INTRODUCTION To report outcomes of our Virtue male sling series and evaluate predictors of surgical success and failure. We also retrofit the Male Stress Incontinence Grading Scale (MSIGS) refined nomogram, including the standing cough test (SCT), to assess its application to our cohort.MATERIALS AND METHODS:A retrospective review was completed at a single institution over a 4 year period of all Virtue male slings implanted for stress urinary incontinence (SUI). Patient demographics including pad usage per day (PPD) and MSIGS were obtained on all patients after their bladders were filled cystoscopically. Failure was defined as > 1 PPD and/or conversion to another anti-incontinence procedure. Incidence, management and outcomes of complications were also evaluated.RESULTS:Forty-six men who underwent Virtue male sling at a median follow up of 15.6 months were analyzed with an objective success rate of 78% and a subjective success rate of 85%. Preoperative predictors of surgical success were ability to stop stream on physical exam, lack of total incontinence and no history of posterior urethral stricture. MSIGS alone was not predictive of sling success or failure. Penile numbness occurred in 11% of patients and reoperation with incision of the sutured together transobturator arms improved sensation in all patients.CONCLUSION:Virtue male sling has high objective and subjective success rates with a manageable side effect profile. Evidence of residual sphincteric function appears to be more predictive of sling success rather than MSIGS.

INTRODUCTION To assess the use, complications, and outcomes of continent cutaneous ileocecal cystoplasty (CCIC) for the management of refractory bladder neck contractures and/or urinary incontinence after prostate cancer therapy. MATERIALS AND METHODS An institutional review board approved database was reviewed for patients who underwent CCIC from January 1, 2003 to December 31, 2018. Preoperative, perioperative and postoperative factors were assessed, including complications and outcomes. RESULTS Thirteen patients were identified. Indications for CCIC included refractory bladder neck contracture (n = 3), urinary incontinence (n = 5), or both (n = 5). Median age was 69. Median follow up was 78.1 months. Seventy-seven percent of patients (10/13) had a history of radiation. The median number of procedures between initial prostate treatment and augmentation was 3. Sixty-nine percent (9/13) of patients had a bladder neck closure along with augmentation (5 transabdominal and 4 transperineal). Median operative time was 375 minutes. Median blood loss was 175 mL. The overall complication rate was 69% (9/13), with 38% (5/13) occurring within 30 days. One patient (8%) required stomal revision. Thirty-three percent (3/9) of patients with bladder neck closure required revision due to perineal fistula. All had a history of radiation therapy. At last follow up all patients were satisfied with their urinary control. Eighty-five percent of patients (11/13) were fully continent via both urethra and stoma. One patient had urethral leakage with bladder spasms controlled with medication and one had mild stomal incontinence. CONCLUSIONS CCIC is an effective means of treating refractory bladder neck contractures and/or urinary incontinence. While morbidity rates are high, subjective patient satisfaction is high.

Evaluation of safety is of paramount importance with adoption of novel surgical technology. Although robotic surgery has become widely used in oncologic surgery, analysis of safety is lacking in comparison to traditional techniques. Standardized assessment of robotic surgical outcomes and adverse events following oncologic surgery is necessary for quality improvement with innovative technology. Between 2003 and 2016, 10,013 unique robotic operations were performed in 9,858 patients. Our prospectively maintained database was retrospectively reviewed for hospital readmissions and Clavien–Dindo grade ≥ 2 complications within 30 days. Multivariable logistic regression was used to identify predictors of surgical complications and hospital readmissions. Cases were stratified by discipline: genitourinary (n = 8240), gynecologic (n = 857), thoracic (n = 457), gastrointestinal (n = 322), hepatobiliary (n = 60), ear/nose/throat (n = 44) and general (n = 33). Intraoperative complications occurred in 42 surgeries (0.4%). Postoperative complications occurred in 946 patients [9.4%, highest grade 2 (n = 574), 3 (n = 288), 4 (n = 72), 5 (n = 10)]. Most frequent complications were ileus (154, 16.3%), anemia (91, 9.6%), cardiac arrhythmia (62, 6.6%), deep vein thrombosis/pulmonary embolus (47, 5.0%), wound infection (45, 4.8%) and urinary leak (43, 4.5%). 405 patients (4.0%) required readmission. Most common causes for hospital readmission were ileus (44, 10.9%), urinary leak (23, 5.7%), urinary tract infection (23, 5.7%), intra-abdominal abscess/fluid collection (23, 5.7%), and small bowel obstruction (19, 4.7%). On multivariable analysis, longer operative time and older age predicted complications and readmissions (p ≤ 0.02). Robotic-assisted surgery appears a safe for oncologic surgery with acceptable hospital readmission and complication rates. Older age and longer operative time were associated with complications and readmission.

