BACKGROUND:This study updates the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention. METHODS:This was a secondary analysis of a multicenter retrospective study including patients with high-grade renal trauma from seven level 1 trauma centers from 2013 to 2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed-effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST OIS. RESULTS:Based on the 2018 OIS grading system, we included 549 patients with AAST grades III to V injuries and computed tomography scans (III, 52% [n = 284]; IV, 45% [n = 249]; and V, 3% [n = 16]). Among these patients, 89% experienced blunt injury (n = 491), and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded, and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from grade IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC, 0.805; revised AUC, 0.883; p = 0.001) and number of units of packed red blood cells transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention. CONCLUSION:A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system. LEVEL OF EVIDENCE:Diagnostic Test/Criteria; Level III.

BACKGROUND Erdheim-Chester disease (ECD) is a rare progressive non -Langerhans' cell histiocytic multisystem disorder with a broad spectrum of clinical manifestations, including infiltrative perinephric with ureteral involvement resulting in hydronephrosis, renal atrophy, and eventual renal failure. OBJECTIVE To present a patient with ECD with bilateral renal/ureteral involvement managed with bilateral percutaneous nephrostomy tubes (PCNT) and trametinib who underwent bilateral robotic upper tract reconstruction, the first such published report. The video demonstrates only the left -sided repair, which posed specific challenges and demonstrates reconstructive techniques useful in complex upper tract repairs with limited tissue availability. MATERIALS AND METHODS A 35 -year -old male initially presented with baseline creatinine of 1.62 and split renal function; 30% right and 70% left by Lasix renogram. Extra -genitourinary manifestations of disease included cardiac hypertrophy and skin ulcers/lesions. Bilateral retrograde pyeloureterography showed proximal ureteral obliteration -4 cm bilaterally. Multiple management options were discussed including PCNTs, but patient elected for definitive repair. He was seen by Cardiology and Anesthesia and deemed to be optimized. He held his trametinib for 1 week before surgery. We demonstrate a difficult ureteral dissection with fibrotic hilum preventing separation. Simultaneous ureteroscopy identified the distal extent of stricture which was excised, leaving a -15 cm gap. Downward nephropexy was performed with ultrasound guidance to identify an inferior calyx. Partial nephrectomy was then performed without vascular control due to hilar fibrosis. Ileal interposition was chosen to bridge the remaining -8 cm gap. Proximal ileo-calyceal and distal ileo-ureteral anastomoses were performed. We then placed a 30 cm x 7 Fr double -J ureteral stent in standard fashion. The ileum was secured to the renal pelvis to maintain a straight lie and an omental flap was secured in place. RESULTS Immediate postoperative course was complicated by partial small bowel obstruction leading to a negative exploratory laparotomy and a subsequent episode of urosepsis. The patient is now voiding well without stents or PCNTs, without infections and with improving renal function, now with GFR (glomerular filtration rate) of 62 from 43 preoperatively. With aggressive hydration, patient has had no obstruction of the distal ureter with mucus. MRI Abdomen/Pelvis 6 months later showed irregularity of the calyces with stable mild hydronephrosis. The patient continues to be medically managed on trametinib for his underlying disease, with surveillance for recurrent fibrosis and obstruction which has not yet occurred. CONCLUSION Robotic ureterolysis and ureterocalycostomy with possible bowel interposition is a reasonable option for upper tract reconstruction in select patients with ECD. UROLOGY 184: e253- e255, 2024. Published by Elsevier Inc.

