Background: Localized prostate cancer (PCa) treatment is associated with reduced health-related quality of life (HRQoL). Current literature is limited by short-term follow-up. Objective: To prospectively evaluate the 5-yr HRQoL outcomes in men undergoing radical prostatectomy (RP), external beam radiotherapy (EBRT), or active surveil-lance (AS). Design, setting, and participants: We prospectively evaluated HRQoL in patients with low-risk/favorable intermediate-risk PCa enrolled in the Center for Prostate Disease Research multicenter database between 2007 and 2017. Intervention: Of 1012 patients included in the study, 252 (24.9%) underwent AS, 557 (55.0%) RP, and 203 (20.0%) EBRT. Patients complete the Expanded Prostate Cancer Index Composite and the 36-item Medical Outcomes Study Short Form at baseline and thereafter each year up to 5 yr after treatment. Outcome measurements and statistical analysis: Temporal changes in HRQoL were compared between treatments and were modeled using linear regression models adjusted for baseline HRQoL, demographic, and clinical characteristics. Results and limitations: RP showed the least irritative symptoms and worse inconti-nence in comparison with AS (p < 0.001 for both subdomains) or EBRT (p < 0.001 for both subdomains) at all time points. RP sexual domain score was worse than the scores of AS (mean difference 22.3 points, 95% confidence interval [CI] 10.5-27.8, p < 0.001) and EBRT (mean difference 16.9 points, 95% CI 12.5-20.3, p < 0.001) dur-ing years 1-3 and not different from that of EBRT (mean difference 2.9 points, 95% CI -4.8 to 8.3, p = 0.3) at years 4 and 5. Bowel function and bother were worse for EBRT than for AS (p < 0.001 for both subdomains) and RP (p < 0.001 for both subdomains) at all time points. During the 3-5-yr period, AS demonstrated the worst decline in all mental health domains (p < 0.001 in comparison with both EBRT and RP). Conclusions: RP results in worse long-term urinary function and incontinence, but in less irritative and obstructive symptoms than EBRT and AS. Sexual domain scores were least affected by AS, while RP shows similar scores to EBRT at long term. Long-term HRQoL changes are critical for advising patients. Patient summary: We evaluated long-term health-related quality of life (HRQoL) in a large US population treated for localized prostate cancer. HRQoL outcomes varied according to treatment modality and time. These changes should inform patients about their expected outcomes following treatment.(c) 2022 The Authors. Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creative-commons.org/licenses/by-nc-nd/4.0/).

