INTRODUCTION:There is no standardized post-operative surveillance for upper tract reconstruction, with frequent use of nuclear medicine renal scans (NMRS). We propose a protocol utilizing renal ultrasonography (RUS) as the initial assessment tool, reserving secondary studies to evaluate patients with worse hydronephrosis or persistent symptoms. METHODS:Retrospective analysis of a prospectively designed imaging protocol at a single-institution, 2016-2022. The protocol uses screening RUS at 3 and 12 months, with NMRS or ureteroscopy (URS) as clinically indicated. Diagnostic accuracy of 3-month RUS was assessed with 95% confidence intervals. RESULTS:136 patients underwent ureteral reconstruction, accounting for 144 reconstructive procedures. Primary success rate was 91.9%, increasing to 94.1% after revision surgery. Among 110 renal units with paired baseline and 3-month RUS, hydronephrosis was improved in 65.5%, stable in 31.8%, and worse in 2.7%. Eleven patients required reintervention. Based on clinical suspicion and/or worsening imaging, 27 patients (19.9%) underwent NMRS and 18 underwent URS. Three-month RUS was highly specific (98.1%) for subsequent reintervention, and 102/107 renal units (95.3%) with stable/improved hydronephrosis required no intervention. Five of the six reinterventions among imaged units followed reassuring ultrasound and were identified by symptom-directed evaluation. CONCLUSIONS:RUS with clinical monitoring is an effective modality for post-operative surveillance following ureteral reconstruction, allowing more than 80% of patients to avoid NMRS. Stable or improved hydronephrosis reliably identified patients requiring no further intervention, while most failures were detected through symptoms rather than imaging alone. Nuclear scans and ureteroscopy should be reserved for patients with symptoms or imaging suggestive of obstruction.