You have accessJournal of UrologyReconstruction: Urethral Reconstruction (including stricture) I (MP06)1 May 2024MP06-07 FROM CONSENSUS TO VALIDATION: DESIGN AND DEVELOPMENT OF A HIGH-FIDELITY HYDROGEL SIMULATION MODEL FOR URETHROPLASTY PROCEDURES Patrick Saba, Lauren Shepard, Katherine T. Anderson, Nick Warner, Nima Baradaran, Cooper Benson, William R. Boysen, Benjamin N. Breyer, Lindsay Hampson, Ty T. Higuchi, Niels V. Johnsen, Joseph J. Pariser, Jay Simhan, Alex J. Vanni, Dmitriy Nikolavsky, Edward J. Wright, Arthur L. Burnett, Andrew Cohen, and Ahmed Ghazi Patrick SabaPatrick Saba , Lauren ShepardLauren Shepard , Katherine T. AndersonKatherine T. Anderson , Nick WarnerNick Warner , Nima BaradaranNima Baradaran , Cooper BensonCooper Benson , William R. BoysenWilliam R. Boysen , Benjamin N. BreyerBenjamin N. Breyer , Lindsay HampsonLindsay Hampson , Ty T. HiguchiTy T. Higuchi , Niels V. JohnsenNiels V. Johnsen , Joseph J. PariserJoseph J. Pariser , Jay SimhanJay Simhan , Alex J. VanniAlex J. Vanni , Dmitriy NikolavskyDmitriy Nikolavsky , Edward J. WrightEdward J. Wright , Arthur L. BurnettArthur L. Burnett , Andrew CohenAndrew Cohen , and Ahmed GhaziAhmed Ghazi View All Author Informationhttps://doi.org/10.1097/01.JU.0001009452.79331.fd.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urethroplasty is the gold standard treatment for urethral stricture repair; however, it is a technically difficult operation due to complex anatomy, large learning curves, lack of intraoperative teaching, and variations in approaches. Utilizing the consensus-building Delphi process, we sought to create a high-fidelity, non-biohazardous, simulation model to train excision and primary anastomosis or graft urethroplasties. METHODS: 20 high volume reconstructive urologists were recruited to complete the Delphi process aimed to reach expert consensus on necessary parameters and design specifications for the simulation model. Consensus>80% was reached regarding procedural realism, anatomical realism, and educational effectiveness. Using previously validated 3D printing and hydrogel molding techniques, researchers fabricated a hydrogel model that incorporated all the expert determined aspects. Prototypes were sent to 55% of the experts who performed a skin-to-skin urethroplasty simulation (Figure 1) as well as a questionnaire evaluating the model to determine if the consensus defined steps were met. The questionnaire utilized a 5-point Likert scale where agreement=4/5, neutral=3, and disagreement=1/2. RESULTS: 91%, 82%, and 100% agreed the model procedurally replicates: the steps necessary to complete the procedure, tissue textures/behaviors, and anatomical relationships including urethral spatulation (91%), suture placement (91%), perineal incision/exposure (91%), and urethral dissection/exposure (100%). 82%, 91%, 64%, 91%, 55%, and 91% agreed it anatomically replicates the; perineum, urethra, fascia over urethra, corpora cavernosa and spongiosum, and bulbospongiosus muscle. 100%, 100%, 100%, 91% and 82% agreed it offers: a safe/non-biohazardous training platform, is useful for teaching/practicing, improving the technical skills, can assess user's ability to perform this procedure and provides useful error feedback. CONCLUSIONS: We successfully designed a high-fidelity, non-biohazardous, simulation model for urethroplasty procedures utilizing expert consensus which displayed high procedural realism, anatomical realism, and educational effectiveness. Ultimately, this model can be used to improve current urethroplasty training. Download PPT Source of Funding: N/A © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e54 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Patrick Saba More articles by this author Lauren Shepard More articles by this author Katherine T. Anderson More articles by this author Nick Warner More articles by this author Nima Baradaran More articles by this author Cooper Benson More articles by this author William R. Boysen More articles by this author Benjamin N. Breyer More articles by this author Lindsay Hampson More articles by this author Ty T. Higuchi More articles by this author Niels V. Johnsen More articles by this author Joseph J. Pariser More articles by this author Jay Simhan More articles by this author Alex J. Vanni More articles by this author Dmitriy Nikolavsky More articles by this author Edward J. Wright More articles by this author Arthur L. Burnett More articles by this author Andrew Cohen More articles by this author Ahmed Ghazi More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyFemale Voiding Dysfunction/ Pelvic Floor Disorders/ Incontinence/ Neuro-Urology (V02)1 May 2024V02-01 DESIGN AND DEVELOPMENT OF A HIGH-FIDELITY HYDROGEL SIMULATION MODEL FOR ARTIFICIAL URINARY SPHINCTER PLACEMENT UTILIZING EXPERT CONSENSUS Patrick Saba, Lauren Shepard, Katherine T. Anderson, Nick Warner, Nima Baradaran, Cooper Benson, William R. Boysen, Benjamin N. Breyer, Lindsay Hampson, Ty T. Higuchi, Niels V. Johnsen, Joseph J. Pariser, Jay Simhan, Alex J. Vanni, Omar RaheeM, Dmitriy Nikolavsky, Edward J. Wright, Arthur L. Burnett, Andrew Cohen, and Ahmed Ghazi Patrick SabaPatrick Saba , Lauren ShepardLauren Shepard , Katherine T. AndersonKatherine T. Anderson , Nick WarnerNick Warner , Nima BaradaranNima Baradaran , Cooper BensonCooper Benson , William R. BoysenWilliam R. Boysen , Benjamin N. BreyerBenjamin N. Breyer , Lindsay HampsonLindsay Hampson , Ty T. HiguchiTy T. Higuchi , Niels V. JohnsenNiels V. Johnsen , Joseph J. PariserJoseph J. Pariser , Jay SimhanJay Simhan , Alex J. VanniAlex J. Vanni , Omar RaheeMOmar RaheeM , Dmitriy NikolavskyDmitriy Nikolavsky , Edward J. WrightEdward J. Wright , Arthur L. BurnettArthur L. Burnett , Andrew CohenAndrew Cohen , and Ahmed GhaziAhmed Ghazi View All Author Informationhttps://doi.org/10.1097/01.JU.0001008636.33664.3e.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Artificial urinary sphincter (AUS) implantation is a safe and effective treatment for severe stress urinary incontinence. However, high rates of reoperation due to device erosion, infection, and mechanical failure, combined with limited amount of training outside of live surgery, creates the need to train the next generation of surgeons without patient risk. Utilizing the consensus-building Delphi process, we sought to create a high-fidelity, non-biohazardous, simulation model for AUS implantation. METHODS: 20 high volume AUS implanters were recruited to complete a Delphi process to reach expert consensus on the necessary parameters and design specifications for the simulation model. Consensus>80% was reached in 46% of 187 questions pertaining to procedural realism, anatomical realism, and educational effectiveness. Using previously validated 3D printing and hydrogel molding techniques, researchers fabricated a hydrogel model that incorporated all the expert determined aspects. Prototypes were sent to 9 of the experts who performed a skin-to-skin AUS implantation and a questionnaire evaluating the model and determining if the consensus defined steps were met. The questionnaire utilized a 5-point Likert scale where agreement=4/5, neutral=3, and disagreement=1/2. RESULTS: 100%, 89%, and 100% agreed the model procedurally replicates; all steps of the procedure, tissue texture/behavior, and anatomical relationships including perineal and urethral incision/exposure (100%), circumferential urethral dissection (89%), AUS device prep (89%), reservoir counter incision (67%), cuff measurement/placement (100%), tubing passage (89%), development of subdartos pouch (78%), pump placement (89%), fashioning of tubing (78%), skin closure (89%), and device cycling (79%). 