You have accessJournal of UrologyCME1 May 2022MP43-20 LONG TERM HEALTH-RELATED QUALITY OF LIFE (HRQOL) OUTCOMES AFTER SURGERY, RADIOTHERAPY, OR ACTIVE SURVEILLANCE FOR LOCALIZED PROSTATE CANCER Eyal Kord, Nathan Jung, Jiji Jiang, Natasza Posielski, On Ho, Sally Elsamanoudi, Gregory T. Chesnut, Ryan Speir, Sean Stroup, John Musser, Alexander Ernest, Timothy Tausch, John Paul Flores, and Christopher Porter Eyal KordEyal Kord More articles by this author , Nathan JungNathan Jung More articles by this author , Jiji JiangJiji Jiang More articles by this author , Natasza PosielskiNatasza Posielski More articles by this author , On HoOn Ho More articles by this author , Sally ElsamanoudiSally Elsamanoudi More articles by this author , Gregory T. ChesnutGregory T. Chesnut More articles by this author , Ryan SpeirRyan Speir More articles by this author , Sean StroupSean Stroup More articles by this author , John MusserJohn Musser More articles by this author , Alexander ErnestAlexander Ernest More articles by this author , Timothy TauschTimothy Tausch More articles by this author , John Paul FloresJohn Paul Flores More articles by this author , and Christopher PorterChristopher Porter More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002609.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Treatment with curative intent for localized prostate cancer (PCa) is associated with a reduction in health-related quality of life (HRQoL). Current literature is limited by short-term follow up and homogenous populations. In this study we prospectively evaluated the 5-year HRQoL outcomes in men undergoing RP, EBRT or active surveillance (AS) in a racially diverse cohort. METHODS: The Center for Prostate Disease Research Multicenter Database was used to identify men with localized PCa diagnosed from 2007-2017. Expanded PCa Index Composite (EPIC) and 36 Item Short Form Health Survey (SF-36) were completed at baseline and yearly for 5 yrs. HRQoL outcomes were compared in RP, EBRT or AS using linear regression models, adjusting for baseline HRQoL, demographics, and clinical characteristics. RESULTS: Of the 1012 patients included in the study (mean age 61.6, 22.2% black), 252 (24.9%) underwent active surveillance (AS), 557 (55.0%) RP, and 203 (20.0%) EBRT. Low risk PCa was seen in 60.7% and intermediate risk in 39.3%. Mean follow up was 5.3 yrs. Urinary function was worse after RP vs. AS or EBRT at all time points. Urinary function after EBRT and AS declined similarly until the first 2 and 3 years respectively, and then plateaued up to 5 years. Irritative symptoms were worst in AS between 2-5 yrs. RP showed the least Irritative symptoms and worse incontinence at all time points. Sexual function and bother scores declined steeply at 1 yr. after RP. They subsequently improved until 5 yrs. RP sexual domain score was worse than AS and EBRT during yrs. 1-3 and equivalent to EBRT at years 4 and 5. AS was least affected in the sexual domains. Bowel function and bother were worse for EBRT vs. AS and RP at all time points while hormonal domains were more affected at the first year. Although AS had the least impact on initial mental health scores, in the 3–5-year period, AS demonstrated the worst decline in all sub-domains. CONCLUSIONS: RP results in worse urinary function and incontinence while irritative symptoms are more common in EBRT and AS. Sexual domain scores are least affected by AS while RP shows similar scores to EBRT at years 4-5. Bowel HRQoL is most impacted by EBRT. Long-term HRQoL changes after treatment are critical for patient counseling in localized PCa. Source of Funding: USU-DoD-HJF Disclaimer: The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of Uniformed Services University of the Health Sciences (USUHS), the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Department of Defense (DoD) or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e749 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eyal Kord More articles by this author Nathan Jung More articles by this author Jiji Jiang More articles by this author Natasza Posielski More articles by this author On Ho More articles by this author Sally Elsamanoudi More articles by this author Gregory T. Chesnut More articles by this author Ryan Speir More articles by this author Sean Stroup More articles by this author John Musser More articles by this author Alexander Ernest More articles by this author Timothy Tausch More articles by this author John Paul Flores More articles by this author Christopher Porter More articles by this author Expand All Advertisement PDF downloadLoading ...

Objectives To investigate impact of age and race on health-related quality of life (HRQoL) in men undergoing radical prostatectomy (RP) using a prospectively maintained, racially diverse cohort. Methods The Center for Prostate Disease Research Multicenter National Database was used to identify patients receiving RP from 2007-2017. The Expanded PCa Index Composite and 36 Item Short-Form Health Survey were completed at baseline and regular intervals. Groups were stratified based on age: <60, 60-70, >70. Longitudinal patterns in HRQoL were assessed using linear regression models, adjusting for baseline HRQoL, demographics, and clinical characteristics. Results In 626 patients undergoing RP, 278 (44.4%) were <60, 291 (46.5%) were 60-70, 57 (9.1%) were >70. Older men had worse baseline urinary bother (P<.01) and sexual HRQoL (P<.01). Baseline urinary function was similar for older and younger men. Post-RP urinary and sexual HRQoL was significantly lower in men >70. However, when adjusting for baseline HRQoL, race, NCCN risk, and comorbidities, no difference was found between age groups in urinary function or bother, or sexual function. Sexual bother was worse in older men until 48 months post-operatively but subsequently improved to levels similar to younger patients. Race independently affected HRQoL outcomes with older African American men reporting worse urinary function and sexual bother. Conclusions When accounting for baseline HRQoL, age does not independently predict worse HRQoL outcomes. Older and younger men experience similar declines in urinary and sexual domain scores after RP. Our findings may be used to better inform patients regarding their expected post RP HRQoL and guide treatment decision-making.

