Christopher McClung

Risk Factors for Erosion of Artificial Urinary Sphincters: A Multicenter Prospective Study

OBJECTIVE To evaluate the short- to medium-term outcomes after artificial urinary sphincter (AUS) placement from a large, multi-institutional, prospective, follow-up study. We hypothesize that along with radiation, patients with any history of a direct surgery to the urethra will have higher rates of eventual AUS explantation for erosion and/or infection. MATERIALS AND METHODS A prospective outcome analysis was performed on 386 patients treated with AUS placement from April 2009 to December 2012 at 8 institutions with at least 3 months of follow-up. Charts were analyzed for preoperative risk factors and postoperative complications requiring explantation. RESULTS Approximately 50% of patients were considered high risk. High risk was defined as patients having undergone radiation therapy, urethroplasty, multiple treatments for bladder neck contracture or urethral stricture, urethral stent placement, or a history of erosion or infection in a previous AUS. A total of 31 explantations (8.03%) were performed during the follow-up period. Overall explantation rates were higher in those with prior radiation and prior UroLume. Men with prior AUS infection or erosion also had a trend for higher rates of subsequent explantation. Men receiving 3.5-cm cuffs had significantly higher explantation rates than those receiving larger cuffs. CONCLUSION This outcomes study confirms that urethral risk factors, including radiation history, prior AUS erosion, and a history of urethral stent placement, increase the risk of AUS explantation in short-term follow-up.

Intralesional Injection of Mitomycin C at Transurethral Incision of Bladder Neck Contracture May Offer Limited Benefit: TURNS Study Group

PURPOSE Injection of mitomycin C may increase the success of transurethral incision of the bladder neck for the treatment of bladder neck contracture. We evaluated the efficacy of mitomycin C injection across multiple institutions. MATERIALS AND METHODS Data on all patients who underwent transurethral incision of the bladder neck with mitomycin C from 2009 to 2014 were retrospectively reviewed from 6 centers in the TURNS. Patients with at least 3 months of cystoscopic followup were included in the analysis. RESULTS A total of 66 patients underwent transurethral incision of the bladder neck with mitomycin C and 55 meeting the study inclusion criteria were analyzed. Mean ± SD patient age was 64 ± 7.6 years. Dilation or prior transurethral incision of the bladder neck failed in 80% (44 of 55) of patients. Overall 58% (32 of 55) of patients achieved resolution of bladder neck contracture after 1 transurethral incision of the bladder neck with mitomycin C at a median followup of 9.2 months (IQR 11.7). There were 23 patients who had recurrence at a median of 3.7 months (IQR 4.2), 15 who underwent repeat transurethral incision of the bladder neck with mitomycin C and 9 of 15 (60%) who were free of another recurrence at a median of 8.6 months (IQR 8.8), for an overall success rate of 75% (41 of 55). Incision with electrocautery (Collins knife) was predictive of success compared with cold knife incision (63% vs 50%, p=0.03). Four patients experienced serious adverse events related to mitomycin C and 3 needed or are planning cystectomy. CONCLUSIONS The efficacy of intralesional injection of mitomycin C at transurethral incision of the bladder neck was lower than previously reported and was associated with a 7% rate of serious adverse events.

Contemporary trends in the immediate surgical management of renal trauma using a national database.