89%, 89%, 78%, 89%, 78%, 89%, and 56% agreed it anatomically replicates the; perineum, urethra, fascia over urethra, corpora cavernosa/spongiosum, bulbospongiosus and pubic bone. 78%, 100%, 100%, 100%, and 89% agreed it offers; useful error feedback, a safe/non-biohazardous training platform, and is useful for teaching/practicing, improving technical skills and assessing trainees. CONCLUSIONS: We successfully created a high-fidelity, non-biohazardous, simulation model for AUS implantation utilizing expert consensus. The model replicated the entire implantation and was rated highly for procedural realism, anatomical realism, and educational effectiveness. Ultimately, this model can be used to improve current AUS training. Source of Funding: n/a © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e100 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Patrick Saba More articles by this author Lauren Shepard More articles by this author Katherine T. Anderson More articles by this author Nick Warner More articles by this author Nima Baradaran More articles by this author Cooper Benson More articles by this author William R. Boysen More articles by this author Benjamin N. Breyer More articles by this author Lindsay Hampson More articles by this author Ty T. Higuchi More articles by this author Niels V. Johnsen More articles by this author Joseph J. Pariser More articles by this author Jay Simhan More articles by this author Alex J. Vanni More articles by this author Omar RaheeM More articles by this author Dmitriy Nikolavsky More articles by this author Edward J. Wright More articles by this author Arthur L. Burnett More articles by this author Andrew Cohen More articles by this author Ahmed Ghazi More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023PD12-01 THE ROLE OF NON-OPERATIVE MANAGEMENT IN SEVERE RENAL INJURIES: DO ALL GRADE V INJURIES NECESSITATE INTERVENTION? Nizar Hakam, Sorena Keihani, Nathan Shaw, Douglas Rogers, Sherry Wang, Joel Gross, Ryan Joyce, Patrick Selph, Judith Hagedorn, Rachel Moses, Ian Schwartz, Shubham Gupta, Christopher Dodgion, Nima Baradaran, Bradley Erickson, Frank Burks, Richard Santucci, Joshua Broghammer, Jeremy Myers, and Benjamin Breyer Nizar HakamNizar Hakam More articles by this author , Sorena KeihaniSorena Keihani More articles by this author , Nathan ShawNathan Shaw More articles by this author , Douglas RogersDouglas Rogers More articles by this author , Sherry WangSherry Wang More articles by this author , Joel GrossJoel Gross More articles by this author , Ryan JoyceRyan Joyce More articles by this author , Patrick SelphPatrick Selph More articles by this author , Judith HagedornJudith Hagedorn More articles by this author , Rachel MosesRachel Moses More articles by this author , Ian SchwartzIan Schwartz More articles by this author , Shubham GuptaShubham Gupta More articles by this author , Christopher DodgionChristopher Dodgion More articles by this author , Nima BaradaranNima Baradaran More articles by this author , Bradley EricksonBradley Erickson More articles by this author , Frank BurksFrank Burks More articles by this author , Richard SantucciRichard Santucci More articles by this author , Joshua BroghammerJoshua Broghammer More articles by this author , Jeremy MyersJeremy Myers More articles by this author , and Benjamin BreyerBenjamin Breyer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Non-operative management has become standard for most renal trauma. Little data exists regarding conservative management of American Association for the Surgery of Trauma (AAST) grade V injuries. We aim to evaluate management of grade V renal trauma, focusing on feasibility and safety of non-operative management. METHODS: Grade V renal trauma cases submitted with available imaging from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We report management patterns categorized as expectant (observation with no interventions), conservative (performing kidney angioembolization, or stent / nephrostomy tube / perirenal drain placement), or operative (performing kidney related surgical interventions). RESULTS: 21 cases were independently radiologically verified as grade V cases by the 2018 AAST classification and were included in analysis. Most were males (15; 71%) with blunt trauma (20; 95%) and median age was 34 years (IQR 25-29). Most common management approach was operative (8, 38%), followed by conservative (7, 33%) and expectant (6, 29%). All those operatively management had nephrectomy, with 2 having a failed angioembolization attempt before nephrectomy. 4 out of 7 patients in the conservative group had angioembolization and the other 3 had a stent or drainage tube. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size, laceration size and proportion of cases with >50% and >95% devascularization (Table 1). Vascular contrast extravasation tended to be higher in operatively managed patients, but was not statistically significant. CONCLUSIONS: There is a significant role for non-operative management for grade V renal trauma, particularly in those with blunt trauma and are stable enough to undergo imaging. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e400 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nizar Hakam More articles by this author Sorena Keihani More articles by this author Nathan Shaw More articles by this author Douglas Rogers More articles by this author Sherry Wang More articles by this author Joel Gross More articles by this author Ryan Joyce More articles by this author Patrick Selph More articles by this author Judith Hagedorn More articles by this author Rachel Moses More articles by this author Ian Schwartz More articles by this author Shubham Gupta More articles by this author Christopher Dodgion More articles by this author Nima Baradaran More articles by this author Bradley Erickson More articles by this author Frank Burks More articles by this author Richard Santucci More articles by this author Joshua Broghammer More articles by this author Jeremy Myers More articles by this author Benjamin Breyer More articles by this author Expand All Advertisement PDF downloadLoading ...

