Alexander T. Rozanski

Immediate Urethral Repair during Explantation Prevents Stricture Formation after Artificial Urinary Sphincter Cuff Erosion

PURPOSE We compare stricture outcomes in patients with artificial urinary sphincter cuff erosion managed with and without synchronous urethral repair. MATERIALS AND METHODS Records of patients who underwent artificial urinary sphincter removal for cuff erosion from 2007 to 2013 were retrospectively reviewed. Two cohorts of patients were evaluated, with those in group 1 treated with in situ urethroplasty and those in group 2 treated with a Foley catheter only. We compared demographic, clinical and radiological data to assess resultant stricture disease, and compared operative times between the cohorts. RESULTS Of the 26 artificial urinary sphincter cuff erosion cases identified 13 underwent in situ urethroplasty while 13 did not. Mean patient age was 73 years (range 61 to 83) with a mean followup of 24 months (range 8 to 69). The rate of urethral stricture formation after artificial urinary sphincter explantation was significantly reduced among patients treated with in situ urethroplasty (5 of 13, 38%) compared to those treated with Foley catheter only (11 of 13, 85%; p=0.047). Mean operative times were similar at 78 minutes (50 to 133) for the in situ urethroplasty group vs 70 minutes (51 to 92) for the Foley catheter only group (p=0.39). Those treated with in situ urethroplasty underwent significantly fewer procedures per patient before artificial urinary sphincter replacement (0.4 vs 1.1, p=0.004) and had a much higher rate of eventually undergoing secondary artificial urinary sphincter implantation (7 of 13, 54% vs 2 of 13, 15%, p=0.04) compared to those with cuff erosion treated with Foley catheter only. CONCLUSIONS Urethral repair at the time of artificial urinary sphincter explantation for cuff erosion appears to prevent stricture development, thus facilitating successful artificial urinary sphincter replacement.

Is Exam under Anesthesia Still Necessary for the Staging of Bladder Cancer in the Era of Modern Imaging

Abstract Background: The ability to accurately determine tumor stage in bladder cancer is critical because it impacts the management paradigm and overall prognosis. There is often discrepancy between clinical and pathologic staging. Historically, exam under anesthesia (EUA) has been recommended to assist in the staging of bladder cancer. Objective: In this era of modern imaging technology, we sought to determine if EUA still contributes meaningfully to the local staging of bladder cancer. Methods: We retrospectively reviewed the charts of 1898 patients from 1994–2013 in our radical cystectomy database at MD Anderson Cancer Center. There were 414 patients that had complete information including EUA and whose surgery was performed by one of two surgeons and included in the final analysis. Univariate and multiple logistic regression models were generated to determine the ability of EUA, imaging, and other patient characteristics to predict pathological fat extension at the time of cystectomy. Results: 38% of patients had≥pT3 disease at the time of cystectomy. 30.9% of patients had findings on EUA suggestive of T3 disease and 28.7% had radiologic findings suggestive of T3 disease. In a model including age, BMI, ethnicity, year of operation, and neoadjuvant chemotherapy among other factors, the only factors predictive of pT3 disease were EUA and imaging (p = 0.002). The combination of EUA and imaging improved the accuracy of clinical staging compared to either modality alone. Conclusions: Despite modern advances in imaging, EUA contributes meaningfully to accurate determination of local bladder cancer stage.

Oxidized Regenerated Cellulose (Fibrillar™) Reduces Risk of Postoperative Corporal Bleeding Following Inflatable Penile Prosthesis Surgery

OBJECTIVE To report our initial experience with oxidized regenerated cellulose (ORC; Surgicel Fibrillar) as a hemostatic adjunct during inflatable penile prosthesis (IPP) surgery. MATERIALS AND METHODS Beginning in April 2016, ORC pledgets were placed within the corporotomy closures of all men undergoing IPP insertion. Perioperative characteristics and outcomes including cumulative postoperative drain output were evaluated among consecutive cases with (April 2016 to October 2016) and without ORC (December 2015 to March 2016) using an identical surgical technique by a single surgeon. RESULTS During the study period, 64 men underwent IPP implantation, of whom 32 (50%) received ORC. There was a significant reduction in median drain output relative to controls (33 mL vs 65 mL; P = .01). Postoperatively, ORC use was associated with a reduction in the number of patient phone calls for scrotal-related concerns in the immediate postoperative period (average 0.5 vs 1.1; P = .03). There were 3 IPP explantations in the non-ORC group (2/3 for infection)-one of which was directly related to an infected hematoma. After controlling for other clinical features, the use of ORC (β -32, 95% confidence interval: -61 to -5; P = .02) was independently associated with a reduction in drain output. CONCLUSION ORC use during IPP corporotomy closure reduces postoperative drain output, a known risk factor for hematoma-related complications.