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I (MP19)1 Apr 2020MP19-09 BIOCHEMICAL RECURRENCE AND OVERALL SURVIVAL IN MEN WITH HIGH-RISK PROSTATE CANCER UNDERGOING ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH LIMITED VS. EXTENDED PELVIC LYMPH NODE DISSECTION Frank Myers, Alex Cantrell, Clayton Lau, Bertram Yuh, Ali Zhumkhawala, Jonathan Yamzon, Kevin Chan, Jim Shen*, Pooya Banapour, and Nora Ruel Frank MyersFrank Myers More articles by this author , Alex CantrellAlex Cantrell More articles by this author , Clayton LauClayton Lau More articles by this author , Bertram YuhBertram Yuh More articles by this author , Ali ZhumkhawalaAli Zhumkhawala More articles by this author , Jonathan YamzonJonathan Yamzon More articles by this author , Kevin ChanKevin Chan More articles by this author , Jim Shen*Jim Shen* More articles by this author , Pooya BanapourPooya Banapour More articles by this author , and Nora RuelNora Ruel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000852.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Extended pelvic lymph node dissection (eLND) at the time of radical prostatectomy has a staging benefit over limited pelvic lymph node dissection (LLND) but an unclear therapeutic benefit. We sought to evaluate biochemical recurrence (BCR) and overall survival (OS) in patients who underwent LLND versus eLND at our institution. METHODS: Between 2003 and 2015, we identified 388 men with D’Amico high-risk prostate cancer who underwent robot assisted radical prostatectomy (RARP) at our institution with concomitant LLND (obturator fossa) or eLND (common iliacs, external and internal iliacs, nodes of Cloquet, bilateral obturator fossa and anterior prostatic fat pad). Biochemical recurrence was defined as post-prostatectomy PSA equal to or greater than 0.2. Survival estimates were made using Kaplan-Meier method and the log-rank statistic was used for comparison of the curves. Patients who received any neo-adjuvant therapy were excluded. Chi-square and Wilcoxon rank-sum tests were used to compare discrete and continuous variables, respectively, across the two groups. RESULTS: The LLND (n=184) and eLND (n=204) groups were similar in regard to preoperative clinical parameters, pathologic stage, and positive surgical margins. ELND patients had more disease involvement of the prostate gland compared to the LLND group (20% vs 12%, p<0.0001). ELND yielded more lymph nodes (median 21 vs 5, p<0.0001) as well as a higher node positive rate (32.4% vs 7.1%, p<0.0001). Similar number of patients received adjuvant hormonal therapy (eLND 27.5% vs LLND 20.1%, p=0.09) and significantly more patients in the LLND group received adjuvant radiation therapy (eLND 15.7% vs LLND 24.5%, p=0.03). Median PSA follow up was 31 vs 85 months in the eLND and LLND groups, respectively. BCRFS at 3 and 5 years for eLND and LLND was 55% vs. 66% and 39% vs. 56%, respectively (p=0.008). The overall survival between the two groups at 5 years (eLND 92.7% vs LLND 95.9%, p=0.2) was not statistically significant. CONCLUSIONS: ELND removes more lymph nodes and improves detection of positive nodes compared to LLND. Analysis of BCR suggests an increased risk of PSA failure for high risk patients undergoing eLND. Despite this, there is no difference in overall survival. Long-term and subset analysis is necessary to determine which patients with high-risk prostate cancer would benefit from extended node dissection. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e301-e302 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Frank Myers More articles by this author Alex Cantrell More articles by this author Clayton Lau More articles by this author Bertram Yuh More articles by this author Ali Zhumkhawala More articles by this author Jonathan Yamzon More articles by this author Kevin Chan More articles by this author Jim Shen* More articles by this author Pooya Banapour More articles by this author Nora Ruel More articles by this author Expand All Advertisement PDF downloadLoading ...

