John M. Lacy

Trends in the Management of Male Urethral Stricture Disease in the Veteran Population

OBJECTIVE To evaluate the relative use of urethral dilation, urethrotomy, and urethroplasty for male stricture disease in the Veterans Affairs (VA) population and examine trends over time in this cohort. METHODS A retrospective chart review was performed using the VA Informatics and Computing Infrastructure database to access the Corporate Data Warehouse. The current procedural terminology codes were used to define a cohort of all men who underwent procedures for urethral stricture disease between October 1999 and August 2013. RESULTS A total of 92,448 procedures were performed: 50,875 urethral dilations (55.03%), 39,785 urethrotomies (43.03%), and 1788 urethroplasties (0.19%). Over the course of the study, there was a shift in the management of male stricture disease. The relative percentage of urethral dilations performed decreased in each quintile (71.27, 58.03, 45.61, 44.39, and 38.67). The relative percentage of urethrotomies increased in each quintile (27.89, 40.80, 52.18, 53.04, and 56.95) as did the relative percentage of urethroplasties performed (0.85, 1.17, 2.21, 2.57, and 4.38). A total of 80.4% of these urethroplasties were performed in locations with a residency program. CONCLUSION Although urethroplasty is still underused, there is a trend toward increased use of urethroplasty for male urethral stricture disease in the VA population. The majority of urethroplasties were performed at VA medical centers in locations with a residency program. We predict continued increases in utilization of urethroplasty for male urethral stricture disease as the number of fellowship-trained reconstructive urologists increases.

A 22-Year-Old Female with Invasive Epithelioid Angiomyolipoma and Tumor Thrombus into the Inferior Vena Cava: Case Report and Literature Review

A 22-year-old female presented with back pain and was discovered to have a right-sided abdominal mass. Computed tomography (CT) scan revealed a 9 cm enhancing right upper pole renal mass with suspicion for tumor thrombus into the right renal vein and possibly the inferior vena cava (IVC). Magnetic resonance imaging (MRI) confirmed tumor thrombus into the inferior vena cava approximately 3 cm below the hepatic venous confluence. Open right radical nephrectomy with inferior vena cava thrombectomy was performed with removal of right kidney and tumor thrombus en bloc. Pathology revealed malignant epithelioid angiomyolipoma (EAML or PEComa). Epithelioid angiomyolipoma is a rare tumor of mesenchymal tissue that has the potential for local invasion and disease progression. Diagnosis of EAML was confirmed by pathology and immunohistochemistry. She was referred to medical oncology for discussion of surveillance versus potential adjuvant therapy and ultimately opted for close surveillance.

A tale of two trials: The impact of 5α-reductase inhibition on prostate cancer (Review)

The use of 5α-reductase inhibitors (5α-RIs) as prostate cancer chemoprevention agents is controversial. Two large randomized trials, the Prostate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) Trial, have both shown a decreased incidence of prostate cancer in patients administered with 5α-RIs. Both studies showed, however, an increased risk of higher-grade prostate cancer. Numerous studies have since analyzed the inherent biases in these landmark studies and have used mathematical modeling to estimate the true incidence of prostate cancer and the risk for high-grade prostate cancer in patients undergoing 5α-RI treatment. All primary publications associated with the PCPT and REDUCE studies were reviewed in detail. Pertinent references from the above publications were assessed and a literature search of all published articles associated with PCPT, REDUCE or 5α-RIs as chemopreventative agents through October 2013 was performed using Pubmed/Medline. PCPT and REDUCE both showed a significant decrease in the incidence of prostate cancer following the administration of 5α-reductase inhibitor, as compared with placebo, suggesting that 5α-RIs may be effective agents for prostate cancer chemoprevention. Inherent biases in the design of these two studies may have caused an artificial increase in the number of high-grade cancers reported. Mathematical models, that integrated data from these trials, revealed neither an increased nor decreased risk of high-grade disease when taking these biases into consideration. Moderately strong evidence exists that 5α-RIs may reduce the risk of prostate cancer. PCPT and REDUCE showed a decreased prevalence of prostate cancer in patients taking 5α-RIs. Urologists should have a working knowledge of these studies and discuss with patients the risks and benefits of 5α-RI treatment. Further studies to evaluate the cost-effectiveness of chemoprevention with 5α-RIs and appropriate patient selection are warranted.

Salvage Brachytherapy for Biochemically Recurrent Prostate Cancer Following Primary Brachytherapy

Purpose. In this study, we evaluated our experience with salvage brachytherapy after discovery of biochemical recurrence after a prior brachytherapy procedure. Methods and Materials. From 2001 through 2012 twenty-one patients treated by brachytherapy within University of Kentucky or from outside centers developed biochemical failure and had no evidence of metastases. Computed tomography (CT) scans were evaluated; patients who had an underseeded portion of their prostate were considered for reimplantation. Results. The majority of the patients in this study (61.9%) were low risk and median presalvage PSA was 3.49 (range 17.41–1.68). Mean follow-up was 61 months. At last follow-up after reseeding, 11/21 (52.4%) were free of biochemical recurrence. There was a trend towards decreased freedom from biochemical recurrence in low risk patients (p = 0.12). International Prostate Symptom Scores (IPSS) increased at 3-month follow-up visits but decreased and were equivalent to baseline scores at 18 months. Conclusions. Salvage brachytherapy after primary brachytherapy is possible; however, in our experience the side-effect profile after the second brachytherapy procedure was higher than after the first brachytherapy procedure. In this cohort of patients we demonstrate that approximately 50% oncologic control, low risk patients appear to have better outcomes than others.