We present a case of a 44-year-old male with cutaneous manifestations of neurofibromatosis type 1 presenting with long-standing urologic symptoms of uncertain etiology including urinary retention from myogenic bladder failure, chronic kidney disease with evidence of bilateral ureteral obstruction and presenting signs of an obstructing left ureterocele. This patient had a complete urologic evaluation and underwent ileocecocystoplasty with a continent catheterizable channel and bilateral ureteral reimplantation. Surgical excision of a left ureteral mound of tissue demonstrated the presence of a neurofibroma involving the bladder that led to obstruction. To our knowledge, this is the first report of such a presentation.

OBJECTIVE To identify factors associated with sexual interest and activity among adults with spina bifida and to describe the sexual profile of those who were sexually active. Sexual health of adults with spina bifida is often neglected and current knowledge on the topic is limited. METHODS An anonymous web-based survey was advertised and administered between March 2018 and September 2018 and participants 16 years and older with spina bifida were included in this study. Respondents were asked about sexual interest, activity, and function using the validated Patient-Reported Outcomes Measurement Information System Sexual Function Profile. Bivariate and multivariable models with ordinal logistic regression were fitted to evaluate predictors of sexual interest and sexual function. RESULTS Of the 261 respondents with a self-reported diagnosis of spina bifida (mean age of 38.5 years), 73.2% noted at least a little bit of interest in sexual activity. In multivariate analysis, women were less likely to report higher sexual interest than men (odds ratio (OR) = 0.53, 95% CI 0.310.92, P = .03) whereas those with higher physical functioning were more likely to have higher sexual interest (OR = 1.04, confidence interval (CI) 1.01-1.07, P = .03). Just less than half of respondents (46.4%) were sexually active in the past 30 days, and those with a ventriculoperitoneal shunt were less likely to engage in sexual activity compared to those without (OR = 0.36, 95% CI 0.19-0.68; P < .01). CONCLUSION The mismatch between sexual interest and sexual activity highlights the importance of exploring issues related to sexual health when counseling adult patients with spina bifida. UROLOGY 185: 143-149, 2024. (c) 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

