INTRODUCTION:Radiation induced urethral stenosis disease represents a complex subset of patients with higher rates of recurrence after treatment. Optilume®, a Paclitaxel drug-coated balloon, has been utilized in anterior urethral strictures with promising results. Although urethroplasty is traditionally regarded as the gold standard for treating radiation-induced posterior urethral stenosis, it can be an invasive and challenging procedure with potential side effects. We aim to evaluate the efficacy of the Optilume® drug-coated balloon as a minimally invasive treatment option for radiation-induced posterior urethral stenosis. METHODS:A retrospective, multi-institutional review was conducted on male patients who underwent Optilume® drug-coated balloon dilation from January 1, 2022, to November 1, 2023. The study involved five surgeons across four institutions. Patients were investigated based on their history of radiation-induced posterior urethral stenosis, and comparisons were made regarding demographics, characteristics of urethral stenosis, and outcomes, including surgical success and complications. RESULTS:Among the 56 patients with radiation-induced posterior urethral stenosis evaluated across all four institutions, 37 men had at least 90-day follow-up data. Of these 37 patients, 30 (81.1%) were deemed successful, defined as being free from repeat intervention. Although 6 patients (10.7%) experienced complications, none were greater than Clavien IIIb, with the most common complication being acute urinary retention. CONCLUSION:Although radiation-induced urethral stenosis is typically associated with high rates of recurrence following conservative treatment, Optilume® drug-coated balloon represents an alternative endoscopic treatment option with encouraging short-term results.

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: The artificial urinary sphincter (AUS) has been used to treat post-prostatectomy incontinence in men for decades with excellent outcomes and low complication rates. A successful AUS placement can dramatically improve the quality of life in men with stress urinary incontinence. Consequently, complications in this population can be devastating for the patient. One of the most troublesome complications is cuff erosion, which necessitates explantation of the device and dooms a man to recurrent incontinence. While the device can be replaced, device replacements are fraught with high erosion rates. Furthermore, it is not uncommon for men undergoing AUS placement to have multiple medical comorbidities that make urgent surgery for explantation unideal. Nonetheless, men with cellulitis and significant symptoms must undergo removal of an eroded AUS. There is little to no literature published on the timing or need for device removal in the man who has an asymptomatic erosion. Case Description: We report a case series of five men undergoing delayed or no explantation of an asymptomatic cuff erosion. All five men were asymptomatic at the time of presentation and underwent a delayed explant or no explant. No man required urgent device explant while the erosion was present. Conclusions: Urgent device explantation may not be necessary in the asymptomatic AUS cuff erosion, and further study may be able to elucidate men who can avoid removal of cuff erosion when no symptoms are present.