INTRODUCTION:Racial differences in Health-Related Quality of Life (HRQoL) after treatment of prostate cancer (PCa) are not well studied. We compared treatment patterns and HRQoL in African American (AA) and non-AA men undergoing active surveillance (AS), radical prostatectomy (RP), or radiation (XRT).METHODS:Men diagnosed with PCa from 2007-2017 in the Center for Prostate Disease Research Database were identified. HRQoL was evaluated using Expanded PCa Index Composite and SF-36 Health Survey.RESULTS:In 1006 men with localized PCa, 223 (22.2%) were AA (mean follow up 5.2 yrs). AA men with low-risk disease were less likely to undergo AS (28.5 vs. 38.8%) and more likely to undergo XRT (22.3 vs. 10.6%) than non-AA men, p < 0.001. In intermediate-risk disease, AA received more XRT (43.0 vs. 26.9%) and less RP (50.5 vs 66.8%), p = 0.016. In all men, RP resulted in worse urinary function and sexual HRQoL compared to AS and XRT. Bowel HRQoL did not vary by treatment in AA men, however, in non-AA men, XRT resulted in worse bowel scores than AS and RP. HRQoL was then compared for each treatment modality. AA men had worse sexual bother (p = 0.024) after RP than non-AA men, No racial differences were found in urinary, bowel, hormonal, or SF-36 scores for men undergoing AS, RP or XRT.CONCLUSION:AA men are less often treated with AS for low-risk disease and are more likely to undergo XRT. AA men experience worse sexual bother after RP, however, the effect of XRT on bowel symptoms is worse in non-AA men.

The practice of urology by United States (U.S.) military urologists has contributed substantially to advancements within the field. These contributions range from optimizing genitourinary reconstruction secondary to war-trauma, to founding the first federally funded institution for the study of prostate disease in the U.S. Military Health Care System. 1 Brassell SA Dobi A Petrovics G Srivastava S McLeod D. The center for prostate disease research (CPDR): a multidisciplinary approach to translational research. Urol Oncol Semin Orig Investig. 2009; 27: 562-569https://doi.org/10.1016/j.urolonc.2009.01.023 Crossref PubMed Scopus (24) Google Scholar Urological disease continues to affect U.S. military service members, dependents, and retirees. However, unlike many other surgical specialties, the majority of diseases treated by urologists are non–traumatic in nature. This holds true for both military and civilian urologists; with exceptions being deployed military urologists or civilian urologists specializing in trauma. 2 Serkin FB Soderdahl DW Hernandez J Patterson M Blackbourne L Wade CE. Combat urologic trauma in US military overseas contingency operations. J Trauma Inj Infect Crit Care. 2010; 69: S175-S178https://doi.org/10.1097/TA.0b013e3181e45cd1 Crossref PubMed Scopus (0) Google Scholar Thus, though war-related genitourinary trauma in the U.S. has decreased over the last decade, U.S. military urologists remain busy meeting the medical and surgical demands of their ever-growing patient population. In order to meet said demands while maintaining mission-critical medical readiness, it is imperative that the U.S. military continues to train new urologists. 3 Williams M Jezior J. Management of combat-related urological trauma in the modern era. Nat Rev Urol. 2013; 10: 504-512https://doi.org/10.1038/nrurol.2013.148 Crossref PubMed Scopus (23) Google Scholar For each service branch, multiple avenues of training exist to ensure that the urological work force remains strong throughout the foreseeable future. Unfortunately, little information is available to the public with regard to the training of military urologists, and interested parties are often left with a piecemeal understanding of the process. This article serves to consolidate various aspects of urology education within the U.S. military — summarizing key historical events, discussing current residency training options, emphasizing the value of military-civilian partnerships, and foreshadowing the future of training.

To compare 5-year health-related quality of life (HRQoL) outcomes between prostate cancer (CaP) patients who underwent robotic-assisted laparoscopic radical prostatectomy (RALP) versus open radical retropubic prostatectomy (RRP) and assess for racial disparities between Caucasian American (CA) and African American (AA) men undergoing surgery. A prospective cohort study of HRQoL data was conducted on patients diagnosed with CaP from 2007 to 2017 and enrolled in the Center for Prostate Disease Research (CPDR) Multicenter National Database. Using the EPIC and SF-36 instruments, changes in urinary, sexual, bowel, and hormonal domains, as well as physical and mental component summary scores were compared across surgery type (RALP versus RRP) at pre-treatment (“baseline”), and annually for 5 years. We further compared HRQoL outcomes in CA and AA men undergoing surgery. Longitudinal HRQoL patterns were modeled using generalized estimating equations (GEE), adjusting for baseline HRQoL and other characteristics. 448 CaP patients (22% AA) met study inclusion criteria, 66% underwent RALP and 34% underwent RRP. At baseline, HRQoL domains were comparable across treatment group (RALP vs. RRP). In the adjusted low-risk cohort, there were only three time points that met a statistically significant HRQoL difference in EPIC scores between RALP and RRP. Urinary function score during year 4 of follow-up showed a 7.5 (95% CI 3.1–11.9, P = 0.01) points difference in favor of RRP. Bowel bother scores favored RRP in year 1 with a difference of 3.1 (95% CI 0.7–5.4, P = 0.04) points, and in year 5 with a difference of 3.8 (95% CI 1.1–6.4, P = 0.03) points. In the intermediate/high-risk cohort, there were no statistically significant differences in any of the domain scores between RALP and RRP during follow-up. The robotic and open approach to radical prostatectomy led to comparable HRQoL outcomes at a follow-up length of 60 months. No HRQoL racial disparities were found between AA and CA men during long-term follow-up.