You have accessJournal of UrologyReconstruction: Ureteral Reconstruction (Including Pyeloplasty) and Bladder Reconstruction (Including Trauma-Related Fistula) I (MP48)1 May 2024MP48-05 DEGREE OF HYDRONEPHROSIS AFTER UPPER TRACT RECONSTRUCTION PREDICTS NEED FOR REINTERVENTION Benjamin Cedars, Nishant Garg, Aaron Scheffler, Kian Ahmadieh, Dhruv Prui, Michael Witthaus, Eric Cho, Sunchin Kim, Thomas Fuller, and Jill Buckley Benjamin CedarsBenjamin Cedars , Nishant GargNishant Garg , Aaron SchefflerAaron Scheffler , Kian AhmadiehKian Ahmadieh , Dhruv PruiDhruv Prui , Michael WitthausMichael Witthaus , Eric ChoEric Cho , Sunchin KimSunchin Kim , Thomas FullerThomas Fuller , and Jill BuckleyJill Buckley View All Author Informationhttps://doi.org/10.1097/01.JU.0001009512.15743.d7.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nuclear medicine scans are commonly obtained within the first year after upper tract reconstruction to evaluate for resolution of obstruction. Renal ultrasound may suffice as a screening surveillance study to mitigate costs and risks of functional imaging when clinical suspicion for failure is low. We hypothesize that less severe hydronephrosis on post-operative imaging will have a lower risk of repeat intervention compared to worse severity. METHODS: We conducted a retrospective analysis of an institutional database on upper tract reconstructive surgery. Clinical variables were abstracted from the EMR. SFU grades (0,1,2,3,4) were assigned for degree of hydronephrosis. Patients with<1 year follow-up or aborted procedures were excluded. We utilized STATA (StataCorp. 2023. Stata Statistical Software: Release 18. College Station, TX: StataCorp LLC) to perform logistic regression with raw SFU scores for pre-operative and 3- and 12-month post-operative hydronephrosis. RESULTS: There were 144 operations performed in 136 patients. There were 12 repeat interventions: 1 stent, 4 percutaneous nephrostomy tubes, and 7 reconstructive operations or nephrectomies. Only 1 patient with improvement on ultrasound at 3 months ultimately required repeat intervention. Seventeen patients demonstrated continued improvement from 3 to 12 months compared to two were worse, one of whom underwent repeat reconstruction. Prior to surgery, a one unit increase in SFU grade was associated with a 1.38 times greater odds (p=0.342, 95 % CI: [0.71, 2.70]) of repeated intervention. At 3 months following surgery, a one unit increase in SFU grade was associated with a 1.91 times greater odds (p=0.030, 95 % CI: [1.07, 3.42]) of repeated intervention. At 12 months following surgery, a one unit increase in SFU grade was associated with a 2.81 times greater odds (p=0.010, 95 % CI: [1.29, 6.16]) of repeated intervention. CONCLUSIONS: Patients with high post-operative SFU grades are at greater risk for reintervention. Severity of hydronephrosis post-operatively may be associated with need for repeat procedure; this association gets stronger from 3 to 12 months after reconstructive surgery. All but one patient with initial improvement continued to do well and did not require another intervention, suggesting ultrasound can help identify potential failures while avoiding unnecessary testing. Further studies will evaluate influence of symptoms and renal function. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e773 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Benjamin Cedars More articles by this author Nishant Garg More articles by this author Aaron Scheffler More articles by this author Kian Ahmadieh More articles by this author Dhruv Prui More articles by this author Michael Witthaus More articles by this author Eric Cho More articles by this author Sunchin Kim More articles by this author Thomas Fuller More articles by this author Jill Buckley More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023MP07-18 EFFECT OF COVID-19 PANDEMIC ON FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY FELLOWSHIP CASE LOGS: ANALYSIS OF THE ACCREDITATION COUNCIL OF GRADUATE MEDICAL EDUCATION NATIONAL DATA REPORTS Adam Daily, Shreeya Patel, Hannah Koenig, Thomas Fuller, and Una Lee Adam DailyAdam Daily More articles by this author , Shreeya PatelShreeya Patel More articles by this author , Hannah KoenigHannah Koenig More articles by this author , Thomas FullerThomas Fuller More articles by this author , and Una LeeUna Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Given widespread disruptions to healthcare during the COVID-19 pandemic, the objective was to assess the national case logs of graduating Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellows for effects on surgical volume. METHODS: The nationally aggregated Accreditation Council for Graduate Medical Education case logs were obtained for graduating FPMRS fellows, both urology and obstetrics and gynecology (OBGYN), for available academic years (AYs) 2018-2019, 2019-2020, and 2020-2021. Standard deviation was derived from percentile data. Case volume differences for tracked index category averages were compared between AYs with one-way analysis of variance. RESULTS: Graduating fellows logged an average of 517.4 (SD 28.6) and 818.0 (SD 37.9) cases, for urology and OBGYN respectively, over their fellowship training during the examined period. Total surgical procedures were not statistically different between pre-COVID AY 2018-2019 and COVID-affected AYs 2019-2020 and 2020-2021 for either specialty. For urology fellows, the only index case category with a statistically significant difference was a decrease in AY 2020-2021 compared to 2019-2020 in GI procedures (8.9 vs 4.2, p=0.04). Reclassification of mesh removal cases to genital procedures in 2020-2021 resulted in a statistical decrease for both specialties of graft/mesh augmentation prolapse cases for that same AY. There were no other statistically significant differences between AYs for OBGYN fellows. CONCLUSIONS: Compared to pre-pandemic case volumes, FPMRS urology and FPMRS OBGYN graduating fellow surgical volume remained stable. Both total surgical procedures and index case categories showed no statistically significant difference between pre-COVID and COVID-affected years. Despite nationwide disruptions in health care, FPMRS trainee case volumes remained consistent. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e92 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adam Daily More articles by this author Shreeya Patel More articles by this author Hannah Koenig More articles by this author Thomas Fuller More articles by this author Una Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023MP42-07 RENAL ULTRASOUND FOR POST-UPPER TRACT RECONSTRUCTION SURVEILLANCE: SAFE AND EFFECTIVE ALTERNATIVE Benjamin Cedars, Michael Witthaus, Eric Cho, Sunchin Kim, Thomas Fuller, and Jill Buckley Benjamin CedarsBenjamin Cedars More articles by this author , Michael WitthausMichael Witthaus More articles by this author , Eric ChoEric Cho More articles by this author , Sunchin KimSunchin Kim More articles by this author , Thomas FullerThomas Fuller More articles by this author , and Jill BuckleyJill Buckley More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Upper tract obstruction can present with flank pain, infections, hematuria, and impaired kidney function. The gold standard for evaluation of obstruction is a MAG3 nuclear renal scan. There is no consensus however on optimal post-operative imaging surveillance strategy. Studies have demonstrated that renal ultrasound (US) may be an effective substitute modality that is quick, easily accessible, low cost, and avoids risks of invasiveness, radiation exposure, and infection. To our knowledge, prior studies collected both US and MAG3 to compare effectiveness. This is the first data of real world surveillance of post-upper tract reconstruction with US. METHODS: Retrospective analysis of an institutional database on reconstructive urologic surgery. Clinical variables were collected through electronic medical record review. Descriptive statistics were used to assess presence of and change in preoperative hydronephrosis, need for MAG3, obstruction, and reintervention. RESULTS: 161 patients underwent upper tract reconstruction over a 6 year period. There was missing data for 29 patients. Overall, success defined by no obstruction on MAG3 was 96%. Pre-op, 3 patients (1.8%) had SFU 0, 19 (12%) SFU 1, 55 (34%) SFU 2, 58 (36%) SFU 3, 28 (17%) SFU 4, 5 (3.1%) had missing data, and 2 (1.2%) had a fistula. First imaging was obtained after surgery at a median (IQR) of 126.5 days (84-154). Post-op, 78 patients (48%) had improved hydronephrosis, 34 (21%) were stable, 2 (1.2%) were worse, and 47 (29%) had missing data. Of the 21 patients who underwent MAG3 studies, 6 (29%) had improved hydronephrosis, 7 (33%) were stable, 2 (10%) were worse. Only 2 patients were obstructed on MAG3. Two patients underwent stenting, 2 had PCN, and 1 had reconstructive surgery. Not all interventions were failures (i.e., placed for an infection). CONCLUSIONS: Renal US is a safe and effective tool for surveillance after upper tract reconstruction. The majority of our patients avoided a MAG3 study, which may influence future practice patterns. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e568 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benjamin Cedars More articles by this author Michael Witthaus More articles by this author Eric Cho More articles by this author Sunchin Kim More articles by this author Thomas Fuller More articles by this author Jill Buckley More articles by this author Expand All Advertisement PDF downloadLoading ...