Abstract Introduction Management of malfunctioning inflatable penile prostheses (IPPs) is varied, with some patients undergoing complete exchange of the entire device and others undergoing exchange of non-functioning components only. The impact of partial component exchange versus complete device exchange on infectious and non-infectious complications is unknown. Objective To describe the infectious and non-infectious complications in men undergoing IPP revision with partial and complete component exchange for device malfunction. Methods We performed a multicenter retrospective cohort study of patients who underwent IPP revision. Men undergoing procedures for implant infection were excluded. Patients were divided into two groups based on whether they had complete exchange of the entire device or partial exchange of only one or two components (i.e. pump revision only, or pump and/or reservoir exchanged but cylinders left in situ). Differences between baseline demographics were assessed with two tailed student t-tests and Fisher’s exact tests. Time to revision was log transformed to reduce deviation from normality. Multivariate analysis was performed controlling for significant covariates and clinically relevant variables. A descriptive analysis was performed of non-infectious complications. Results 466 men underwent IPP revision. Of these, 377 had complete exchange of the entire device and 89 had partial component exchange. Men undergoing partial exchange had a significantly higher infection rate (6.7% vs 2.1%, p=0.034). Although the partial exchange group was more likely to receive antifungals (52.8 vs 17.8%, p<0.001) and have a modified salvage washout (78.4 vs 61.2%, p=0.003), this cohort was less likely to receive vancomycin and gentamicin for antimicrobial prophylaxis (60.7 vs 81.7%, p<0.001). Time to revision from original implantation was significantly shorter in the partial exchange group (46 vs 168 months, p<0.001). In multivariate analysis, partial exchange surgery (OR 2.6, 95%CI 0.7-9.5, p=0.15), vancomycin and gentamicin antimicrobial prophylaxis (OR 0.4, 95%CI 0.1-1.5, p=0.20), modified salvage washout (OR 1.6, 95%CI 0.3-8.4, p=0.54), and antifungal prophylaxis (OR 2.7, 95%CI 0.7-10.3, p=0.13) were no longer associated with postoperative infections. The partial exchange group had greater rates of mechanical complications (20.2% vs 10.6%, p=0.019) such as pump malfunction and tubing breakage. Conclusions While patients undergoing partial component revision were more likely to receive non-standard antibiotics, antifungal prophylaxis, and undergo a modified salvage washout, they had more infectious and mechanical/non-infectious complications. These findings suggest that partial component exchange increases the risks in men undergoing IPP revision for non-infectious indications. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, Antares Pharma, Clarus Therapeutics, Cynosure, Promescent, Sprout, Viome

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 ...

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 ...