ABSTRACT Objective: Many patients who undergo inflatable penile prosthesis (IPP) replacement are often upsized to larger cylinders, suggesting the IPP may serve as a tissue expander and increase internal penile length. The objective of this study is to evaluate whether cylinder length increases with subsequent IPP insertion. Materials and Methods: We queried American Medical Systems and Coloplast Patient Information Form databases to identify patients who underwent IPP placement and replacement between 2004-2013. Patients were grouped by device type and time to replacement (<2 or ≥2 years). We selected the 2-year mark for subgroup analysis to allow time for tissue expansion to occur and to exclude patients who underwent early explantation (e.g. erosion or infection). Results: Two thousand, seven hundred and forty nine patients (1,532 AMS 700 LGX, 717 AMS 700 CX, and 500 Coloplast Titan) met the inclusion criteria. Mean time between implants was earlier for LGX (29 months) than CX (39 months) and Titan (48 months) patients (p<0.001). Patients who underwent device replacement at <2 years did not experience an increase in mean cylinder length. On the contrary, patients who underwent device replacement at ≥2 years did experience significant increases in mean cylinder length (LGX 1.2 cm, CX 1.1 cm, and Titan 0.9 cm, p<0.001). The mean increases in length at ≥2 years were similar between the 3 devices (p=0.20). Sixty percent of patients demonstrated increases of >0.5 cm and 40% demonstrated increases of ≥1 cm. Conclusions: As demonstrated, the IPP may provide tissue expansion over time. Further evaluation is needed to determine if increased cylinder length correlates to increased functional length and patient satisfaction.

INTRODUCTION:We compare the costs associated with primary endoscopic realignment vs delayed elective bulbomembranous anastomotic urethroplasty after initial management of pelvic fracture urethral injuries with suprapubic tubes.METHODS:Decision analysis was performed comparing the costs associated with suprapubic tube placement with a definitive bulbomembranous urethroplasty performed 2 to 3 months after injury to those associated with primary endoscopic realignment. Model assumptions based on literature review included success rates of 30% for primary endoscopic realignment, 92% for bulbomembranous urethroplasty and 50% for direct vision internal urethrotomy. Using an institutional patient database of patients undergoing suprapubic tube placement, bulbomembranous urethroplasty and direct vision internal urethrotomy, costs were estimated based on hospital and operating room costs and Medicare reimbursement rates. Sensitivity analyses were performed by varying model assumptions. Using data from the Nationwide Inpatient Sample and the National Trauma Data Bank®, the annual incidence of pelvic fracture urethral injuries nationwide was estimated.RESULTS:The total average cost of treating a pelvic fracture urethral injury with attempted primary endoscopic realignment is $11,043 vs $9,743 for suprapubic tube with elective bulbomembranous urethroplasty, for a savings of $1,300 (12%) per patient. For primary endoscopic realignment to be preferred, a success rate of 40% or better would be necessary. In addition, cost analysis calculation revealed that when bulbomembranous urethroplasty demonstrates an efficacy of 78% or greater, then suprapubic tube and elective bulbomembranous urethroplasty become more cost-effective than primary endoscopic realignment.CONCLUSIONS:Given the added costs and variable outcomes of primary endoscopic realignment and subsequent endoscopic interventions, the durability of definitive urethroplasty appears to be cost-effective in treating men with pelvic fracture urethral injuries.

