a higher success rate (14/24 or 58%) compared to procedures without CIC (36/112 or 32%, P = .02). Successful outcomes were seen in 50 of 71 patients (73%) with 2 patients requiring ONB removal.

CONCLUSION

Individual endoscopic treatments of BNC in the ONB were met with 37% success. The rate did not decrease with subsequent procedures. Adjuvant CIC improved the outcomes. Overall, a successful outcome was achieved for most patients, but the majority required more than one procedure.

The effect of length of ureteral resection on benign ureterointestinal stricture rate in ileal conduit or ileal neobladder urinary diversion following radical cystectomy

OBJECTIVES

To assess the effect of the length of the ureter resected and other clinical variables on ureterointestinal anastomotic (UIA) stricture rate following radical cystectomy and ileal segment urinary diversion.

METHODS AND MATERIALS

We identified 519 consecutive patients who underwent cystectomy and ileal conduit or ileal orthotopic neobladder diversion from January 2007 to August 2012. The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted for pathologic analysis. The primary end point was the risk of UIA stricture formation, assessed by Cox proportional hazards analysis.

RESULTS

A total of 463 patients met the inclusion criteria with complete data. Median follow-up was 459 days (interquartile range [IQR]: 211-927). Median time to stricture formation was 235 (IQR: 134-352) and 232 days (IQR: 132-351) on the right and the left ureter, respectively. Overall stricture rate per ureter was 5.9% on the right vs. 10.0% on the left (P = 0.03). There was no difference in demographic, operative, or perioperative variables between patients with and without UIA strictures. On multivariate analysis adjusted for age, sex, anastomosis technique (running vs. interrupted), and length of ureter resected, only a Clavien complication≥III (hazard ratio = 2.11, 1.01-4.40) and urine leak (hazard ratio = 3.37, 1.08-10.46) significantly predicted for left- and right-sided stricture formation, respectively. The length of the ureter resected did not predict UIA stricture formation on either side.

CONCLUSIONS

The etiology of benign UIA strictures following ileal urinary diversion is likely multifactorial. Our data suggest that a complicated postoperative course and urine leak are risk factors for UIA stricture formation. The length of the distal ureter resected did not significantly affect stricture rate.

Comparison of clinical outcomes between "ideal" and "nonideal" transobturator male sling patients for treatment of postprostatectomy incontinence

OBJECTIVE

To review the clinical outcomes of "ideal" vs "nonideal" postprostatectomy stress urinary incontinence (PPI) patients who underwent male sling placement.

METHODS

The medical records of 95 consecutive patients with PPI who underwent male sling insertion (AdVance male sling, American Medical Systems, Minnetonka, MN) were reviewed. Patients were divided into "ideal" vs "nonideal" cohorts. The ideal group consisted of patients with mild to moderate incontinence (<4 pads/day or <300 g daily pad weight), ability to volitionally contract the external urinary sphincter, no history of pelvic radiation or cryotherapy, no history of previous anti-incontinence surgical procedures, the ability to generate a volitional detrusor contraction when voiding, and a postvoid residual urine volume <100 mL. Patients in the nonideal group did not satisfy all these criteria.

RESULTS

Significant reductions in daily pad usage and weight were noted in both cohorts. In the ideal patient group, 66 of 72 patients (92%) would undergo the procedure again. Conversely, only 7 of 23 nonideal men (30%) would undergo the procedure again.

CONCLUSION

Preoperative patient selection can influence favorable outcomes after the treatment of PPI with AdVance male slings. Attention to ideal vs nonideal patient characteristics should be used when counseling men considering male sling surgery.

Incidence, risk factors, and complications of postoperative delirium in elderly patients undergoing radical cystectomy

OBJECTIVE

To identify the risk factors for, and complications associated with, the development of delirium after radical cystectomy.

MATERIALS AND METHODS

From July 2008 to December 2009, 59 patients, aged ≥65 years and undergoing radical cystectomy, were prospectively enrolled. The baseline cognitive status was assessed using the Mini-Mental Status Examination. Postoperative delirium was assessed using the Confusion Assessment Method.