You have accessJournal of UrologyCME1 Apr 2023MP71-16 RETROSPECTIVE MULTICENTER OBSERVATIONAL STUDY OF IMMEDIATE VOIDING AT END OF CONTINENCE SURGERY [REMOVE] Thomas Kozar, John Michael Kaylor, Cynthia Hinderscheid, Jamee Schoephoerster, Albert Holler, Edward Wright, Joseph Pariser, William Boysen, Lucas Wiegand, Patrick Selph, and Andrew Cohen Thomas KozarThomas Kozar More articles by this author , John Michael KaylorJohn Michael Kaylor More articles by this author , Cynthia HinderscheidCynthia Hinderscheid More articles by this author , Jamee SchoephoersterJamee Schoephoerster More articles by this author , Albert HollerAlbert Holler More articles by this author , Edward WrightEdward Wright More articles by this author , Joseph PariserJoseph Pariser More articles by this author , William BoysenWilliam Boysen More articles by this author , Lucas WiegandLucas Wiegand More articles by this author , Patrick SelphPatrick Selph More articles by this author , and Andrew CohenAndrew Cohen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003339.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Placement of an artificial urethral sphincter (AUS) for stress urinary incontinence may result in postoperative urinary retention. Therefore, patients often remain catheterized for a 23-hour period, despite a lack of evidence to support this practice. Our study aims to evaluate the feasibility of outpatient, catheter-free continence surgery using a multi-institutional database. We hypothesize that between catheterized controls and patients without a catheter, there would be no difference in rate of urinary retention or post-operative complications. METHODS: We conducted an IRB-approved retrospective review of patients undergoing first-time AUS placement from 2009-2021. Patients were stratified by postoperative catheter status into either immediate decatheterization — leaving the procedure without a catheter — or controls — placement of an indwelling catheter for 23 hours. Data were collected on demographic and surgical variables from five institutions. The primary outcome, urinary retention, was defined as catheterization due to subjective voiding difficulty or documented PVR over 250 mL. Analyses were performed using STATA with p<0.05 considered significant. RESULTS: Our study identified 302 controls and 123 immediate decatheterization. Twenty (6.6%) historic controls and nine (7.3%) immediate decatheterization patients developed urinary retention requiring short term catheterization (p=0.80). The immediate decatheterization cohort had a higher rate of complication (19.2% vs 33.3%), but there was no difference in the rate of urinary tract infections (UTI) (2.6% vs 2.4%, p=0.90), surgical site infections (SSI) (1.3% vs 2.4%, p=0.41), or device erosions between groups (1.7% vs 0.8%, p=0.51). Kaplan-Meier survival analysis revealed no significant difference in the rate of revision surgery (Figure 1). CONCLUSIONS: In our cohort, there was no difference in urinary retention, device erosion, UTI, and SSI rates between immediate intraoperative catheter removal and those catheterized for 23 hours. Early decatheterization enables outpatient incontinence surgery without altering reoperation over medium-term follow up. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1021 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas Kozar More articles by this author John Michael Kaylor More articles by this author Cynthia Hinderscheid More articles by this author Jamee Schoephoerster More articles by this author Albert Holler More articles by this author Edward Wright More articles by this author Joseph Pariser More articles by this author William Boysen More articles by this author Lucas Wiegand More articles by this author Patrick Selph More articles by this author Andrew Cohen More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023PD42-02 PARTIAL COMPONENT EXCHANGE OF A NON-INFECTED IPP IS ASSOCIATED WITH A HIGHER COMPLICATION RATE David Barham, Muhammed Hammad, Edward Choi, Daniel Swerdloff, Brittany Berk, Eric Chung, Jonathan Clavell-Hernandez, Martin Gross, Tung-Chin Hsieh, James Jones, Martin Kathrins, Aaron Lentz, Patrick Selph, Jay Simhan, Robert Welliver, and Faysal Yafi David BarhamDavid Barham More articles by this author , Muhammed HammadMuhammed Hammad More articles by this author , Edward ChoiEdward Choi More articles by this author , Daniel SwerdloffDaniel Swerdloff More articles by this author , Brittany BerkBrittany Berk More articles by this author , Eric ChungEric Chung More articles by this author , Jonathan Clavell-HernandezJonathan Clavell-Hernandez More articles by this author , Martin GrossMartin Gross More articles by this author , Tung-Chin HsiehTung-Chin Hsieh More articles by this author , James JonesJames Jones More articles by this author , Martin KathrinsMartin Kathrins More articles by this author , Aaron LentzAaron Lentz More articles by this author , Patrick SelphPatrick Selph More articles by this author , Jay SimhanJay Simhan More articles by this author , Robert WelliverRobert Welliver More articles by this author , and Faysal YafiFaysal Yafi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003352.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Management of malfunctioning inflatable penile prostheses (IPPs) is varied. The impact of partial component exchange versus complete device exchange on complications is unknown. We sought to describe the infectious and non-infectious complications in men undergoing IPP revision with partial and complete component exchange for device malfunction. METHODS: We performed a multicenter retrospective cohort study of patients who underwent IPP revision. Men undergoing procedures for implant infection were excluded. Patients were divided into two groups based on whether they had complete exchange of the entire device or partial exchange of only one or two components (i.e. pump revision only, or pump and reservoir exchanged but cylinders left in situ). Differences between baseline demographics were assessed with two tailed student t-tests and Fisher’s exact tests. Multivariable analysis was performed controlling for significant covariates and clinically relevant variables. A descriptive analysis was performed of non-infectious complications. RESULTS: 453 men underwent IPP revision. 368 had complete exchange of the entire device and 85 had partial component exchange. Men undergoing partial exchange had a significantly higher infection rate (7.1% vs 2.2%, p=0.031). The partial exchange group also was more likely to receive antifungals (51.8 vs 16.8%, p<0.001), have a modified salvage washout (77.4 vs 60.2%, p=0.004), and less likely to receive vancomycin and gentamicin (63.5 vs 83.7%, p<0.001). Time to revision was significantly shorter in the partial exchange group (44.9 vs 168.2 months, p<0.001). In multivariable analysis, partial exchange surgery (OR 2.6, 95% CI 0.7-9.3, p=0.17), vancomycin and gentamicin prophylaxis (OR 0.3, 95% CI 0.1-1.2, p=0.11), modified salvage washout (OR 1.8, 95% CI 0.3-9.2, p=0.48), and antifungal prophylaxis (OR 2.7, 95% CI 0.7-10.3, p=0.13) were no longer associated with postoperative infections. The partial exchange group had greater rates of non-infectious complications (21.2% vs 9.5%, p=0.005) such as pump malfunction and tubing breakage. CONCLUSIONS: While patients undergoing partial component revision were more likely to receive non-standard antibiotics, antifungal prophylaxis, and undergo a modified salvage washout, they had more infectious and mechanical/non-infectious complications. These findings suggest that partial component exchange increases risks in men undergoing IPP revision for non-infectious indications. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1111 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information David Barham More articles by this author Muhammed Hammad More articles by this author Edward Choi More articles by this author Daniel Swerdloff More articles by this author Brittany Berk More articles by this author Eric Chung More articles by this author Jonathan Clavell-Hernandez More articles by this author Martin Gross More articles by this author Tung-Chin Hsieh More articles by this author James Jones More articles by this author Martin Kathrins More articles by this author Aaron Lentz More articles by this author Patrick Selph More articles by this author Jay Simhan More articles by this author Robert Welliver More articles by this author Faysal Yafi More articles by this author Expand All Advertisement PDF downloadLoading ...