INTRODUCTION We implemented a standardized Standing Cough Test (SCT) for assessment of men with post-prostatectomy incontinence (PPI) and stratified results according to an objective clinical grading scale in an attempt to facilitate male anti-incontinence surgical procedure selection. MATERIALS AND METHODS SCT was routinely performed during the initial outpatient consultation for PPI. Incontinence severity was recorded based on a novel Male Stress Incontinence Grading Scale (MSIGS) to stratify PPI. Each patient was assigned an incontinence grade score of 0 through 4 during the SCT. Men with mild stress urinary incontinence (SUI) (grades 0-2) were offered sling surgery while those with heavier SUI (grades 3-4) were offered artificial urinary sphincter (AUS). MSIGS grade was correlated to preoperative patient-reported pads per day (PPD), and patient-reported outcomes of anti-incontinence surgery were assessed. RESULTS Among 62 consecutive PPI patients, 20 (32%) were graded as mild based on SCT, while the majority (42/62, 68%) were graded as moderate-severe. Average time from prostatectomy to treatment was 6 years. MSIGS grade demonstrated a strong correlation with preoperative PPD (r = 0.74). Among the 53 patients who underwent surgery for PPI, 14 with mild SUI received a sling, while 39 (74%) more severe cases received an AUS. Patient-reported improvement was high overall in both groups (median 95%). CONCLUSION Most men with chronic PPI present for definitive treatment in a delayed manner after prostatectomy despite having severe incontinence. The SCT provides immediate, objective information about the severity of PPI which strongly correlates with patient-reported pads-per-day and may expedite anti-incontinence surgical procedure selection.

OBJECTIVE To examine the association between decreased serum testosterone levels and artificial urinary sphincter (AUS) cuff erosion.MATERIALS AND METHODS We evaluated serum testosterone levels in 53 consecutive patients. Low testosterone was defined as <280 ng/dL and found in 30/53 patients (56.6%). Chi-square and Student t tests, Kaplan-Meier analysis, binary logistic regression, and Cox regression analysis were used to determine statistical significance.RESULTS Nearly all men with AUS cuff erosions had low serum testosterone (18/20, 90.0%) compared to those without erosions (12/33, 36.4%, P<.001). Mean time to erosion was 1.70 years (0.83-6.86); mean follow-up was 2.76 years (0.34-7.92). Low testosterone had a hazard ratio of 7.15 for erosion in a Cox regression analysis (95% confidence interval 1.64-31.17, P = .009) and Kaplan-Meier analysis demonstrated decreased erosion-free follow-up (log-rank P = .002). Low testoster-one was the sole independent risk factor for erosion in a multivariable model including coronary artery disease and radiation (odds ratio 15.78; 95% confidence interval 2.77-89.92, P = .002). Notably, history of prior AUS, radiation, androgen ablation therapy, or concomitant penile implant did not confound risk of cuff erosion in men with low testosterone levels.CONCLUSION Men with low testosterone levels are at a significantly higher risk to experience AUS cuff erosion. Appropriate counseling before AUS implantation is warranted and it is unclear whether testosterone resupplementation will mitigate this risk. (C) 2016 Elsevier Inc.

Bladder neck contracture is an infrequent but challenging occurrence following prostate surgery. While uncomplicated cases can be managed with favorable outcomes, identifying an appropriate intervention for advanced instances can prove elusive. As a result, options available to the urologist for treating this disease range from minimally invasive outpatient procedures to major open surgery. Here, the numerous therapeutic modalities for treating bladder neck contracture are reviewed.

INTRODUCTION:We developed an objective clinical grading scale to characterize post-prostatectomy incontinence (PPI) and evaluated its use as a tool to facilitate male anti-incontinence procedure selection.PROTOCOL:Between September 2014 and July 2015, we prospectively implemented a novel Male Stress Incontinence Grading Scale (MSIGS) to stratify PPI patients based on incontinence severity. Patients included were those referred for PPI who had no prior anti-incontinence surgery. During the initial outpatient consultation, each patient was prospectively assigned an incontinence grade score of 0 through 4 based on the consensus of 2 examiners performing a standing cough test (SCT). All patients refrained from voiding for at least 60 minutes prior to the SCT. Men with mild SUI (MSIGS grades 0-2) were offered AdVance sling surgery while those with heavier SUI (MSIGS grades 3-4) were offered artificial urinary sphincter (AUS). MSIGS grade was correlated to patient-reported pads-per-day (PPD), and patient-reported outcomes of anti-incontinence surgery were assessed.OUTCOME:Of 62 consecutive new PPI patients, 20 were graded as mild based on SCT [five (8%) grade 0, 10 (16%) grade 1, five (8%) grade 2] while 42 were graded as moderate-severe [10 (16%) grade 3, 32 (52%) grade 4]. MSIGS grade demonstrated a strong correlation with preoperative PPD (r=0.74). Among the 53 patients who underwent surgical intervention for PPI, 14 with mild SUI were treated with AdVance® male urethral sling (MSIGS grade 0, 1, or 2) while 39 more severe cases received AUS (MSIGS grade 3 or 4). Patient-reported improvement was high overall (median 95%) and similar for sling and AUS patients (95% and 96.5% respectively, p=0.596). The median time from radical prostatectomy to anti-incontinence surgery was 5.4 years (range 1-20).DISCUSSION:The Male Stress Incontinence Grading Scale provides a rapid, simple, non-invasive, objective assessment of PPI severity which strongly correlates with patient-reported pads-per-day and appears to facilitate anti-incontinence surgical procedure selection.