PD22-03 OXIDIZED REGENERATED CELLULOSE (FIBRILLAR™) REDUCES RISK OF POSTOPERATIVE HEMATOMA FOLLOWING INFLATABLE PENILE PROSTHESIS

INTRODUCTION AND OBJECTIVES: Oxidized regenerated cellulose (ORC) (Fibrillar ) is a topical absorbable hemostatic agent widely used in various urologic surgical procedures. Little is known regarding the impact of hemostatic agents in reducing risk of hematoma formation among men undergoing urologic prosthetic surgery. This study reports our initial experience with ORC as a hemostatic adjunct during inflatable penile prosthesis (IPP) surgery to determine the effect on postoperative drain output and subsequent complications. METHODS: Beginning in March 2016 ORC was placed as a pledget within the corporotomy closure of all men undergoing IPP insertion. Demographic, intraoperative, and postoperative parameters including cumulative overnight postoperative drain output were evaluated among cases with (March 2016 to present) and without ORC (December 2015 to March 2016) using an identical surgical technique by a single surgeon. Continuous variables were compared with the Mann-Whitney U test. Categorical variables were compared with Fisher’s exact test. RESULTS: During the study period 61 men underwent IPP procedures. ORC was used in 27/61 cases (44%) causing a 38% reduction in median drainage output compared to the control group (40 mL vs. 65 mL; p1⁄40.01). There was no difference in demographic, perioperative, or device-related characteristics. There were 2 IPP explantations secondary to infection, both of which occurred in the control group; one of which was directly related to hematoma formation. After controlling for other clinical features, the use of ORC (b -31, 95% CI: -61 to -1.3; p1⁄40.04) was the only factor independently associated with a reduction in drain output. CONCLUSIONS: This study suggests that the use of ORC pledgets during corporotomy closure of IPP reduces risk of hematoma formation.

PD34-12 TERTIARY URETHROPLASTY: IS THE THIRD TIME A CHARM?

INTRODUCTION AND OBJECTIVES: Approximately 10-20% of patients will have a recurrence after urethroplasty. Initial management of these recurrences is often with urethral dilation (UD) and direct vision internal urethrotomy (DVIU) but the success rates of these procedures are not well known. METHODS: We retrospectively reviewed bulbar urethroplasty data from 5 surgeons from the Trauma and Urologic Reconstruction Network of Surgeons (TURNS). Men who underwent UD or DVIU for a <17F lumen plus symptoms of recurrence were identified. Analyses compared success rates of recurrence management (UD vs. DVIU) and initial urethroplasty type (substitution vs. excisional repair, EPA) using time to event statistics: Kaplan Meier curves and Cox regression models. Failure of UD or DVIU was defined as the inability to pass a 17Fr cystoscope through the urethra into the bladder. RESULTS: There were 53 men with recurrence that were initially managed endoscopically, 10 with UD and 43 with DVIU. Mean time to recurrence after urethroplasty was 7.6 months. At a mean followup of 16.3 months after UD or DVIU, success was 41.5% in the overall cohort: 48.8% for DVIU vs. 10% for UD. Kaplan Meier curves are shown in Figure 1. On Cox modeling, UD had a higher rate of subsequent failure compared to DVIU (hazard ratio, HR: 3.15, p1⁄40.03). Patients undergoing EPA had a trend towards higher rates of recurrence after secondary endoscopic procedures vs. those undergoing substitution urethroplasty (HR: 2.41, p1⁄40.05) CONCLUSIONS: DVIU is more successful than UD in the management of stricture recurrence after bulbar urethroplasty. DVIU appears to be more successful for patients with a recurrence after a substitution urethroplasty compared to after an EPA, perhaps indicating a different mechanism of recurrence for EPA (ischemic) versus substitution urethroplasty (technical) Source of Funding: None

PD17-12 TWENTY-YEAR EXPERIENCE WITH THE ANTERIOR VAGINAL WALL SUSPENSION PROCEDURE: A NATIVE TISSUE VAGINAL REPAIR FOR STRESS URINARY INCONTINENCE WITH EARLY STAGE ANTERIOR COMPARTMENT PROLAPSE

METHODS: A retrospective analisis of a prospectively maintained database of women undergoing cystocele repair between 2000 and 2015 was performed. In a cohort of 123 women, the follow-up was completed in 109: 42 patients underwent AC, 19 AC-P, and 48 AC-M. Mean follow-up was 94.80 51.72 months. Subjectives outcomes have been evaluated by validated questionnaires. The personal patient satisfaction rate was also measured by the questions “are you satisfied with the surgical procedure?” and “would you confirm the same surgical choice at the time of the counseling before surgery?”. Objective outcomes have been evaluated considering a failure an anterior vaginal wall recurrence 1⁄4 II POP-Q and 2 Baden-Walker Halfway System. RESULTS: In all the surgical techniques used the results of PGI-I questionnaire showed a general perceived benefit of treatment as well as the results of PPBC questionnaire indicated an improvement from the previous bladder condition. The personal patient’s satisfaction rate was higher in the AC-P group. In all groups most of the interviewed women would confirm the same surgical choice. We find anatomical success rate > 80% in all groups with no statistically significant difference. Data showed a higher rate of complications in the AC-M group (p<0.05). Table 1 summarizes the characteristics of the patients, outcomes and complications. The larger number of complications in AC-M group (p<0.05) could explain the lower subjective satisfaction of patients. CONCLUSIONS: Considering the recent FDA order to reclassify surgical mesh to class III, and the recent SCENHIR document on “Safety of surgical meshes used in urogynecological surgery” our data show in the AC group good results in a very long follow-up. The additional support given by a mesh, or a xenograft, does not increase with statistically significance the anatomic cure rate. Rather, the use of prosthetic devices leads more complications rate.