Purpose: Patients may remain catheterized after artificial urinary sphincter surgery to prevent urinary retention, despite a lack of evidence to support this practice. Our study aims to evaluate the feasibility of outpatient, catheter-free continence surgery using a multi-institutional database. We hypothesize that between catheterized controls and patients without a catheter, there would be no difference in the rate of urinary retention or postoperative complications.Materials and Methods: We conducted a retrospective review of patients undergoing first-time artificial urinary sphincter placement from 2009-2021. Patients were stratified by postoperative catheter status into either no-catheter (leaving the procedure without a catheter) or catheter (postoperative indwelling catheter for similar to 24 hours). The primary outcome, urinary retention, was defined as catheterization due to subjective voiding difficulty or documented postvoid residual over 250 mL. Results: Our study identified 302 catheter and 123 no-catheter patients. Twenty (6.6%) catheter and 9 (7.3%) no-catheter patients developed urinary retention (P = .8). On multivariable analysis, controlling for age, cuff size, radiation history and surgeon, there was no statistically significant association between omitting a catheter and urinary retention (OR: 0.45, 95% CI: 0.13-1.58; P = .2). Furthermore, at 30 months follow-up, Kaplan-Meier survival analysis revealed that device survival was 70% (95% CI: 62%-76%) vs 69% (95% CI: 48%-82%) for the catheter and no-catheter group, respectively. Conclusions: In our multi-institutional cohort, overall retention rates were low (7%) in groups with a catheter and without. Obviating postoperative catheterization facilitates outpatient incontinence surgery without altering reoperation over medium-term follow-up.

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 determine the role of race in surgical outcomes of and complications after urethroplasty.METHODS A single institution, retrospective review was conducted from 2011 to 2019 on male patients >= 18 years of age who underwent urethroplasty. Exclusion criteria included previous urethral cancer, lack of follow up, or revision urethroplasty. Failure of urethroplasty was defined as requiring revision surgery or recurrence on imaging or cystoscopy. Risk factors for recurrence were determined using descriptive statistics, Wilcoxon comparisons, and multivariate logistic regression.RESULTS Three hundred and seven patients were identified with 234 patients meeting inclusion criteria. 63.2% identified as White/Caucasian (CA), 32.5% Black/African American (AA), and 4.3% other race. Mean age was 49.4 years. Between CA and AA patients, there was no difference in mean age, body mass index, smoking status, prior urethroplasty, or prior dilation/DVIU. CAs were more likely to have a fossa navicularis stricture compared to AAs (P = .0094), but there were no significant differences in bulbar, penile, or posterior stricture rates (all P >.05) or length (P = .32). The overall stricture recurrence rate was 15.8% with a median of 242 days to recurrence and no significant difference by race for either outcome (P = .83, P = .64). The only predictor of stricture recurrence was prior dilation/DVIU (P = .0404, OR 2.3, 95% CI 1.0, 5.6). Overall complication rate was 17.5%, with no difference between CA and AAs rates (P = .83) or complication type (P = .62).CONCLUSION There was no significant difference in the rate of surgical failure for urethral stricture repair based on race. The only predictor of surgical failure was having a prior urethral dilation/DVIU. UROLOGY 163: 69-75, 2022. (c) 2021 Elsevier Inc.