A 69-year-old male with no documented past medical history presented to an outside institution with a 2.9 cm left lower pole renal mass that was incidentally discovered on imaging performed for abdominal and back pain. He denied any history of hematuria or flank pain. He was referred to the interventional radiology service for CT-guided percutaneous biopsy and cryoablation of the left renal mass. Three core needle biopsies were performed using a 20 gauge cutting needle with coaxial technique. Hydrodissection was used to displace the colon in preparation for cryoablation due to the lesion's anterior location. Three cryoprobes were used to ablate the tumor and 2 cycles of freezing followed by active thawing were performed. Good coverage of the tumor was seen and there were no complications noted. The biopsy results showed renal cell carcinoma (RCC). No nuclear grade was assigned.

INTRODUCTIONUrologists partnered with anesthesiologists to implement a model of perioperative and postoperative care known as the multidisciplinary perioperative surgical home in order to improve the quality and efficiency of care. We describe early outcomes associated with implementation of the perioperative surgical home.METHODSRetrospective chart review was performed of patients at a single institution undergoing radical prostatectomy, radical cystectomy, partial nephrectomy and radical nephrectomy from January 2014 to March 2016. Outcomes measured were length of stay and 30-day reoperation, readmission, unexpected intensive care unit admission and mortality rates. Statistical analysis was performed using the independent samples Mann-Whitney U test and Fisher exact test with p <0.05 considered significant. Univariate and multivariate analyses were performed to determine whether implementation of the perioperative surgical home was associated with improved outcomes.RESULTSLength of hospital stay decreased from 4.79 to 3.19 days and 30-day complication rate decreased from 15.3% to 5.7% after implementation of the perioperative surgical home (p <0.01 for both). There was no change in the 30-day readmission rate. On multivariate analysis surgery occurring after perioperative surgical home implementation was associated with decreased length of stay (p = 0.008). The direct cost savings resulting from this length of stay reduction totaled $1,245,585 for the study period.CONCLUSIONSThe adoption of a perioperative surgical home is associated with a significantly decreased postoperative hospital stay and 30-day complication rate for urologic oncology cases.

Background: Ischemia is thought to contribute to benign ureteroenteric stricture (UES) after radical cystectomy with urinary diversion (RCUD). Our institution adopted the use of ureteral perfusion assessment during all RCUDs using real-time indocyanine green angiography using the SPY fluorescence imaging platform (Stryker Corp., Kalamazoo, MI, USA). This guides the location of ureteral transection prior to ureteroenteric anastomosis. We sought to compare UES rates before and after adoption of SPY. Methods: A retrospective chart review was undertaken for the first 47 consecutive cases of RCUD using SPY as well as the previous 47 consecutive cases, which were performed without SPY. Fisher's exact and Wilcoxon rank-sum tests were used to compare benign UES rates and the length of ureter excised during anastomosis. A p < 0.05 indicated statistical significance. Results: Median follow up was 12.0 months for SPY cases and 24.3 months for non-SPY cases. The UES rate for SPY RCUDs was 0% (0/93 ureters) compared with 7.5% (7/93 ureters) for non-SPY RCUDs (p = 0.01). Amongst SPY RCUDs, 86 ureters had no hydronephrosis and 7 had mild hydronephrosis with reflux on loopogram. A total of 34.4% of ureters (32/93) had poor distal perfusion, requiring a more proximal anastomosis. The median length excised for ureters with poor distal perfusion was 3.8 cm, compared with 2.2 cm for ureters with good distal perfusion (p < 0.0001). No complications attributable to the use of SPY were noted. Conclusion: Use of SPY to assess ureteral perfusion was associated with a decrease in the UES rate after RCUD. A total of 34.4% of ureters demonstrated poor distal perfusion, requiring a significantly more proximal ureteroenteric anastomosis.