Background: The authors present their experience with reconstructive strategies for men with various manifestations of adult buried penis syndrome, and propose a comprehensive anatomical classification system and treatment algorithm based on pathologic changes in the penile skin and involvement of neighboring abdominal and/or scrotal components. Methods: The authors reviewed all patients who underwent reconstruction of adult buried penis syndrome at their referral center between 2007 and 2015. Patients were stratified by location and severity of involved anatomical components. Procedures performed, demographics, comorbidities, and clinical outcomes were reviewed. Results: Fifty-six patients underwent reconstruction of buried penis at the authors’ center from 2007 to 2015. All procedures began with a ventral penile release. If the uncovered penile skin was determined to be viable, a phalloplasty was performed by anchoring penoscrotal skin to the proximal shaft, and the ventral shaft skin defect was closed with scrotal flaps. In more complex patients with circumferential nonviable penile skin, the penile skin was completely excised and replaced with a split-thickness skin graft. Complex patients with severe abdominal lipodystrophy required adjacent tissue transfer. For cases of genital lymphedema, the procedure involved complete excision of the lymphedematous tissue, and primary closure with or without a split-thickness skin graft, also often involving the scrotum. The authors’ overall success rate was 88 percent (49 of 56), defined as resolution of symptoms without the need for additional procedures. Conclusion: Successful correction of adult buried penis often necessitates an interdisciplinary, multimodal approach. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I1 Apr 2016PD16-09 HYPOGONADISM IS A RISK FACTOR FOR ARTIFICIAL URINARY SPHINCTER CUFF EROSION Matthias D Hofer, Kunj R Sheth, Timothy J Tausch, Jordan Siegel, Billy H Cordon, Nicholas L Kavoussi, Alexandra Klein, Claus G Roehrborn, and Allen F Morey Matthias D HoferMatthias D Hofer More articles by this author , Kunj R ShethKunj R Sheth More articles by this author , Timothy J TauschTimothy J Tausch More articles by this author , Jordan SiegelJordan Siegel More articles by this author , Billy H CordonBilly H Cordon More articles by this author , Nicholas L KavoussiNicholas L Kavoussi More articles by this author , Alexandra KleinAlexandra Klein More articles by this author , Claus G RoehrbornClaus G Roehrborn More articles by this author , and Allen F MoreyAllen F Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1161AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In order to determine a possible relationship between hypogonadism and AUS cuff erosion, we evaluated the serum testosterone levels among men having artificial urinary sphincter (AUS) cuff erosions and compared these results to a cohort of uncomplicated AUS patients. METHODS After obtaining IRB approval, we reviewed 46 patients in whom serum testosterone levels were available and who received an AUS between 2007 and 2014. We defined hypogonadism as testosterone serum level <280 ng/dl. Mean follow-up was 2.96 years (range 1.01-7.67 years). Demographics of 18 patients with cuff erosion (39.1%) and 28 patients without erosion (60.9%) were similar with respect to cuff size, prior surgeries, radiation therapy, diabetes, or hypertension. Statistical analysis was performed with chi-square test, t-test, Kaplan-Meier analysis, and Cox regression analysis. RESULTS Of 18 AUS cuff erosions, 16 patients (88.9%) were hypogonadal compared to only 10 of 28 patients without cuff erosions (35%, p<0.001). Mean time to AUS erosion was 1.92 years (0.08-6.86 years). Cox regression analysis revealed that hypogonadism had a hazard ratio of 5.1 for AUS erosion compared to patients with normal testosterone levels (95% CI 1.1-22.6, p=0.003). Kaplan-Meier analysis demonstrated a significant decrease of erosion-free follow-up time in hypogonadal men compared to normogonadal men (log-rank p=0.018). There was no difference between hypogonadal and normogonadal men in respect to cuff size used, prior surgery, radiation therapy or comorbidities. Transcorporal placement was used more frequently in hypogonadal compared to normogonadal men (9/25 (36%) vs. 2/20 (10%), p=0.006). CONCLUSIONS Hypopgonadism in patients undergoing AUS implantation is a significant risk factor for subsequent cuff erosion. It is unknown whether testosterone supplementation prior to surgery would mitigate this almost unacceptable risk. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e397 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Matthias D Hofer More articles by this author Kunj R Sheth More articles by this author Timothy J Tausch More articles by this author Jordan Siegel More articles by this author Billy H Cordon More articles by this author Nicholas L Kavoussi More articles by this author Alexandra Klein More articles by this author Claus G Roehrborn More articles by this author Allen F Morey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Value of Care: Cost and Outcomes Measures II1 Apr 2016MP46-04 COST-EFFECTIVENESS OF ELECTIVE URETHROPLASTY WITHOUT PRIMARY REALIGNMENT IN TREATMENT OF PELVIC FRACTURE URETHRAL INJURIES Timothy Tausch, Yair Lotan, Lee Zhao, and Allen Morey Timothy TauschTimothy Tausch More articles by this author , Yair LotanYair Lotan More articles by this author , Lee ZhaoLee Zhao More articles by this author , and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.302AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We performed a cost-analysis comparing suprapubic tube (SPT) placement followed by elective bulbomembranous anastomotic urethroplasty (BMAU) to primary endoscopic realignment (PER) for patients with pelvic fracture urethral injuries (PFUI). METHODS Decision analysis was performed comparing the costs associated with a strategy of SPT with a definitive BMAU performed 2-3 months following injury to those associated with PER (figure). Model assumptions based on literature review included a PER success rate of 30% and a BMAU success rate of 92%. For failures, direct vision internal urethrotomy (DVIU) success was estimated at 50%, with failures undergoing definitive BMAU. Using an institutional patient database of patients undergoing SPT placement, BMAU, and DVIU, costs were estimated based on hospital and operating room charges and Medicare reimbursement rates. Sensitivity analyses were performed by varying model assumptions. Using data from the Nationwide Inpatient Sample (NIS) and the National Trauma Data Bank (NTDB), we estimated the annual incidence of PFUIs nationwide. RESULTS Based on our model, the total average cost of a patient with a PFUI who undergoes an attempt at PER is $11,043, compared to $9,743 for patients who have an SPT placed and an elective BMAU, for a savings of $1,300 (12%) per patient. Using a sensitivity analysis, the model suggests that in order for PER to be as cost-effective as SPT/BMAU, a PER success rate of 40% or better would be necessary. Based on NIS and NTDB data, we found an estimated 348 PFUIs annually in the US, which would translate to a cost savings of $452,400 annually favoring the SPT/BMAU management strategy. CONCLUSIONS Given the currently reported poor performance rates of PER and subsequent endoscopic interventions, the durability of definitive urethroplasty has proven cost-effective in managing men with PFUIs. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e617-e618 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Timothy Tausch More articles by this author Yair Lotan More articles by this author Lee Zhao More articles by this author Allen Morey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