You have accessJournal of UrologyCME1 Apr 2023PD12-02 URINARY EXTRAVASATION AFTER RENAL TRAUMA: SHOULD IT BE A CRITERION FOR THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GRADE IV INJURY? Sorena Keihani, Douglas Rogers, Sherry Wang, Joel Gross, Ryan Joyce, Judith Hagedorn, J. Patrick Selph, Rachel Moses, Rachel Sensenig, Joshua Broghammer, Shubham Gupta, Nima Baradaran, and Jeremy Myers Sorena KeihaniSorena Keihani More articles by this author , Douglas RogersDouglas Rogers More articles by this author , Sherry WangSherry Wang More articles by this author , Joel GrossJoel Gross More articles by this author , Ryan JoyceRyan Joyce More articles by this author , Judith HagedornJudith Hagedorn More articles by this author , J. Patrick SelphJ. Patrick Selph More articles by this author , Rachel MosesRachel Moses More articles by this author , Rachel SensenigRachel Sensenig More articles by this author , Joshua BroghammerJoshua Broghammer More articles by this author , Shubham GuptaShubham Gupta More articles by this author , Nima BaradaranNima Baradaran More articles by this author , and Jeremy MyersJeremy Myers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary extravasation (UE) is a main criterion for grade IV renal trauma. An appropriately-timed excretory phase CT is needed for accurate diagnosis. We aimed to assess the compliance with excretory phase imaging in a multi-center study and evaluate the management of UE after high-grade renal trauma (HGRT). METHODS: We used HGRT data from 7 Level-1 trauma centers. Patients with CT scans were included. Demographics, injury and imaging characteristics, and interventions were reviewed. We assessed compliance with obtaining excretory phase CT and its timing (9 minutes delay considered as adequate), and the rate of interventions for UE. We defined UE information as Ux (unknown/excretory imaging not done), U0 (no UE in excretory imaging), and U1 (UE present). RESULTS: We reviewed data from 550 patients with HGRT (grades III: 284 [51.5%]; IV: 250 [45.5%]; V: 16 [3%]) according to the 2018 AAST grading system. Only 324 (59%) had excretory phase images available within the initial CT to assess for UE with compliance rates between 26% to 100% between different centers. The median time between the arterial and delayed phase was 8 minutes (IQR: 4–11); 51% of the excretory images were inadequately timed (<9 minutes). Overall, 94 (17%) were diagnosed with UE either initially (n=62) or in follow up images (n=32). Of these, 22 (23%) underwent ureteral stent placement and 5 (5%) received peri-renal drains. Of the 262 with U0, 21 had UE diagnosed in follow up studies (8% missed UE with initial excretory imaging). Of the 226 with Ux, 11 were diagnosed with UE in follow up imaging (5% missed UE without initial excretory imaging). 59 of 94 patients with UE (63%) would have been grade IV only due to UE. Compared to the other patients with UE, these had lower rates of bleeding interventions (8% vs. 31%), active bleeding, and had smaller hematoma and lacerations sizes. CONCLUSIONS: About 40% of those with HGRT did not undergo excretory phase imaging in the initial assessment. The compliance in obtaining these images and the timing were variable and suboptimal. These can lead to inaccurate and incomplete grading of renal injuries in regards to UE. UE status can be provided as separate information or be included under grade III renal injuries. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e400 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sorena Keihani More articles by this author Douglas Rogers More articles by this author Sherry Wang More articles by this author Joel Gross More articles by this author Ryan Joyce More articles by this author Judith Hagedorn More articles by this author J. Patrick Selph More articles by this author Rachel Moses More articles by this author Rachel Sensenig More articles by this author Joshua Broghammer More articles by this author Shubham Gupta More articles by this author Nima Baradaran More articles by this author Jeremy Myers More articles by this author Expand All Advertisement PDF downloadLoading ...