ObjectiveTo assess the national case logs of the first graduating urologic resident cohorts to have trained during the COVID-19 pandemic for effects on surgical volumes.MethodsThe nationally aggregated Accreditation Council for Graduate Medical Education urology resident case logs were obtained for graduates of academic years (AYs) 2015-2016 through 2020-2021. Case volume differences for tracked index categories were compared between AYs with a 1-way analysis of variance. Data were then combined into pre-COVID and COVID-affected resident cohorts and differences in average cases logged were analyzed with 2-tailed student's t-tests.ResultsGraduating urology residents logged an average of 1322 (SD 24.8) cases over their residency during the examined period. Total cases had multiple statistical differences between AYs but the only index category with a statistically significant decrease for a COVID-affected AY compared to pre-COVID AY was pediatric majors: AY 2020-2021 logged fewer cases than AY 2015-2016 (53.9 vs 63.0, P = .004) and AY 2018-2019 (53.9 vs 61.2, P = .04). When aggregated into pre- and COVID-affected cohorts, both pediatric minor (123.4 vs 117.5, P = .049) and pediatric major (61.4 vs 56.8, P = .003) case averages decreased for the COVID-affected cohort of residents, but no adult index category decreased.ConclusionNational graduating urology resident surgical volume for adult index categories was maintained through the pandemic. Pediatric cases saw a statistical decrease in volume of questionable clinical significance. This does not eliminate concern that individuals may have experienced a detrimental impact on their resident education.