INTRODUCTION To present an updated experience using our previously reported lateral perineal '7-flap' technique for perineal urethrostomy (PU), highlighting its role in a variety of patients with advanced urethral stricture disease. MATERIALS AND METHODS All patients who underwent 7-flap PU from 2009-2013 were reviewed. PU was constructed by advancing a "7"-shaped laterally based perineal skin flap into a spatulated, amputated bulbomembranous urethra. The contralateral side of the amputated proximal urethra was then matured to the advanced perineal skin. Patients were stratified by body mass index (BMI) and outcomes were compared. RESULTS Among 748 patients undergoing urethroplasty during the study period, 22 men (2.9%; mean age 61, range 31-80) received a 7-flap PU for advanced stricture disease (mean follow up 32 months). A majority of patients (14/22, 64%) were obese (BMI = 30). Disease etiologies consisted primarily of lichen sclerosus (9/22, 41%) while 6/22 (27%) had failed prior urethral reconstructions elsewhere. Mean operative time was 108 min (range 54-214), mean estimated blood loss (EBL) was 76 cc (30-200), and all patients were discharged immediately after surgery. Urethrostomy creation was possible in all patients regardless of BMI (mean 33, range 22-43), and there were no differences with regards to EBL (p = 0.71), operative time (p = 0.38), or success rate (p = 0.76) in obese versus non-obese patients undergoing 7-flap PU. Nearly all patients (21/22, 95%) are voiding spontaneously on follow up without the need for any additional procedure. CONCLUSION In our updated experience, performance of 7-flap urethrostomy has resulted in durable long term success with acceptable performance in technically challenging cases.