OBJECTIVE To contextualize the challenges that persons with congenital genitourinary conditions (CGC) may encounter in adulthood, we examined health care access, readiness for self-management, and health care utilization of adults with spina bifida (SB).METHODS Through surveys distributed via social media, persons with SB were asked about access and barriers to care, readiness for self-management, and health care utilization (ie, medical visits, missed visits, emergency room [ER] visits, hospital admissions) within the past year. Multivariable models were fitted to examine determinants of utilization.RESULTS Of the 270 eligible respondents (mean age 39), 24.5% had not received care from a urologist in the past year. The odds of missing any medical visits were increased among those with more prior urologic surgeries (odds ratio (OR) 1.35, 95%confidence interval (CI) 1.05-1.78) and those with ER visits for urologic condition within the past year (OR 2.65, 95%CI 1.22-6.01). Those with private insurance had lower odds of having ER visits for urologic condition (OR 0.46, 95%CI 0.22-0.84). The odds of hospital admission related to urologic condition were increased among female (OR 2.35, 95%CI 1.01-6.64), those with more prior urologic surgeries (OR 1.18, 95%CI 1.09-1.51), and those with a urologist (OR 2.98, 95%CI 1.15-14.47).CONCLUSION A substantial proportion of adults with CGC lack routine urologic care. Considering the sig-nificant barriers to care and lapses in care, efforts to improve access and optimize health care services utilization for this population with high medical complexity are warranted. UROLOGY 181: 174-181, 2023.(c) 2023 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Introduction: Fournier's gangrene (FG), is a progressive, necrotizing soft tissue infection of the external genitalia, perineum, and/or anorectal region. How treatment and recovery from FG impacts quality of life related to sexual and general health is poorly characterized. Our purpose is to evaluate the long term impact of FG on overall and sexual quality of life using standardized questionnaires through a multi-institutional observational study. Materials and methods: Multi-institutional retrospective data were collected by standardized questionnaires on patient-reported outcome measures including the Changes in Sexual Functioning Questionnaire (CSFQ) and the Veterans RAND 36 (VR-36) survey of general health-related quality of life. Data were collected via telephone call, email, and certified mail, with a 10% response rate. There was no incentive for patient participation. Results: Thirty-five patients responded to the survey, with 9 female and 26 male patients. All patients in the study underwent surgical debridement between 2007-2018 at three tertiary care centers. Further reconstructions were performed for 57% of respondents. Values for respondents with overall lower sexual function were reduced in all component categories (pleasure, desire/ frequency, desire/interest, arousal/excitement, orgasm/ completion), and trended toward male sex, older age, longer time from initial debridement to reconstruction, and poorer self-reported general health-related quality of life metrics.Conclusion: FG is associated with high morbidity and significant decreases in quality of life across general and sexual functional domains.

You have accessJournal of UrologyCME1 Apr 2023MP52-06 CLINICAL AND SOCIODEMOGRAPHIC CHARACTERISTICS OF PATIENTS WITH SPINAL CORD INJURY ARE INDEPENDENTLY ASSOCIATED WITH CHOICE OF BLADDER MANAGEMENT METHOD Megan Stout, Juan Peng, Yu-Ying Chen, Huacong Wen, Jan Schwab, and Nima Baradaran Megan StoutMegan Stout More articles by this author , Juan PengJuan Peng More articles by this author , Yu-Ying ChenYu-Ying Chen More articles by this author , Huacong WenHuacong Wen More articles by this author , Jan SchwabJan Schwab More articles by this author , and Nima BaradaranNima Baradaran More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003300.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Clinical factors are known to impact choice of bladder management method (BMM) in patients with spinal cord injury (SCI) such as injury level, impairment severity, manual dexterity, as well as patient preference. The primary objective of this study was to evaluate the effect of sociodemographic characteristics of patients in this context. METHODS: From the Spinal Cord Injury Model System adult patients (>18 at time of injury) were screened. Exclusion criteria included death within one year of injury and lack of BMM data. Outcomes of interest included age, gender, race, education, marital status, household income, employment status, health insurance type, injury level, injury etiology, ventilatory status, neurological impairment category (quadriplegic vs paraplegic), composite poverty scale, and American Spine Injury Association (ASIA) impairment scale. Logistic regression models and multivariate analysis was used to determine associations between sociodemographic factors and use of indwelling catheters as primary choice of BMM. RESULTS: A total of 12,708 patients were screened and 9,097 were included. Majority of patients were male (79.4%), white (71.2%), had an average annual income of <$25,000 (33.3%) and public insurance (68.5%). Most were tetraplegic (47.3%) with ASIA score of “A” (complete impairment, 57.5%).The BMM breakdown was those that used indwelling catheters (34.4%) versus those with “other” methods (intermittent catheterization, external catheters, or urinary diversion; 65.6%). On multivariate analysis, after adjusting for disease characteristics, men were significantly more likely to be impacted by sociodemographic factors. In men, white race, non-Hispanic ethnicity, having public insurance, lower income, higher impairment severity, older age at injury and longer injury duration was associated with higher use of indwelling catheters (Figure 1). In females, only age at injury and neurologic impairment were significant. CONCLUSIONS: Sociodemographic variables are significantly associated with the choice of BMM in men with SCI. The reason for the discrepancy between genders is unknown. Further analysis utilizing this database to discern BMM choice between groups could guide future patient counseling and optimization of care. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e704 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Megan Stout More articles by this author Juan Peng More articles by this author Yu-Ying Chen More articles by this author Huacong Wen More articles by this author Jan Schwab More articles by this author Nima Baradaran More articles by this author Expand All Advertisement PDF downloadLoading ...

not associated with the patient's age, body mass index, a history of urethroplasty, or the type of urethroplasty (simple perineal or elaborate approach). However, an open bladder neck on antegrade cystoscopy and/or cystourethrography (OR 11.85, 95% CI 2.23-62.9, p [ 0.004) and a longer MUL (every extra millimeter, OR 0.87, 95% CI 0.76-1.00, p [ 0.04) were signi fi cant predictors of PUI on multivariate analysis. CONCLUSIONS: A greater preoperative MUL is signi fi cantly and positively associated with PUI in male patients with PFUI. MUL on MRI may be potentially valuable to reconstructive urologists when counseling patients in clinical practice, prior to urethroplasty.