It is generally accepted that robotic ureteral reconstruction provides equivalent results to open and laparoscopic approaches while decreasing pain and length of stay. There is a rapid expansion of robotic ureteral reconstructive techniques, platforms, and adjunctive technologies, enabling more efficient, safer, and novel surgical approaches that could not be done in the past. For instance, indocyanine green use allows rapid, precise location of ureteral stenosis and determination of tissue perfusion. Multi-image display allows the surgeon to integrate the robotic field and ureteroscopic images. Novel robotic surgical techniques, such as buccal mucosa ureteroplasty, are changing the treatment algorithm for ureteral strictures.

You have accessJournal of UrologyCME1 May 2022PD31-05 REPEATED TRANSURETHRAL INTERVENTIONS INCREASE ELASTIN DEGRADATION AND STRICTURE SEVERITY Michael Witthaus, Jathin Bandari, Thomas Will Fuller, Valmik Bhargava, Jill Buckley, and Mahadevan Rajasekaran Michael WitthausMichael Witthaus More articles by this author , Jathin BandariJathin Bandari More articles by this author , Thomas Will FullerThomas Will Fuller More articles by this author , Valmik BhargavaValmik Bhargava More articles by this author , Jill BuckleyJill Buckley More articles by this author , and Mahadevan RajasekaranMahadevan Rajasekaran More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002582.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Repeated transurethral interventions can cause or exacerbate urethral stricture disease by increasing tissue damage. A clear understanding of molecular mechanisms involved in increased fibrogenesis would enable development of optimal strategies to minimize progression or prevent stricture recurrence. Recently elastin, an extracellular matrix protein has been implicated in heart, liver and kidney fibrosis. We hypothesize repeated transurethral mechanical stretch accelerates elastin degradation and increases stricture severity. METHODS: Electrocautery was used to induce strictures in middle aged rabbits (12 months; n=6; Fig A). Rabbits (n=3) that showed evidence of stricture development at 14 days post-injury were further subjected to urethral wall stretch using a Foley catheter (balloon inflated to 14 mm diameter for 10 minutes, once a week for 4 weeks; Fig B). Animals were then allowed to recover and subjected to retrograde urethrogram (RUG) to confirm stricture progression and sacrificed at 45 days post-injury. Urethral tissues were harvested and subjected to immunostaining (Verhoeff–Van Gieson; VVG) for elastin. Results were then validated in human urethral scar tissues (n=3) obtained from patients undergoing urethroplasty. RESULTS: RUG findings are summarized in the Fig C. The RUGs performed showed a significant increase in stricture severity after balloon dilation (Fig C -bottom panel). The methodology utilized in the animal model was confirmed fluoroscopically to be replicable. VVG showed strong labeling for elastin (Fig E-F; black stain; yellow arrows) in rabbit and human (Fig G) scar tissues relative to controls (Fig D). CONCLUSIONS: Our findings confirm that this approach is a viable model to study transurethral intervention induced fibrogenesis. It further supports our hypothesis that urethral wall stretch worsens stricture severity due to elastin degradation. This may be an initiating factor in tissue remodeling after injury. Targeting elastin using an elastase may be a potential pharmacological intervention to treat or prevent stricture recurrence after transurethral interventions. Source of Funding: UCSD Academic Senate © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e542 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Witthaus More articles by this author Jathin Bandari More articles by this author Thomas Will Fuller More articles by this author Valmik Bhargava More articles by this author Jill Buckley More articles by this author Mahadevan Rajasekaran More articles by this author Expand All Advertisement PDF DownloadLoading ...

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.