Fournier's gangrene is an uncommon necrotizing infection affecting the genital and perineal area. Penile involvement in particular is rare owing to its rich vascular supply. In this report, we document a case of Fournier's gangrene involving penile and urethral tissue requiring multiple debridements resulting in significant penile deformity and a non-healing wound. Eventually, the patient underwent penectomy and perineal urethrostomy creation. In this case, penectomy and perineal urethrostomy provide a functional outcome for highly refractory and complex patients with Fournier's gangrene involving penile tissue.

OBJECTIVE To present a novel algorithm for definitive reconstruction of penile curvature in men undergoing inflatable penile prosthesis (IPP) surgery as an alternative to manual penile modeling and grafting procedures.METHODS Patients with erectile dysfunction and concomitant penile curvature undergoing IPP placement were divided into 2 treatment groups: (1) group 1, penile deformity known preoperatively, and (2) group 2, penile curvature recognized intraoperatively after IPP placement. Group 1 patients underwent penile plication after artificial erection and immediately before IPP insertion via the same penoscrotal incision, whereas group 2 patients were treated with a Yachia (Heineke-Mikulicz) corporoplasty over the intact cylinders. Patients completed postoperative Patient Global Impression of Improvement (PGI-I) questionnaires assessing overall satisfaction.RESULTS Among 405 men receiving IPP at our institution from 2007 to 2014, 30 patients received synchronous correction of penile curvature (7%). Group 1 included 23 of 30 (77%) patients, and 7 of 30 (23%) were in group 2. Overall mean initial curvature was 36 degrees, and all patients were corrected to <10 degrees. Average operative times were 18 minutes longer compared with patients who underwent IPP placement alone (82 vs 64 minutes, P < .05). At an average follow-up of 13 months (range 7-32), 19 of 20 (95%) group 1 and 6 of 7 (86%) group 2 patients who completed surveys reported an improved overall condition. No patient reported chronic pain, recurrent deformity, or device malfunction.CONCLUSION Penile curvature can be safely and reliably corrected at the time of IPP placement, regardless of whether the deformity was identified preoperatively. (C) 2015 Elsevier Inc.

PURPOSE:We compared functional outcomes in patients who received an artificial urinary sphincter in the space of Retzius vs the same device placed at a high submuscular location.MATERIALS AND METHODS:We reviewed a prospectively maintained database of patients who received an artificial urinary sphincter between July 2007 and December 2014. After cuff placement was completed via a perineal incision, a 61 to 70 cm H2O pressure regulating balloon was placed through a separate high scrotal incision in the space of Retzius or in a high submuscular tunnel. Demographics, perioperative comorbidities and functional outcomes were compared between the groups.RESULTS:A total of 294 consecutive patients underwent artificial urinary sphincter placement. Mean followup was 23 months. Space of Retzius and high submuscular placement was performed in 140 (48%) and 154 patients (52%), respectively. Functional outcomes were similar between the groups, including the continence rate (defined as 0 or 1 pad daily) in 81% vs 88% (p = 0.11), the erosion rate in 9% vs 8% (p = 0.66) and the explantation rate in 10% vs 11% (p = 0.62). Artificial urinary sphincter revision for persistent incontinence was required in a similar proportion of the 2 groups (13% vs 8%, p = 0.16) with a comparable mean followup (24 vs 23 months, p = 0.30). Kaplan-Meier analysis revealed no difference between the groups in the rate of explantation (p = 0.70) or revision (p = 0.06).CONCLUSIONS:High submuscular placement of a pressure regulating balloon at artificial urinary sphincter surgery is a safe, effective alternative with functional outcomes equivalent to those of traditional placement in the space of Retzius.