Objective To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury. Methods Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score. Results There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (P < 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (P < 0.001). Conclusion In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed.

You have accessJournal of UrologyCME1 May 2022V04-01 TRANSANAL APPROACH TO ROBOTIC REPAIR OF A RECTOURETHRAL FISTULA Jennifer Rosen, J. Patrick Selph, and Daniel Chu Jennifer RosenJennifer Rosen More articles by this author , J. Patrick SelphJ. Patrick Selph More articles by this author , and Daniel ChuDaniel Chu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002560.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Our case is that of a 62 year old male who underwent a robotic assisted laparoscopic prostatectomy complicated intraoperatively by a rectal injury. This injury was recognized at the time and repaired. However, he presented 1 week post op after catheter removal with leakage of urine per rectum. A CT scan confirmed a fistula to his rectum, thus an indwelling foley was placed and a diverting colostomy was performed by colorectal surgery. The patient presented to our clinic at 3 months post op to discuss definitive repair of his rectourethral fistula. METHODS: The attached video highlights our experience with a transanal approach to robotic repair of a rectourethral fistula. RESULTS: The patient was discharged home on post op day 1 with the catheter in place. At his 4 week follow up, his vcug was negative for leak and his catheter was removed. He follow up with colorectal surgery at 3 months, and barium enema at that time was negative for stricture or leak and he is currently awaiting ostomy reversal. CONCLUSIONS: In this video, we demonstrate the feasibility of an incisionless transanal approach to repairing a rectourethral fistula using the multiport robot. Our approach is similar to a york-mason repair, but the use of the transanal port and robotic technology eliminate the need for any incision through the rectal sphincter. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e367 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jennifer Rosen More articles by this author J. Patrick Selph More articles by this author Daniel Chu More articles by this author Expand All Advertisement PDF DownloadLoading ...

Pelvic radiotherapy for the treatment of malignancy is known to cause unintended urinary toxicity including urinary retention and urethral stricture disease (USD). In the treatment of prostate cancer with radiotherapy, the reported rate of USD is between 1.7–5.2% while urinary toxicity has been reported in as high as 16% of patients that undergo radiotherapy for the treatment of rectal cancer. The purpose of this review article is to evaluate literature regarding the role of pelvic radiotherapy in causing urinary retention and to discuss the unique treatment considerations for urinary retention in the irradiated man ranging from urinary catheter placement to transurethral dilation (UD) to open surgical repair.

ABSTRACT Introduction Extratunical grafting is a surgical option for men with Peyronie's disease who have an hourglass deformity or indentation defect. Rather than necessitating neurovascular bundle elevation and tunical incision, the procedure can be done without mobilization of the bundle. This benefit limits the risk of de novo erectile dysfunction and glans hypoesthesia. Here we present a case of a penile plication combined with extratunical grafting for a man with dorsal curvature and a right sided indentation defect. Objective To present a video presentation of extratunical grafting during penile plication for Peyronie's disease Methods An artificial erection is done to confirm the location and extent of the penile deformity and curvature. A midline ventral penile incision is made and carried down to the tunica albunigea as is standard for a penile plication. A penile plication is performed with 2-0 polyester suture to correct the dorsal curvature. At the site of the indentation defect, a pericardium allograft is doubly-folded on itself and sewn to the tunica albuginea. The indentation repair is demonstrated, and the surgical site is closed. Results The patient reports high satisfaction with the indentation correction and improvement in dorsal curvature with no new erectile dysfunction or hypoesthesia. Conclusions Extratunical grafting is a viable, straightforward option for men with Peyronie's disease and indentation defects or an hourglass deformity that can be combined with penile plication to treat symptomatic men. Disclosure No