INTRODUCTION:In an effort to decrease physician contribution to the opioid crisis, we utilized a narcotic free pathway (NFP) after urethroplasty. Our objectives were to demonstrate feasibility of a NFP and identify patients at higher risk for requiring postoperative narcotics.MATERIALS AND METHODS:We implemented a NFP for patients undergoing urethroplasty. Pain was assessed using the Likert scale (1-10). Narcotic use was quantified using oral morphine equivalents (OMEs).RESULTS:Forty-six patients underwent urethroplasty following the NFP over a 7-month period. Fifteen patients were excluded, leaving 31 patients in the final analysis. Postintervention data was compared to 30 patients who underwent urethroplasty prior to implementation of the NFP. The groups had similar demographics except for a history of heroin abuse (0% preintervention, 12.9% postintervention, p = 0.04). Surgical characteristics were not statistically different aside from length of surgery (183.6 minutes preintervention, 145.5 minutes postintervention, p = 0.01). The mean [SD] perioperative OME use preintervention was 194.9 [151] mg, compared to 40.4 [111.9] mg postintervention (p < 0.001). Six patients postintervention were discharged with a narcotic prescription (mean 27.5 mg OME) compared to 26 patients preintervention (mean 76 mg OME) (p < 0.001). There was no difference in pain scores at any time interval. Patients with a history of chronic opioid use were more likely to require narcotics (OR 5.33, CI 1-28.44).CONCLUSIONS:The narcotic free pathway resulted in a dramatic reduction in narcotic prescriptions without a significant difference in postoperative pain scores. Opioid use can be minimized following urethral and perineal surgery.

OBJECTIVE To demonstrate the feasibility and success of a robotic approach to reconstruction of ureterovesical anastomotic strictures in kidney transplants. MATERIALS AND METHODS Between November 2017 and December 2019, a total of 5 patients with transplant ureteral stricture were identified and treated with robot assisted laparoscopic repair. All patients were confirmed to have ureteral stricture with a preoperative antegrade nephrostogram through their nephrostomy tube and cystogram. The patients demographics, ureteral characteristics, type of procedure, and outcomes are reported. RESULTS All patients were diagnosed after evaluation for renal deterioration. The average age of the patients was 49 years old. The average stricture length was 2.5 cm, and the location was variable, though more commonly in the distal ureter. Three patients required a pyelo-vesicostomy, while 2 required a ureteroneocystostomy. The mean length of stay was 2.2 days. Average follow-up was 97 days, with all 5 patients having successful outcomes, no strictures or delayed leaks were identified. There were no wound infections or readmissions within 30 days. CONCLUSION Though a complex repair, the robot-assisted approach to transplant ureter reconstruction using either an end to side neoureterocystotomy or direct pyelo-vesicotomy is technically feasible and successful. Given the many advantages inherent in comparison to an open approach, the robotic repair offers significant advantages to both the patient and the surgeon who is experienced with robotic surgery and reconstructive principles. UROLOGY 144: 208-213, 2020. (c) 2020 Elsevier Inc.

PURPOSE:Risk factors for complications after artificial urinary sphincter surgery include a history of pelvic radiation and prior artificial urinary sphincter complication. The survival of a second artificial urinary sphincter in the setting of prior device complication and radiation is not well described. We report the survival of redo artificial urinary sphincter surgery and identify risk factors for repeat complications. MATERIALS AND METHODS:A multi-institutional database was queried for redo artificial urinary sphincter surgeries. The primary outcome was median survival of a second and third artificial urinary sphincter in radiated and nonradiated cases. A Cox proportional hazards survival analysis was performed to identify additional patient and surgery risk factors. RESULTS:Median time to explantation of the initial artificial urinary sphincter in radiated (150) and nonradiated (174) cases was 26.4 and 35.6 months, respectively (p=0.043). For a second device median time to explantation was 30.1 and 38.7 months (p=0.034) and for a third device it was 28.5 and 30.6 months (p=0.020), respectively. The 5-year revision-free survival for patients undergoing a second artificial urinary sphincter surgery with no risk factors, history of radiation, history of urethroplasty, and history of radiation and urethroplasty were 83.1%, 72.6%, 63.9% and 46%, respectively. CONCLUSIONS:Patients without additional risk factors undergoing second and third artificial urinary sphincter surgeries experience revision-free rates similar to those of their initial artificial urinary sphincter devices. Patients who have been treated with pelvic radiation have earlier artificial urinary sphincter complications. When multiple risk factors exist, revision-free rates decrease significantly.