RESULTS

A total of 49 patients completed the surgery and all assessments. The incidence of postoperative delirium was 29%, with duration of 1-5 days. On univariate analysis, older age and preoperative Mini-Mental Status Examination score were associated with postoperative delirium. On multivariate analysis, only age was associated with postoperative delirium (odds ratio 1.52, 95% confidence interval 1.04-2.22, P=.03). The 2 groups did not differ in pathologic stage, length of surgery, intraoperative and postoperative narcotic usage, body mass index, age-adjusted Charlson comorbidity index, activities of daily living scores, smoking history, preoperative hematocrit, estimated blood loss, urinary tract infection, interval to a regular diet, or length of hospital stay. The patients who developed postoperative delirium were more likely to undergo readmission (odds ratio 10.7, 95% confidence interval 2.2-51.8, P=.01) and reoperation (odds ratio 9.2, 95% confidence interval 1.5-55.3, P=.03) but did not differ in the 90-day and 1-year mortality rates or incidence of postoperative complications.

CONCLUSION

In patients aged≥65 years, a lower preoperative Mini-Mental Status Examination score and older age were significantly associated with the development of postcystectomy delirium, as measured using the Confusion Assessment Method. The patients who developed delirium were more likely to undergo readmission and reoperation. Larger studies with multiple surgeons are needed to validate these findings.

The use of botulinum toxin for treatment of lower urinary tract symptoms

In the last decade we have seen the emergence of botulinum toxin (BTX) as a successful treatment of patients with neurogenic and idiopathic detrusor overactivity that are refractory to antimuscarinic medication. The success of BTX in this patient population has led to use BTX in patients with other causes of lower urinary tract symptoms such as benign prostatic hyperplasia (BPH) and urethral sphincter anomalies. Despite this success, the protocol for BTX injection has not yet been standardized. Various studies are on the way in order to determine the best injection protocol for bladder injection of BTX. The use of BTX in patients with BPH is in its early stages. Further large randomized controls trials in patients with BPH are needed to determine the efficacy of BTX in this patient population.

The surgical technique and early postoperative complications of the Gynecare Prolift pelvic floor repair system

INTRODUCTION

The Gynecare Prolift pelvic floor repair system (GPS) comprises a synthetic mesh placed via a transvaginal, transobturator approach. We present our technique focusing on the safety and feasibility of the GPS.

MATERIALS AND METHODS

GPS candidates are evaluated in the office with a full history, physical examination, urinalysis and when appropriate, urodynamic evaluation. Patients were offered total vaginal vault prolapse repair or isolated anterior repair dependent of site of defect. Follow-up comprised a full history, physical examination, and global assessment of subjective satisfaction (2 and 6 weeks, 6 months postoperative). Concentration was placed on intraoperative and short-term postoperative complications and assessment of prolapse recurrence.

RESULTS

GPS prolapse repair has been used in 12 patients for anterior or total vault prolapse. Mean postoperative follow-up time is 42 weeks. There were no major perioperative complications. De novo enterocele development was seen in one patient without any other incidence of recurrence. No incidence of mesh erosion or sexual dysfunction has been observed.

CONCLUSIONS

The GPS is a safe and reproducible system for use in transvaginal repairs of vaginal vault prolapse. Long-term studies are needed to evaluate repair durability and for potential complications.

Botulinum toxin type A inhibits sensory neuropeptide release in rat bladder models of acute injury and chronic inflammation

OBJECTIVE

To determine the effect of botulinum toxin type A (BTX-A) on the release of the neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) from isolated bladder preparations after acute injury with HCl and the induction of cyclophosphamide (CYP)-induced cystitis, as neurogenic inflammation has been increasingly identified in urological disorders such as interstitial cystitis.