INTRODUCTION AND OBJECTIVES: Concern has been raised about the oncologic soundness of robot-assisted radical cystectomy (RARC). We present our experience with disease recurrence and metastasis after RARC for bladder cancer. METHODS: The City of Hope RARC database was queried to identify all patients who underwent RARC for primary urothelial carcinoma of the bladder between 2003 and 2015. Disease recurrences and metastases were categorized by location. The reverse Kaplan-Meier method was used to calculate time to recurrence- or metastasis-free (RMFS) and overall survival (OS). Log rank test was used to compare survival curves. Univariate and multivariate analysis were performed to identify predictors of RMFS and OS. RESULTS: 379 patients fit the study criteria. The median follow up was 61 months. 97 patients (25.6%) developed recurrence or metastasis during the study period. The most common site of recurrence or metastasis was the pelvis (n=33), followed by the lungs (n=24), retroperitoneum (n=23), bone (n=19), and liver (n=13). The most distant extent of disease in these patients was locoregional recurrence in 20 patients, retroperitoneal recurrence in 13 patients, distant metastasis in 54 patients, and peritoneal carcinomatosis in 10 patients. 11 of 379 (2.9%) patients had positive surgical margins. 12.4% of patients who did not develop recurrence or metastasis were node-positive (35/282), compared to 44.3% (43/97) of patients who did develop recurrence or metastasis. 3 year RMFS for <pT2, pT2, pT3, and pT4 disease was 89.9%, 73.3%, 57.6%, and 36.5%, respectively (p<0.0001). 3 year OS for these stages was 86.7%, 61.5%, 40.1%, and 21.5%, respectively (p<0.0001). On multivariate analysis, pathologic T stage and pN+ disease predicted RMFS. American Society of Anesthesiologists score (ASA), pathologic T stage, and pN+ disease predicted OS. CONCLUSIONS: RARC demonstrates acceptable RMFS and OS across disease stages. Pathologic T stage and pN+ disease predict RMFS and OS after RARC. ASA also predicts OS after RARC. Table. No title available. Source of Funding: None

You have accessJournal of UrologyBladder Cancer: Epidemiology & Evaluation I (MP05)1 Apr 2019MP05-19 OUTCOMES OF SALVAGE CYSTECTOMY AFTER FAILURE OF TRIMODALITY THERAPY Jim Shen*, Nora Ruel, Mitchell Bassett, Brian Blair, Alexander Cantrell, Kevin Chan, Clayton Lau, Jonathan Yamzon, Ali Zhumkhawala, and Bertram Yuh Jim Shen*Jim Shen* More articles by this author , Nora RuelNora Ruel More articles by this author , Mitchell BassettMitchell Bassett More articles by this author , Brian BlairBrian Blair More articles by this author , Alexander CantrellAlexander Cantrell More articles by this author , Kevin ChanKevin Chan More articles by this author , Clayton LauClayton Lau More articles by this author , Jonathan YamzonJonathan Yamzon More articles by this author , Ali ZhumkhawalaAli Zhumkhawala More articles by this author , and Bertram YuhBertram Yuh More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000554990.15052.1eAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: A minority of patients undergoing trimodality therapy for bladder cancer will go on to require salvage cystectomy. We report the outcomes in a small cohort of open and minimally invasive salvage cystectomies with both incontinent and continent urinary diversions. METHODS: From April 1998 to October 2013, 16 cystectomies were performed on patients with a known history of bladder cancer treated with both chemotherapy and radiation therapy. Demographics, pathology, complications, and outcomes data were collected by chart review. The Kaplan-Meier method was used to calculate metastasis-free and overall survival. The log-rank test was used to compare survival curves. RESULTS: Cystectomy was done for locally recurrent disease in 15 patients and refractory hematuria in one patient. Median age was 75.5 years. Median BMI was 23.6 kg/m2. Median Charlson comorbidity index was 6. 10 of 16 cystectomies were started via a minimally invasive approach (8 robotic, 2 laparoscopic). One robotic and one laparoscopic cystectomy was converted to open. In patients who had lymphadenectomy, median nodal yield was 13 (IQR 6-30). 11 patients had ileal conduit urinary diversion and 5 had continent diversion (4 Indiana pouch, 1 Studer neobladder). Median estimated blood loss was 500 mL and 9 patients required intraoperative blood transfusion. At 90 days after surgery, 5 patients developed a Clavien-Dindo complication grade ≥3 (1 mortality). Median hospital stay was 11 days. Five patients developed distant metastasis at a median of 13.3 months after surgery. Median overall survival was 31.4 months (95% CI 4.2-96.8). Patients who had cisplatin-based chemotherapy experienced longer overall survival than those who had non cisplatin-based chemotherapy (67.9 vs. 16.3 months, p=0.03). CONCLUSIONS: Although salvage cystectomy is a morbid surgery, a subset of patients experienced significant metastasis-free and overall survival. Robotic approaches and continent urinary diversions are feasible. Additional study is needed to guide management in this rarely studied patient population. Source of Funding: None Duarte, CA© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e46-e47 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jim Shen* More articles by this author Nora Ruel More articles by this author Mitchell Bassett More articles by this author Brian Blair More articles by this author Alexander Cantrell More articles by this author Kevin Chan More articles by this author Clayton Lau More articles by this author Jonathan Yamzon More articles by this author Ali Zhumkhawala More articles by this author Bertram Yuh More articles by this author Expand All Advertisement PDF downloadLoading ...