OBJECTIVE:To describe the use of the robotic platform for proximal suture placement during perineal urethroplasty in the posterior and proximal anterior urethra. Repair of posterior urethral and proximal bulbar strictures requires deep perineal dissection, making visualization and accurate placement of sutures challenging. The robotic platform has demonstrated benefits in these characteristics in deep pelvic surgery.METHODS:We report a retrospective review of 10 patients who underwent robotic-assisted urethroplasty at a single institution by a single surgeon in a 1 year period. All patients underwent a standard perineal dissection with robotic-assisted placement of proximal sutures. Postoperative outcomes include urethroplasty leak rate as determined by voiding cystourethrograms, urethroplasty success rate, and perioperative complications.RESULTS:The mean age of this cohort was 43 years old (14-68). Average stricture length was 2.2 cm (1.5-3.0 cm) and most frequently in the bulbar urethra (5/10). Seven patients underwent nontransecting urethroplasties while 3 underwent transecting anastomotic repair. At postoperative voiding cystourethrograms, no patient had urinary extravasation. Average set-up time for the robotic portion of the surgery was 15 minutes with 30-45 minutes needed for suture placement.CONCLUSION:Robotic-assisted urethroplasty provides excellent visualization and ergonomics for posterior and proximal bulbar urethral reconstruction. This is particularly helpful in patients with narrow pelvic anatomy and long distances from the perineal skin to the proximal urethral edge. Operative and postoperative outcomes are comparable to the standard approach with improved surgeon comfort and visualization. Additional follow-up is required to assess long-term outcomes in comparison to a standard approach.

OBJECTIVE To determine the prevalence of penile cancer in patients with adult acquired buried penis (AABP). Penile cancer is a rare but aggressive cancer. Several case reports have recently been published that indicate that AABP may increase the risk of penile cancer. MATERIALS AND METHODS A retrospective review was conducted of adults diagnosed with AABP and penile cancer between January, 2008 and December, 2018 seen at a tertiary referral center. Demographics including age, BMI, comorbidities, etiology of AABP, smoking history, circumcision status, and premalignant lesions (condyloma, lichen sclerosus [LS] carcinoma in situ [CIS]) were recorded. For patients with penile cancer, AJCC staging, grade, TNM staging and treatments were recorded. Basic descriptive statistics were performed for the overall cohort. We used Chi-square tests and Fisher exact tests to compare differences between patients with benign pathology and patients with malignant or pre-malignant pathology. RESULTS We identified 150 patients with the diagnosis of AABP. The prevalence of penile squamous cell carcinoma was 7%. There was a 35% rate of premalignant lesions. This study is limited by its retrospective and single-institution nature. CONCLUSION AABP is a condition that incorporates multiple risk factors for penile cancer. The prevalence of penile cancer appears to be higher in patients with AABP; however, more data are needed to confirm these initial findings. Patients with AABP should be counseled on these risks and should be considered for buried penis repair if a physical examination cannot be performed. (C) 2019 Elsevier Inc.

To describe the epidemiology, pathogenesis, and management of vesicourethral anastomotic stenosis after prostate cancer treatment. Injectable scar modulating agents administered at the time of direct visual internal urethrotomy of vesicourethral anastomotic stenoses have been shown to improve endoscopic treatment outcomes. Trials are ongoing to find the optimal agent and delivery system. Novel tissue engineering techniques are in development and hold promise. Vesicourethral anastomotic stenosis after the treatment of prostate cancer is a challenging complication for patients and urologists. Stenoses are prone to recurrence after endourologic treatment. Open repair is technically demanding and carries substantial patient morbidity. The need for adjuvant or salvage radiation therapy after radical prostatectomy worsens outcomes of both endourologic and formal repairs. Postoperative worsening of urinary incontinence is common after vesicourethral anastomotic stenosis repair and can ultimately require placement of an artificial urinary sphincter or male sling. Occasionally urinary diversion, indwelling foley catheter, or clean intermittent catheterization is necessary when reconstructive options have been exhausted. Adjunctive measures to improve endourologic management such as hyperbaric oxygen and transurethral injection of anti-fibrotic agents have been an area of interest in recent years and show promise.