ABSTRACT Introduction Contemporary management of inflatable penile prosthesis (IPP) infections involves removal and replacement to minimize corporal fibrosis and penile shortening. Many urologists prefer a malleable prosthesis (MP) followed by staged conversion to IPP, a technique thought to improve outcomes by allowing treatment of the infection while maintaining intracorporeal volume. A staged procedure involves additional surgery with associated risks. Previous studies suggest an 18% infection risk of placing a second device in a non-infected, revision setting, and that infection risk increases with each subsequent procedure. Objective Our study aims to delineate whether immediate IPP salvage in an infected field yields similar complication rates to the staged approach. Methods Retrospective review at 5 different institutions from February 2010 to October 2020 identified patients with IPP infection who underwent IPP salvage. Patient demographic, laboratory, operative, and microbiology data were collected. Emphasis was placed on the salvage operative technique, duration of antibiotics, and post-salvage complications. Results Overall, 19 patients underwent immediate salvage with IPP in the setting of a suspected infection. Average age at initial implantation was 59.9 years. Median time from initial implant to presentation with infectious symptoms was 2.4 months, and revision was performed a median of 1.5 days after presentation and initiation of antibiotics. Intraoperative complications were rare (5.3%), and post-salvage complications were 21.1%, including 1 cylinder herniation and 3 post salvage infections (15.8%). Only 1 post-salvage infection showed concordance with initial cultures while 1 was discordant and the third showed no growth (Table 1). Fisher's exact test showed diabetes, purulence in the operative field, use of drain, or washout type were not associated with infection post-salvage. Conclusions Immediate IPP salvage in the setting of an acutely infected field shows a complication profile not exceeding published data in the staged revision setting. Although staged MP-IPP salvage has been favored by many surgeons, the complication profile may be equivalent to immediate IPP salvage, and the risks of a subsequent operation should be considered. Disclosure No

OBJECTIVE To retrospectively evaluate enhanced recovery after surgery (ERAS) protocol administration, hospital length of stay, 30-day readmission, and complication rates among cystectomy and/or urinary diversion patients with benign or malignant indication. MATERIALS AND METHODS Data was extracted retrospectively for cystectomy and/or urinary diversion performed at our institution from June 2016 to May 2019. Descriptive statistics, Chi squared, Wilcoxon rank-sum, binary logistic regression, and linear regression functions in R 4.0.4 (R Foundation), R Package "Tidverse" V1.3.0.9, and RStudio V1.44.1106 (RStudio, PBC) were used to analyze data. RESULTS 102 patients met selection criteria with 36 and 66 patients in the benign and malignant indication cohorts, respectively. Significant differences between cohorts included BMI, age, opioid exposure, and spinal anomalies. The malignant cohort had higher ERAS completion rates for preoperative and intraoperative protocols (41% and 53% vs 14% and 19%). The mean ERAS item administration for benign and malignant indication patients differed significantly (2.9 vs 4.2, P < 0.01). Logistic regression demonstrated benign indication was significantly associated with ERAS failure (OR 4.25, 95% CI 1.18 - 21.03, P = 0.043). Higher ERAS item administration sum was associated with shorter hospitalizations and lower complication rates (P = < 0.01, P = 0.019). No association was observed for 30-day readmission. CONCLUSION The benign urinary diversion/cystectomy population more frequently possesses characteristics adverse to ERAS protocol completion and in our study received fewer ERAS protocol items. This was associated with longer hospitalizations and higher postoperative complication rates. Population-specific ERAS protocols targeted at increasing ERAS completion could reduce morbidity. (c) 2021 Elsevier Inc.

BACKGROUND:Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI. METHODS:Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction. RESULTS:There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784). CONCLUSION:In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter. LEVEL OF EVIDENCE:Therapeutic/Care Management; Level III.