MATERIALS AND METHODS

Adult rats had either an intraperitoneal injection with CYP or saline over a 10-day period to induce chronic bladder inflammation, after which the bladder was harvested, or normal bladder explants were injured acutely with incubation (20 s) in HCl (0.4 m). To measure the effect of BTX-A on the release of neurotransmitters, harvested bladders were incubated in an organ bath containing BTX-A (10 U) or vehicle. Bladders were transferred to a subsequent bath (physiological saline) and incubated for 15 min, and the bathing medium analysed to measure neurotransmitter release, as determined by radioimmunoassay. Bladder specimens from sham treatment, controls and experimental rats were compared histologically.

RESULTS

Acute injury with HCl caused a significantly greater release of both CGRP and SP release (1235 and 1655 pg/g, respectively) than in controls (183 and 449 pg/g, respectively; P < 0.001). This increase in neurotransmitter release was partly inhibited by exposure to BTX-A (870 and 1033 pg/g (P < 0.05 and <0.01). CYP-induced chronic inflammation caused significantly greater release of SP than in the controls (1060 and 605 pg/g, respectively; P < 0.005). Exposure to BTX-A partly inhibited the release of SP after CYP-induced cystitis (709 pg/g, P < 0.05).

CONCLUSIONS

The application of BTX-A inhibits the release of sensory neurotransmitters from isolated bladder preparations in rat bladder models of both acute injury and chronic inflammation, suggesting a potential clinical benefit of BTX-A in the treatment of neurogenic inflammation.

Surgical technique using AdVance sling placement in the treatment of post-prostatectomy urinary incontinence

OBJECTIVES

To describe and illustrate a new minimally invasive approach to the treatment of male stress urinary incontinence following prostatectomy.

SURGICAL TECHNIQUE

Our initial experience consisted of four patients treated with the Advance sling for post-prostatectomy urinary incontinence. Sling placement involves the following steps: 1. Urethral dissection and mobilization, 2. Identification of surgical landmarks, 3. Placement of needle passers through the obturator foramen, 4. Mesh advancement, 5. Mesh tensioning and fixation, 6. Incision closure.

COMMENTS

Based on our initial experience, we believe that the Advance Male Sling System may be a safe technique for the treatment of male stress urinary incontinence. This technique is easy to perform and may offer a reproducible, transobturator approach. Further patient accrual is ongoing to assess the safety and reproducibility of this technique. Also, additional study will focus on efficacy standards and complication rates.

Current Use of Artificial Urinary Sphincters in the United States

PURPOSE

Significant improvement and high patient satisfaction are seen after artificial urinary sphincter implantation for male stress urinary incontinence. However, only a small percent of men are treated with an artificial urinary sphincter nationally. We defined trends in current artificial urinary sphincter use in the United States, specifically focusing on regional differences in use. Current rates of radical prostatectomy and the regional distribution of urologists were analyzed as possible factors to explain these disparities.

MATERIALS AND METHODS

Data provided by American Medical Systems, Minnetonka, Minnesota on the number of artificial urinary sphincter units sold were analyzed by state, regional and city distribution. American Urological Association data on the number of urologists were used to estimate urologist use of artificial urinary sphincters. The number of radical prostatectomies reported by the American College of Surgeons National Cancer Database were used to estimate artificial urinary sphincter use per radical prostatectomy.

RESULTS

In the most populous states and cities generally the most artificial urinary sphincter units were purchased, the most urologists were reported and the most radical prostatectomies were performed. The proportional use of artificial urinary sphincters per radical prostatectomy by state varied from 1% to 10% (national average approximately 6%). The number of urologists per 100,000 men older than 50 years appeared uniform across states (national average 34). However, artificial urinary sphincter use by urologist appeared localized and concentrated. Nationally 1 artificial urinary sphincter unit was purchased for every 3 urologists in the United States.

CONCLUSIONS

Artificial urinary sphincter use demonstrates considerable state and regional variation even when controlled for differences in the frequency of radical prostatectomy and the distribution of urologists. Overall the data suggest that artificial urinary sphincters may be underused in some areas of the country, particularly for post-prostatectomy incontinence.