BACKGROUND The National Trauma Data Bank was used to analyze open surgical management of renal trauma during the first 24 hours of hospital admission, excluding those who were treated with conservative measures. A descriptive analysis of initial management trends following renal trauma was also performed as a secondary analysis. METHODS With the use of the National Trauma Data Bank, patients with renal injuries were identified, and Abbreviated Injury Scale (AIS) codes were stratified to a corresponding American Association for the Surgery of Trauma (AAST) renal injury grade. Trends in initial management were assessed using the following initial treatment categories: observation, minimally invasive surgery, and open renal surgery. Analysis of initial open surgery was further examined according to etiology of injury (blunt vs. penetrating), type of open renal surgery, concomitant abdominal surgery, patient demographics, and time to surgery. RESULTS A total of 9,002 renal injuries (0.3%) were mapped to an AAST renal grade. Of these, 1,183 patients underwent open surgery for their renal injury in the first 24 hours. There were 773 penetrating and 410 blunt injuries within this cohort. The majority of surgical patients sustained a high-grade renal injury (AAST Grades 4–5, 64%). The overall nephrectomy rate in the first 24 hours was 54% and 83% for the penetrating and blunt groups, respectively. While the overall nephrectomy rate for AAST Grade 1 to 3 renal injuries in the first 24 hours was low (1.8%), the nephrectomy rate was higher in the setting of an exploratory laparotomy (30%). Of those undergoing renal surgery in the first 24 hours, 86% had concomitant surgery performed for other abdominal injuries. Mean time from emergency department presentation to surgery was less for penetrating trauma. CONCLUSION Of the patients requiring open surgery for renal trauma within 24 hours of admission, nephrectomy is the most common surgery. Continued effort to reduce nephrectomy rates following abdominal trauma is necessary. LEVEL OF EVIDENCE Epidemiologic study, level III.

Lower urinary tract pain and anterior urethral stricture disease: prevalence and effects of urethral reconstruction

PURPOSE Anterior urethral stricture disease most commonly presents as urinary obstruction. Lower urinary tract pain is not commonly reported as a presenting symptom. We prospectively characterized lower urinary tract pain in association with urethral stricture disease and assessed the effects of urethroplasty on this pain. MATERIALS AND METHODS Men (18 years old or older) with anterior urethral stricture disease were prospectively enrolled in a longitudinal, multi-institutional, urethral reconstruction outcomes study from June 2010 to January 2013 as part of TURNS (Trauma and Urologic Reconstruction Network of Surgeons). Preoperative and postoperative lower urinary tract pain was assessed by the validated CLSS. Voiding and sexual function was assessed using validated patient-reported measures, including I-PSS. RESULTS Preoperatively 118 of 167 men (71%) reported urethral pain and 68 (41%) reported bladder pain. Age was the only predictor of urethral pain with men 40 years or younger reporting more pain than those 60 years old or older (81% vs 58%, p = 0.0104). Lower urinary tract pain was associated with worse quality of life and overall voiding symptoms on CLSS and I-PSS (each p <0.01). Postoperatively lower urinary tract pain completely resolved in 64% of men with urethral pain and in 73.5% with bladder pain. There were no predictive factors for changes in lower urinary tract pain after urethral reconstruction. CONCLUSIONS Lower urinary tract pain is common in urethral stricture disease, especially in younger men. It is associated with worse quality of life and voiding function. In most men lower urinary tract pain resolves after urethral reconstruction.

Critical Analysis of the Use of Uroflowmetry for Urethral Stricture Disease Surveillance.

OBJECTIVE To critically evaluate the use of uroflowmetry (UF) in a large urethral stricture disease cohort as a means to monitor for stricture recurrence. MATERIALS AND METHODS This study included men that underwent anterior urethroplasty and completed a study-specific follow-up protocol. Pre- and postoperative UF studies of men found to have cystoscopic recurrence were compared to UF studies from successful repairs. UF components of interest included maximum flow rate (Qm), average flow rate (Qa), and voided volume, in addition to the novel post-UF calculated value of Qm minus Qa (Qm-Qa). Area under the receiver operating characteristic curves (AUC) of individual UF parameters was compared. RESULTS Qm-Qa had the highest AUC (0.8295) followed by Qm (0.8241). UF performed significantly better in men ≤40 with an AUC of 0.9324 and 0.9224 for Qm-Qa and Qm respectively, as compared to 0.7484 and 0.7661 in men >40. Importantly, of men found to have anatomic recurrences, only 41% had a Qm of ≤15 mL/s at time of diagnostic cystoscopy, whereas over 83% were found to have a Qm-Qa of ≤10 mL/s. CONCLUSION Qm rate alone may not be sensitive enough to replace cystoscopy when screening for stricture recurrence in all patients, especially in younger men where baseline flow rates are higher. Qm-Qa is a novel calculated UF measure that appears to be more sensitive than Qm when using UF to screen for recurrence, as it may be a better numerical representation of the shape of the voiding curve.