PurposeTo investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management.MethodsWe used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery).ResultsEighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found.ConclusionSuccessful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

OBJECTIVE:To evaluate the impact of bladder management method, specifically chronic indwelling catheter (IndC), on survival in patients with spinal cord injury (SCI) in Spinal Cord Injury Model System database. METHODS:Spinal Cord Injury Model System is a multicenter longitudinal database since 1970 with >40,000 patients with SCI. Adult patients (>18 at the time of injury) were screened. Patients who died within 1 year of injury and had 2 or more changes in method of bladder management, or reported normal volitional void were excluded. Outcome of interest was death from nonpulmonary, nonwound related sepsis (NPNWS). Left truncation cox regression method using age as the time-scale was used to calculate hazard ratios. RESULTS:A total of 13,616 patients were included. Comparison was performed between "IndC" group (n = 4872; 36.1%) vs "Other" (n = 8744; 63.9%). After adjusting for age and change in bladder management method, "IndC" is associated with elevated NPNWS mortality (2.10; 95% confidence interval 1.72-2.56, P < .001). Multivariable analysis, adjusting for age at injury, gender, race, education, insurance status, etiology of SCI, injury level, neurologic impairment level, and change in bladder management method, showed IndC was associated with significantly higher risk of death from NPNWS compared to other methods of bladder management. CONCLUSION:In a large cohort of SCI patients, bladder management with IndC is predictive of significantly propagated NPNWS related mortality compared to other methods of bladder management. While identifying IndC is an independent mortality risk factor, a better understanding of the underlying mechanisms could inform strategies to improve neurourological care and survival after SCI.

OBJECTIVE To identify demographic and clinical characteristics associated with depression, anxiety, and social isolation among adults with spina bifida. We hypothesize that lower urinary tract dysfunction is associated with poor psychosocial outcomes. METHODS An anonymous survey was distributed via Facebook advertising to individuals with congenital urologic conditions. Adults with spina bifida were included in our analysis. Lower urinary tract dysfunction was assessed with the Neurogenic Bladder Symptom Score. Depression, anxiety, and social isolation T-scores were measured using Patient-Reported Outcome Measures Information System instruments. A composite depression-anxiety score was calculated. Separate adjusted linear models assessed the association between lower urinary tract dysfunction and depression, anxiety, composite depression-anxiety, and social isolation. RESULTS Around 195 participants were included. Rates of depression, anxiety, and social isolation were 48%, 47%, and 43%, respectively. Comorbid depression and anxiety occurred in 39% of subjects. On adjusted regression analysis, lower urinary tract dysfunction was associated with depression (P < 001), anxiety (P < .001), composite depression-anxiety (P < .001), and social isolation (P = .010). CONCLUSION Depression, anxiety, and social isolation are common in individuals with spina bifida relative to the general population, and associated with lower urinary tract dysfunction. Interventions focused on optimizing lower urinary tract symptoms and function, transition-age adults, group psychotherapy, and comorbid depression and anxiety may be of particular value in this population. (C) 2020 Elsevier Inc.

BACKGROUND Renal trauma grading has a limited ability to distinguish patients who will need intervention after high-grade renal trauma (HGRT). A nomogram incorporating both clinical and radiologic factors has been previously developed to predict bleeding control interventions after HGRT. We aimed to externally validate this nomogram using multicenter data from level 1 trauma centers. METHODS We gathered data from seven level 1 trauma centers. Patients with available initial computed tomography (CT) scans were included. Each CT scan was reviewed by two radiologists blinded to the intervention data. Nomogram variables included trauma mechanism, hypotension/shock, concomitant injuries, vascular contrast extravasation (VCE), pararenal hematoma extension, and hematoma rim distance (HRD). Mixed-effect logistic regression was used to assess the associations between the predictors and bleeding intervention. The prediction accuracy of the nomogram was assessed using the area under the receiver operating characteristic curve and its 95% confidence interval (CI). RESULTS Overall, 569 HGRT patients were included for external validation. Injury mechanism was blunt in 89%. Using initial CT scans, 14% had VCE and median HRD was 1.7 (0.9–2.6) cm. Overall, 12% underwent bleeding control interventions including 34 angioembolizations and 24 nephrectomies. In the multivariable analysis, presence of VCE was associated with a threefold increase in the odds of bleeding interventions (odds ratio, 3.06; 95% CI, 1.44–6.50). Every centimeter increase in HRD was associated with 66% increase in odds of bleeding interventions. External validation of the model provided excellent discrimination in predicting bleeding interventions with an area under the curve of 0.88 (95% CI, 0.84–0.92). CONCLUSION Our results reinforce the importance of radiologic findings such as VCE and hematoma characteristics in predicting bleeding control interventions after renal trauma. The prediction accuracy of the proposed nomogram remains high using external data. These variables can help to better risk stratify high-grade renal injuries. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.