Solitary Kidney [ 25 Bilateral Cancer [ 8 Non-functioning contralateral kidney [ 3 Tumour size 6.2 cm (2.6-18 cm) Single tumour [ 31 Multi-focal disease [ 5 R.E.N.A.L. Nephrometry score Highly complex [ 34 Moderately complex [ 2 Peri-operative outcomes Positive Surgical Margins 2/36 (5.5%) Post operative dialysis 18/36 (50%) Complications (Clavien III-V) 20/36 (56%) 30 day mortality 2/36 (5.6%)Long term outcomes Duration of Follow up: Mean [ 60 months (6-156) Cancer Specific Survival 96% Recurrence free Survival 79% Overall Survival 88% Dialysis free survival 83% of patients still alive CONCLUSIONS: EPN though complex and potentially hazardous offers an excellent chance of renal preservation without compromising cancer control EPN should be considered a viable treatment option in selected patients

Introduction: Volume of renal parenchymal loss is known to affect postoperative renal function after partial nephrectomy (PN). We utilize a novel comparison using donor nephrectomy (DN) patients to demonstrate the primary effect parenchymal volume loss plays on postoperative renal function following PN. Materials and Methods: Records of 250 living donor (DN) and 118 PN patients were retrospectively reviewed. Baseline characteristics and preoperative estimated glomerular filtration rate (eGFR)s were recorded. Percent changes in eGFR and incidences of surgically induced chronic kidney disease (CKD-S) in short, intermediate, and long-term postoperative periods were compared. Univariate and multivariate analyses of prognostic factors for development of CKD-S were performed. The PN group was further divided into subgroups with different lengths of warm ischemia time (WIT) and compared with DN patients. Results: At baseline, DN patients were younger, less likely to be male, had lower body mass index, lower American Society of Anesthesiologists, and higher preoperative eGFR (all p < 0.001). At hospital discharge, intermediate follow-up, and latest follow-up, renal function changes in DN and PN groups were -40.5% vs. -3.6%, -34.1% vs. -5.5%, and -33.2% vs. -4.4%, respectively (all p < 0.001). More DN than PN patients developed CKD-S (p < 0.001). DN was a significant risk factor for the development of chronic kidney disease on univariate and multivariate analyses (p < 0.001). On subgroup analysis, both subgroups with WIT 1 to 30 minutes and 31 to 60 minutes had less renal function decline at all time points compared with DN (p < 0.001). Conclusions: Volume of renal parenchyma retained is the dominant driver of postoperative renal function after nephrectomy, compared with all other factors. Surgeons should minimize parenchymal loss during PN to optimize postoperative renal function.