Practice patterns of recently fellowship-trained reconstructive urologists

OBJECTIVE To analyze the practice patterns of recently fellowship-trained reconstructive urologists to help guide fellowship program curriculum development and to evaluate the impact that formal reconstructive urology training has on academic urology programs. METHODS We evaluated the case logs of 7 recently fellowship-trained reconstructive urologists affiliated with US academic institutions from August 2009 to August 2011 (median years in practice = 2, range 1-6 years). We categorized cases into endoscopic, oncological, female, general (nononcological), and reconstructive. Our primary outcome was the volume of reconstructive procedures as a percentage of all procedures. Our secondary outcome was the correlation between years in practice and reconstructive volume and case complexity. RESULTS A total of 3561 cases were analyzed, representing 12 surgeon-years. Endoscopic surgery was most common (42.7%), followed by reconstructive (36.1%), general urologic (10.5%), and oncological (3.7%). The most common type of reconstructive procedure performed was anterior urethroplasty (mean 42.8 per year) followed by bladder reconstruction (mean 17.7 per year). The percentage of yearly cases considered reconstructive was positively associated with total years in practice (r = .688, P = .013) as was the complexity of artificial urinary sphincter cases (r = .857, P = .0004), but not urethral reconstructive complexity (r = .40, P = .197). CONCLUSION The demand for services delivered by fellowship-trained reconstructive urologists is high, as evidence by the large percentage of reconstructive procedures in this cohort even early in practice. With additional years in practice comes further specialization.

Multicenter Analysis of Urinary Urgency and Urge Incontinence in Patients with Anterior Urethral Stricture Disease before and after Urethroplasty

PURPOSE Little published data exist on the impact of urethral stricture surgery on urinary urgency. We evaluated urinary urgency and urge incontinence before and after anterior urethroplasty. MATERIALS AND METHODS Male patients who underwent 1-stage anterior urethroplasty were retrospectively identified at 8 centers. Patients with preoperative and 2-month or greater postoperative subjective urinary urgency assessments were included in study. Patients who received anticholinergic medications preoperatively were excluded. Univariate and multivariate analysis was done to analyze the association of patient characteristics with preoperative and postoperative symptoms as well as improvement or worsening of symptoms after surgery. RESULTS Symptom and followup data on urgency and urge incontinence were available in in 439 and 305 patients, respectively. Preoperatively 58% of the men reported urgency and 31% reported urge incontinence. Postoperatively this decreased to 40% of men for urgency and 12% for urge incontinence (each p <0.01). Of the men 37% reported improvement in urgency and 74% experienced improvement in urge incontinence. Few of those without preoperative symptoms showed worse symptoms, including urgency in 9% and urge incontinence in 5%. New urgency was more likely to develop in men with a higher body mass index (OR 1.09, p = 0.02). Men with stricture recurrence were less likely to show improvement in urgency (OR 0.24, p = 0.03). Older men were more likely to have new urge incontinence (OR 1.06, p = 0.01) and less likely to notice improvement in urge symptoms (OR 0.92, p <0.01). CONCLUSIONS The prevalence of urgency and urge incontinence in male patients with anterior urethral stricture is high. The majority of men experience symptom stability or improvement in urinary urge symptoms following anterior urethroplasty.

The International Prostate Symptom Score (IPSS) Is an Inadequate Tool to Screen for Urethral Stricture Recurrence After Anterior Urethroplasty

OBJECTIVE To validate the use of the International Prostate Symptom Score (IPSS) as a stand-alone tool to detect urethral stricture recurrence following urethroplasty. MATERIALS AND METHODS This study included 393 men who had undergone anterior urethroplasty and were enrolled in a multi-institutional outcomes study. Data analyzed included pre- and post-operative answers to the IPSS in addition to findings from a same- day cystoscopy. IPSS from men found to have cystoscopic recurrence were then compared to scores from those with successful repairs, and receiver operating characteristic curves were plotted to illustrate the predictive ability of these questions to screen for cystoscopic recurrence. RESULTS Mean postoperative scores were lower (fewer symptoms) in successful repairs; IPSS improved from preoperative values regardless of recurrence. Successful repairs had significantly better degree of improvement in question #5 (assessing weak stream) compared to recurrences. Receiver operating characteristic curves demonstrated the highest area under the curve for the IPSS quality of life question (0.66) that alone outperformed the complete IPSS questionnaire (0.56). CONCLUSION The IPSS had inadequate sensitivity and specificity to be used as a stand-alone screening tool for stricture recurrence in this large cohort of men, highlighting the need to continue development of a disease-specific, validated patient-reported outcome measure.