Recurrent male anterior urethral stricture disease is a complex surgical challenge that should be managed by reconstructive urologists with experience in stricture management. Diagnosis of recurrence requires both anatomic narrowing and patient symptoms identified on validated questionnaires, with limited role for intervention in asymptomatic treatment "failures". Endoscopic management has a very specific role in recurrence, and the choice of technique for urethroplasty depends on pre-operative urethrography and cystoscopy. Surgical success depends on addressing patient concerns, complete stricture excision, tissue quality optimization, and the use of multi-stage repair when indicated. Augmentation with genital skin flaps and/or grafts is often required, with buccal mucosa as the ideal graft source if local tissue is compromised. Salvage options including urinary diversion and perineal urethrostomy must also be considered in debilitated patients with severe disease or repeated treatment failures. Unique patient populations including patients with hypospadias and lichen sclerosis are among the highest risk for repeated recurrence and require special care in surgical technique, graft selection, and post-operative management.

OBJECTIVE To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates. METHODS We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS <= 8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS). RESULTS A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P <.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55). CONCLUSION Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage. (C) 2021 Elsevier Inc.

Background Our objective is to better comprehend treatment considerations for urethral stricture disease (USD) in patients requiring long-term clean intermittent catheterization (CIC). Patient characteristics, surgical outcomes and complications are unknown in this population. Methods Six members of the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) participated in a prospective (2009 to present) and retrospective (prior to 2009) database recording patient demographics, surgical approach and outcomes. We included all patients undergoing urethroplasty who perform CIC. Descriptive statistics were used to analyze results. Results A total of 37 patients with 39 strictures were included. Bladder dysfunction was characterized as detrusor failure in 35% and neurogenic etiology in 65%. Median stricture length was 3 cm (IQR: 1.5–5.5) with 28% repaired with dorsal onlay buccal mucosal graft, 26% excision and primary anastomosis, 8% dorsal inlay, 8% ventral and dorsal, 8% flap based 8% non-transecting and 15% other. Functional success was 90%: 4 patients required DVIU or dilation due to recurrence, with 2 of those ultimately requiring repeat urethroplasty. 86% of patients returned to CIC; no patients reported new pad use for urinary leakage after urethroplasty. During a median follow-up period of 3.1 years (IQR: 1.0–5.3), no patients underwent urinary diversion. Conclusions Urethroplasty is suitable, safe and effective for patients dependent on CIC suffering from USD. The effect of continual CIC on long-term outcomes remains uncertain.

OBJECTIVE 1) To identify baseline characteristics of caregivers of school-aged children with spina bifida; 2) To identify independent predictors of caregiver burden in this population. MATERIALS AND METHODS A survey was distributed via Facebook advertising to caregivers of patients with congenital genitourinary anomalies from May to September 2018. Eligible participants (n = 408) entailed English-speaking adults who are involved in the patient's care and attend >50% of their medical appointments. Caregiver burden was assessed using the Caregiver Burden Inventory (CBI), where higher scores indicate higher burden. CBI >24 indicates need for respite and CBI >36 indicates high risk of burnout. Bivariate analyses (t-tests and chi-square tests) were conducted using STATA software. RESULTS Our analysis includes 408 caregivers caring for patients with spina bifida. In our study population, 59.3% of caregivers were in need of respite due to caregiver burden and 26.7% of caregivers were so burdened that they are at risk of burning out (CBI score >36). Bivariate analysis showed that caregiver gender and number of tasks performed by the caregiver were significantly associated with risk of burnout (CBI > 36). Multivariable analysis of overall caregiver burden showed increased risk of burnout (CBI > 36) among older caregivers, female caregivers, and those performing more caregiving tasks. CONCLUSION Caregiver burden is common among caregivers of patients with spina bifida, and further research is needed to identify strategies and resources for mitigating caregiver burden. UROLOGY 153: 339 -344, 2021. (c) 2021 Elsevier Inc.