You have accessJournal of UrologyRenal Oncology I (V10)1 Apr 2019V10-12 ROBOT-ASSISTED CYTOREDUCTIVE NEPHRECTOMY AND RESECTION OF PELVIC METASTASIS AFTER RENAL CRYOABLATION Jim Shen*, Patrick Kilday, Avinash Chenam, Juzar Jamnagerwalla, Bertram Yuh, and Clayton Lau Jim Shen*Jim Shen* More articles by this author , Patrick KildayPatrick Kilday More articles by this author , Avinash ChenamAvinash Chenam More articles by this author , Juzar JamnagerwallaJuzar Jamnagerwalla More articles by this author , Bertram YuhBertram Yuh More articles by this author , and Clayton LauClayton Lau More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000557192.60001.bfAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Tumor seeding or intraperitoneal spread of disease occurs rarely after percutaneous biopsy or ablation of renal cell carcinoma. We present a case of robot-assisted cytoreductive nephrectomy and resection of pelvic metastasis after percutaneous cryoablation of renal cell carcinoma. METHODS: A 69 year old male was referred to City of Hope with a prior history of percutaneous cryoablation of a 3 cm biopsy-proven clear cell renal cell carcinoma. At 4 and 9 months after ablation, CT scan showed no evidence of disease recurrence. At 13 months after surgery, a CT showed a 3 cm renal mass suspicious for recurrent cancer and a 3.8 cm mass involving the right seminal vesicle. Pulmonary metastases were also found. CT-guided biopsy of both masses confirmed renal cell carcinoma. RESULTS: After discussion of treatment options, cytoreductive robot-assisted left radical nephrectomy with pelvic mass resection was performed. The renal cancer was adherent to the colonic mesentery and the mesentery was widely resected in this area. After nephrectomy was complete, the patient was re-positioned into dorsal lithotomy position and the pelvic mass was resected. The right seminal vesicle was resected in order to ensure that the disease was completely resected. The postoperative course was uncomplicated and the patient was discharged on postoperative day 2. Final pathology results demonstrated pT4 grade 4 clear cell renal cell carcinoma with sarcomatoid features, locally invading the colonic mesentery. CONCLUSIONS: Though rare, pelvic metastasis may occur after cryoablation of renal cell carcinoma. Robot-assisted techniques may be applied in this situation. Source of Funding: None Duarte, CA© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e1037-e1037 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jim Shen* More articles by this author Patrick Kilday More articles by this author Avinash Chenam More articles by this author Juzar Jamnagerwalla More articles by this author Bertram Yuh More articles by this author Clayton Lau More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II (MP61)1 Apr 2019MP61-17 OUTCOMES OF CONTINENT AND INCONTINENT URINARY DIVERSION DURING PELVIC EXENTERATION FOR NON-UROLOGIC MALIGNANCY: A CANCER CENTER EXPERIENCE Brian M. Blair*, Jim Shen, Nora Ruel, Jonathan Yamzon, Ali Zhumkhawala, Clayton Lau, Bertram Yuh, and Kevin Chan Brian M. Blair*Brian M. Blair* More articles by this author , Jim ShenJim Shen More articles by this author , Nora RuelNora Ruel More articles by this author , Jonathan YamzonJonathan Yamzon More articles by this author , Ali ZhumkhawalaAli Zhumkhawala More articles by this author , Clayton LauClayton Lau More articles by this author , Bertram YuhBertram Yuh More articles by this author , and Kevin ChanKevin Chan More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000556819.78973.59AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Radical cystectomy during multi-visceral resection for locally advanced pelvic malignancy requires urinary diversion. Outcomes with incontinent and continent urinary diversions performed during pelvic exenteration for non-urologic malignancy are not well documented in urologic literature. The aim of the study is to report our experience with urinary reconstruction in this complex operation. METHODS: A single tertiary-care institution, multi-surgeon, retrospective chart review was performed for patients undergoing urinary diversion as part of pelvic exenteration for non-urologic malignancy between February 1999 and April 2017. Patient demographics, surgical parameters, and complication rates were analyzed and then compared by diversion type. Statistical significance was set at p<0.05. RESULTS: 57 patients were included with a median age of 56.0 years (IQR 47.0 - 67.0) and BMI 27.1 kg/m2 (IQR 21.8 - 31.5). 70.2% (n=40) were female and 29.8% male (n=17), with 68.4% having an ASA classification ≥ III. Patient’s primary malignancy was categorized as colorectal for 49.1%, gynecologic for 43.9%, and other for 7.0% (sarcoma, adenocarcinoma). Prior chemotherapy (77.2%), pelvic radiation (71.9%), or chemoradiation (63.2%) was common. Indiana pouch (IP) continent diversion was used in 19.3% (n=11), and incontinent diversions included ileal conduit (IC) in 77.2% (n=44) and colon conduit in 3.5% (n=2). Comparing IP to IC diversions, there was no difference in age, gender, BMI, or tumor type. Those undergoing IP were less likely to have prior chemotherapy (36.4 vs 88.6%, p=0.0007) or radiation (63.6 vs 72.7%, p=0.007), and less likely to require intraoperative (36.4 vs 75.7%, p=0.02) or postoperative transfusion (18.2 vs 27.3%, p=0.02). Clinically, operative time was longer in patients who underwent IP compared to IC (650.5 vs 480 minutes, p=0.2), with comparable 30-day (63.6 vs 72.7%, p=0.4) and 31-90-day (36.4 vs 29.5%, p=0.3) complications. Fewer IP patients underwent adjuvant chemotherapy (9.1 vs 34.1%, p=0.05), and follow-up was longer for the IP group (34.1 vs 10.0 months, p=0.03), perhaps owing to better disease prognosis in those receiving a continent diversion. CONCLUSIONS: This data provides insight into a scarcely reported topic in urologic literature. Diversion type should be individualized, with continent diversions in patients undergoing pelvic exenteration for non-urologic malignancy remaining a feasible option with comparable outcomes to incontinent diversions in appropriately selected patients. Source of Funding: None Duarte, CA© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e884-e884 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brian M. Blair* More articles by this author Jim Shen More articles by this author Nora Ruel More articles by this author Jonathan Yamzon More articles by this author Ali Zhumkhawala More articles by this author Clayton Lau More articles by this author Bertram Yuh More articles by this author Kevin Chan More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II (MP61)1 Apr 2019MP61-05 TIME COURSE OF URETEROENTERIC STRICTURES AFTER RADICAL CYSTECTOMY WITH URINARY DIVERSION Jim Shen*, Juzar Jamnagerwalla, Bertram Yuh, Jonathan Warner, Avinash Chenam, Patrick Kilday, Ali Zhumkhawala, Jonathan Yamzon, Clayton Lau, and Kevin Chan Jim Shen*Jim Shen* More articles by this author , Juzar JamnagerwallaJuzar Jamnagerwalla More articles by this author , Bertram YuhBertram Yuh More articles by this author , Jonathan WarnerJonathan Warner More articles by this author , Avinash ChenamAvinash Chenam More articles by this author , Patrick KildayPatrick Kilday More articles by this author , Ali ZhumkhawalaAli Zhumkhawala More articles by this author , Jonathan YamzonJonathan Yamzon More articles by this author , Clayton LauClayton Lau More articles by this author , and Kevin ChanKevin Chan More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000556807.66404.64AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Benign ureteroenteric strictures (UES) may occur after radical cystectomy with urinary diversion. Timely treatment is instrumental in preventing renal insufficiency. There has been a lack of published data regarding the timing of these strictures. We present our experience with UES revision, with a focus on the time course of stricture development. METHODS: We identified all patients who underwent robot-assisted radical cystectomy with extracorporeal urinary diversion that subsequently required open revision of their ureteroenteric anastomosis. All revisions were performed between January 2005 and March 2017. Patients with malignant strictures were excluded. UES was diagnosed if hydronephrosis was identified on imaging and diuretic renogram and loopogram or pouchogram were consistent with obstruction. All patients in this study underwent renal ultrasound or CT of the abdomen and pelvis no later than 2 months post-cystectomy. Demographic data, perioperative data, and imaging results were collected. RESULTS: 29 patients had unilateral strictures and 4 had bilateral strictures, for a total of 37 strictures in 33 patients. 6 patients underwent Indiana pouch diversion (18.2%), with 11 patients undergoing ileal conduit (33.3%) and the remainder undergoing Studer neobladder (48.5%). For 35/37 ureters (94.6%), hydronephrosis was present on initial post-cystectomy imaging. For the remaining 2 ureters, hydronephrosis developed at 3 and 4 months post-cystectomy. The mean time to identification of hydronephrosis was 1.52 months and the median time from cystectomy to revision surgery was 4.63 months (IQR 3.95-6.12). Median follow up was 34.3 months. CONCLUSIONS: Almost all patients who required revision of ureteroenteric anastomosis due to stricture demonstrated evidence of functional obstruction on imaging done no later than 2 months post-cystectomy. This suggests an intraoperative etiology such as ischemia. Clinicians may consider early imaging to identify strictures and intervene early to prevent renal insufficiency. Source of Funding: None Duarte, CA© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e879-e879 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jim Shen* More articles by this author Juzar Jamnagerwalla More articles by this author Bertram Yuh More articles by this author Jonathan Warner More articles by this author Avinash Chenam More articles by this author Patrick Kilday More articles by this author Ali Zhumkhawala More articles by this author Jonathan Yamzon More articles by this author Clayton Lau More articles by this author Kevin Chan More articles by this author Expand All Advertisement PDF downloadLoading ...