Urinary Diversion for Severe Urinary Adverse Events of Prostate Radiation: Results from a Multi-Institutional Study

Purpose: We evaluated the short and long‐term surgical outcomes of urinary diversion done for urinary adverse events arising from prostate radiation therapy. We hypothesized that patient characteristics are associated with complications after urinary diversion. Materials and Methods: We performed a retrospective cohort study of 100 men who underwent urinary diversion (urinary conduit or continent catheterizable pouch) due to urinary adverse events after prostate radiotherapy from 2007 to 2016 from 9 academic centers in the United States. Outcome measurements included predictors of short and long‐term complications, and readmission after urinary diversion of patients who had prostate cancer treated with radiotherapy. The data were summarized using descriptive statistics and univariate associations with complications were identified with logistic regression controlling for center. Results: Mean patient age was 71 years and median time from radiotherapy to urinary diversion was 8 years. Overall 81 (81%) patients had combined modality therapy (radical prostatectomy plus radiotherapy or various combinations of radiotherapy). Grade 3a or greater Clavien‐Dindo complications occurred in 31 (35%) men, including 4 deaths (4.5%). Normal weight men had more short‐term complications compared to overweight (OR 4.9, 95% CI 1.3–23.1, p=0.02) and obese men (OR 6.3, 95% CI 1.6–31.1, p=0.009). Hospital readmission within 6 weeks of surgery occurred for 35 (38%) men. Surgery was needed to treat long‐term complications after urinary diversion in 19 (22%) patients with a median followup of 16.3 months. Conclusions: Urinary diversion after prostate radiotherapy has a considerable short and long‐term surgical complication rate. Urinary diversion most often cannot be avoided in these patients but appreciation of the risks allows for informed shared decision making between surgeons and patients.

Ureteral Reimplantation in Adults: Open Versus Robotic

OPEN to 24 open ureteral reimplants. Statistically signifiINDICATIONS for adult ureteral reimplantation include extirpation of malignancy, iatrogenic injury and benign stricture disease. Causes of iatrogenic ureteral injury include complications of gynecologic surgery (hysterectomy), colorectal surgery (low anterior resection and abdominoperineal resection) and urological surgery (ureteroscopy and prostatectomy). Causes of benign ureteral stricture include retroperitoneal fibrosis secondary to vascular bypass grafting and radiation. The definitive management of ureteral strictures and ureteral injury is a common reconstructive problem that the urologist must manage, as endoscopic techniques have marginal long-term success rates. When the distal ureter cannot be reimplanted directly into the bladder due to insufficient length, ancillary techniques are required, which include a psoas hitch and Boari flap. The question has been asked as to whether open or robotic surgery is the optimal method to manage ureteral reimplantation. The psoas hitch was originally described by Witzel in 1896 but did not gain popularity until the work of Zimmerman and Turner-Warwick in the 1960s. While the Boari flap was initially used in an animal model in 1894, it was not described in humans until 1947. Now with more than 50 years of open surgical experience, the data on open reconstructive outcomes are mature. Single center series with as many as 181 patients at 4.5 years of followup document a 97% success rate. In the last 20 years our field has witnessed the evolution and application of minimally invasive surgery to urology, starting with laparoscopy and progressing to robotic assisted surgery. Robotic assisted surgery has been used for prostate cancer, renal cancer and bladder cancer. As with any new surgical approach, comparison to established techniques must be made to assess outcomes, complications and costeffectiveness. Although these data are most mature for prostatectomy, they are still developing for ureteral reconstruction. Our current best level of evidence to compare robotic to open surgical distal ureteral reconstruction is level 3b, based on a case control study by Kozinn et al comparing 10 robotic