PURPOSE:To better characterize metabolic stone risk in patients with neurologically derived musculoskeletal deficiencies (NDMD) by determining how patient characteristics relate to renal calculus composition and 24-hour urine parameters.MATERIALS AND METHODS:We performed a retrospective cohort study of adult patients with neurologically derived musculoskeletal deficiencies presenting to our multidisciplinary Kidney Stone Clinic. Patients with a diagnosis of NDMD, at least one 24-hour urine collection, and one chemical stone analysis were included in the analysis. Calculi were classified as primarily metabolic or elevated pH. We assessed in clinical factors, demographics, and urine metabolites for differences between patients who formed primarily metabolic or elevated pH stones.RESULTS:Over a 16-year period, 100 patients with NDMD and nephrolithiasis were identified and 41 met inclusion criteria. Thirty percent (12 / 41) of patients had purely metabolic calculi. Patients with metabolic calculi were significantly more likely to be obese (median body mass index 30.3kg / m2 versus 25.9kg / m2), void spontaneously (75% vs. 6.9%), and have low urine volumes (100% vs. 69%). Patients who formed elevated pH stones were more likely to have positive preoperative urine cultures with urease splitting organisms (58.6% vs. 16.7%) and be hyperoxaluric and hypocitraturic on 24-hour urine analysis (37mg / day and 265mg / day versus 29mg / day and 523mg / day).CONCLUSIONS:Among patients with NDMD, metabolic factors may play a more significant role in renal calculus formation than previously believed. There is still a high incidence of carbonate apatite calculi, which could be attributed to bacteriuria. However, obesity, low urine volumes, hypocitraturia, and hyperoxaluria suggest an underrecognized metabolic contribution to stone formation in this population.

Purpose: To better characterize traumatic renal injury a revision to the 1989 American Association for the Surgery of Trauma renal injury scale was proposed in which grade IV includes all collecting system and segmental vascular injuries and grade V includes main renal hilar injury. We sought to validate the 2009 grading scale, emphasizing reclassifications between the 1989 and 2009 versions, and subsequent management. Materials and Methods: Patient demographics and renal injury characteristics, computerized tomography imaging, radiology reports and subsequent management were recorded in a prospective trauma database. Multivariable logistic regression models for intervention were compared using 1989 and 2009 grades to evaluate which grading scale better predicted management. Results: Of 256 renal injury cases 56 (21.9%) were reclassified using the revised 2009 scale, including 50 (19.5%) which were upgraded, 6 (2.3%) which were downgraded and 200 (78.1%) which were unchanged. Of grade III or higher cases management was nonoperative in 112 (78.9%), angioembolization in 9 (6.3%), nephrectomy in 9 (6.3%) and renorrhaphy in 12 (8.5%). Management was significantly associated with original and revised grades (chi-square p = 0.02 and <0.001, respectively). Further, the multivariable model using the 2009 grades significantly outperformed the 1989 model. Radiology reports rarely included renal injury scales. Conclusions: Using the revised renal injury grading scale led to more definitive classification of renal injury and a stronger association with renal trauma management. Applying the revised criteria may facilitate and improve the multidisciplinary care of renal trauma.

Electronic cigarette (EC) use is gaining popularity as a substitute for conventional smoking due to the perception and evidence it represents a safer alternative. In contrast to the common perception amongst users that ECs represent no risk initial studies have revealed a complex composition of e-cigarette liquids. Conventional cigarette smoking is a known risk factor for developing bladder cancer and prior reports raise concern some of those causative compounds may exist in EC liquids or vapor. Urine samples were collected from 13 e-cigarette using subjects and 10 non e-cigarette using controls. Five known bladder carcinogens that are either present in conventional cigarettes, products of combustion, or solvents believed to be used in some e-cigarette formulations were quantified by liquid chromatography – mass spectrometry (LC-MS). Analysis of e-cigarette user urine revealed the presence of two carcinogenic compounds, o-toluidine and 2-naphthylamine, at a mean 2.3 and 1.3 fold higher concentration (p-value of 0.0013 and 0.014 respectively). Many of these subjects (9/13) were long term nonsmokers (>12 months). Further study is needed to clarify the safety profile of e-cigarettes and their contribution to the development of bladder cancer given the greater concentration of carcinogenic aromatic amines in the urine of e-cigarette users.