Purpose Intravesical electrical stimulation treatment (IVES) has been successfully used to treat neurogenic bladder. We report the results of an observational study regarding the use of IVES for women with overactive bladder syndrome (OAB) and/or urgency urinary incontinence (UUI). Materials and Methods IVES was performed in women with OAB (defined by frequency ≥8/day, nocturia ≥2/night, or ≥3 episodes of UUI on 3-day voiding diary) who failed prior medical therapy. Subjects underwent 4 weeks of treatment with an 8-Fr Detruset™ IVES catheter. Primary outcome was Patient Global Impression of Improvement (PGI-I) at 3 months. Secondary outcomes included Visual Analog Scale (VAS), Short Form OAB Questionnaire (OAB-q SF), Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact Questionnaire (PFIQ), reduction in frequency and UUI on voiding diary, and adverse effects. Analysis was done with paired t-tests and Wilcoxon signed rank tests. Results Seventeen subjects completed the study. At 4 weeks post-treatment, 15 improved on PGI-I (11 subjects: ‘a little better’, 2: ‘much better’, 2: ‘very much better’). There were significant improvements in symptom bother and health-related quality of life as measured by OAB-q SF and pelvic organ prolapse and urinary distress as measured by PFDI. Frequency decreased from 10.3±4.3 at baseline to 8.9±2.3 (p=0.04) at 3 months. No pain was reported during treatment. There was one urinary tract infection during the study period. No other adverse events were reported. Conclusions IVES appears to be a safe and effective novel treatment for OAB. Larger comparative studies are needed to investigate its potential for long-term treatment.

BACKGROUND Translabial ultrasound (TUS) can provide an inexpensive alternative imaging modality for evaluating pelvic floor structures and synthetic slings as mesh can be difficult to identify on pelvic exam or cystoscopy, patients may be unable to provide an accurate history of previous pelvic surgery, and cross-sectional imaging with computed tomography and magnetic resonance imaging can be inadequate for evaluating synthetic slings. OBJECTIVE To demonstrate the use of TUS in the evaluation of female pelvic floor structures and mesh. METHODS Translabial ultrasound can be used in the Urology clinic or intraoperative setting using a curvilinear transducer. Following identification of anatomic landmarks in the various planes of the pelvic floor, TUS can evaluate for pelvic floor disorders and the type and location of synthetic mesh material. Artifacts, such as air pockets in the vagina or rectum and the hypoechoic pubic symphysis, are also considered. RESULTS Real-time imaging allows for dynamic examination of pelvic organ prolapse and urethral hyper mobility that can contribute to pelvic exam findings. Bladder ultrasound can help evaluate for lesions, calculi, and even mesh erosion. Translabial ultrasound can also be used to differentiate hyperechoic retropubic and transobturator slings by identifying the position of sling arms and the appearance of the sling at different planes. Evaluation with TUS can demonstrate sling disruption, folding, urethral impingement, and erosion into pelvic floor structures. This can be particularly useful in patients presenting with pain, recurrent infections, or voiding dysfunction in which problems with mesh may not be easily identified on pelvic exam or cystoscopy. This imaging modality can complement a patient's history, aid in preoperative planning, and enable intraoperative identification of mesh slings. CONCLUSION Translabial ultrasound provides a quick, readily available, and easy-to-learn imaging modality for evaluating pelvic floor structures and mesh in the office or intraoperative setting. (C) 2018 Elsevier Inc.

Purpose of studyEndourologic procedures require the use of multiple foot pedals to activate different instruments. Limited working space, surgical drapes, plastic covers, and low-light operating room (OR) settings can risk inaccurate foot pedal activation during these cases. A range of complications

Purpose: Endourologic procedures such as percutaneous nephrolithotomy (PCNL) employ the use of foot pedals in low-light operating room (OR) settings. These pedals can be especially difficult to locate or distinguish when several pedals are present during a single operation. Improper instrument activation in the OR has led to serious complications ranging from unintentional electrocautery to patient burns and even an intraoperative explosion. This study evaluates the impact of color-coded illumination on speed and efficiency of foot pedal activation. Materials and Methods: During a simulated PCNL procedure, the foot pedals for a C-arm, laser, and ultrasonic lithotripter (USL) were placed in random positions. Ten participants performed pedal activation in a randomized sequence. Objective outcomes included time to instrument activation, number of attempted pedal presses, number of incomplete pedal presses, and number of incorrect pedal presses. Subjective preferences for pedal illumination were also determined. Data were analyzed using Mann-Whitney U, Wilcoxon signed-rank, and Chi-square tests with p<0.05 indicating statistical significance. Results: Illuminated foot pedals were associated with decreases in the average activation time for all instruments collectively (3.95 seconds vs 6.49 seconds; p=0.017) and individually (C-arm: 3.07 seconds vs 4.21 seconds; p=0.006; laser: 13.04 seconds vs 15.18 seconds; p<0.001; USL: 3.28 seconds vs 4.91 seconds; p<0.001) compared with nonilluminated pedals. Illuminated pedals were associated with fewer attempted pedal presses (33.5 vs 39.5; p=0.007) and incomplete pedal presses (1.5 vs 8.5; p=0.002). The number of incorrect pedal presses decreased with illumination, but this did not reach statistical significance (0 vs 0.5; p=0.08). Participants reported that illumination simplified pedal activation and recommended its use (p<0.01). Conclusion: Color-coded illumination improved the speed and efficiency of foot pedal activation during simulated PCNL. Participants subjectively preferred using illuminated foot pedals for endourologic procedures and felt that they improved safety and efficiency.