Risk Factors for Removal or Revision of Penile Prostheses in the Veteran Population

OBJECTIVE To identify comorbid conditions that may increase the likelihood of revision surgery after primary penile prosthesis implantation. To evaluate trends in utilization of prostheses and selection of device within the Veterans Affairs (VA) system. METHODS A retrospective review of the VA Informatics and Computing Infrastructure database was performed using Current Procedural Technology codes to identify any Veteran who underwent penile prosthesis surgery between January 2000 and December 2013. Age, race, procedure type, and relevant comorbidities were identified and compared between groups. RESULTS A total of 6586 patients underwent primary penile prosthesis placement with at least 1 year of follow-up. Peripheral vascular disease (P <.001), smoking (P <.001), hypertension (P = .012), and history of prostate cancer (P = .043) were each associated with a significant increased risk of revision or removal surgery. There was an increase in overall number of implants placed during the study and increased durability with malleable penile prosthesis (MPP), but there was a downward trend in the number of MPP placed relative to inflatable penile prosthesis (P <.001). MPP were more likely to be placed with increasing age (P <.05) and there was a trend toward increased MPP placement in African Americans compared with Caucasians (P = .06). CONCLUSION Peripheral vascular disease, hypertension, smoking, and history of prostate cancer are associated with increased risk for secondary surgery. This raises a provocative question of how vascular insufficiency may play a role in the likelihood of secondary surgery after penile prosthesis placement. Utilization of penile prosthesis placement in the VA system is steadily increasing, most notably with increased numbers of inflatable penile prosthesis placement.

MP24-14 NO STOMA, ONE, OR TWO? SETTING EXPECTATIONS FOR PATIENTS WITH RECTOURETHRAL FISTULA

INTRODUCTION AND OBJECTIVES: Rectourethral fistula (RUF) is a rare and challenging condition to manage. We report our experience to aid the management of patients who are candidates for repair with no resultant diversion (no stoma), either urinary or fecal diversion (1 stoma), or double diversion (2 stomas). METHODS: We identified patients presenting with RUF between 2005 and 2015. Demographics, follow up, RUF and surgical details, outcomes including diversion status, complications, resolution, recurrence, or persistence of RUF were collected through retrospective chart review. Suprapubic tube was considered a form of urinary diversion. Univariable and multivariable logistic regression models were used for statistical analyses. RESULTS: We identified 110 patients with RUF, 7 were lost to follow up early and excluded from our analyses. Median age was 63 (IQR 59-70) years. Mean follow up was 31 (IQR 6-42) months. 85 (83%) patients had RUF following PCa treatment (28 surgery alone, 10 surgery + radiation, 16 XRT + brachytherapy, 31 either type of radiation alone). In addition to these treatments, 30 had undergone secondary treatments (prostate cryotherapy, HIFU, TUNA, urethral or rectal instrumentation). The remainder were related to colorectal malignancy (9), inflammatory bowel disease (3), and other (6). 29 patients had prior failed RUF repair. At last follow up, 53% of all 103 patients had no stoma. 17% and 12% had fecal and urinary diversion respectively, and 17% had 2 stomas. 78% had resolution while 8% had recurrence and 15% had persistence of RUF. 82 (80%) patients had undergone surgery for RUF repair at our institution (63 transperineal, 8 transanal, 6 abdominal, 5 cystectomy with diversion). 60% had no stoma, 15% and 17% had fecal or urinary diversion, 9% had 2 stomas. 25% of these 82 patients had complications (7 recurrences, 1 bowel anastomotic leak, 3 bowel obstruction, 1 cutaneous fistula, 1 ureteral injury, 6 infection, 2 deaths due to sepsis). Of the 75 patients with 1 or no stoma, 69 (92%) had resolution of RUF. Secondary treatments (as listed above) are associated with lower likelihood of 00no stoma00 (OR 0.28, p 1⁄4 0.049). CONCLUSIONS: Although the rate of RUF resolution is high, patients should be counseled on the possibility of permanent diversion and carefully selected for the optimal surgical management. In our overall series, 53% patients had no stoma, 39% had 1 stoma, and 17% had 2 stomas at 31-month follow up. Those with secondary treatments are less likely to have no stoma. Careful evaluation of the rectal repair is necessary prior to takedown of fecal diversion, as most complications occurred after this maneuver.

MP46-06 COMPARISON OF ADJUVANT RADIATION THERAPY BEFORE OR AFTER ARTIFICIAL URINARY SPHINCTER PLACEMENT: A MULTI-INSTITUTIONAL ANALYSIS

INTRODUCTION AND OBJECTIVES: Artificial Urinary Sphincter (AUS) remains the gold standard in the management of male stress urinary incontinence following radical prostatectomy. However, the impact of AUS placement before or after adjuvant radiation therapy has limited coverage in the literature. The objective of this study was to determine if the timing of radiation therapy has an impact on AUS outcomes, as well as identify predictors of AUS-related complications. METHODS: A retrospective review was conducted across five academic institutions of men who received AUS placement and adjuvant radiation therapy between 1993 and 2016. A total of 306 men were included in the study. Out of the 306 men, 292 (95.4%) received radiation before AUS placement (Group 1) and 14 (4.6%) men received radiation after AUS placement (Group 2). Collected variables included demographics, type of prostate cancer therapy, and AUS device specifications. Primary endpoints included complication rates, revision rates, and number of pads per day before and after AUS treatment. Bivariate analysis was used to examine the association between pretreatment comorbidities and the incidence of AUS-related complications postoperatively. RESULTS: Median duration of follow-up for the entire cohort was 30 months (range 4-148 months). Group 1 was followed for a median of 29 months (range 4-148 months), while Group 2 was followed for a median of 49 months (range 12-141 months). There was no difference between groups in the percentage of men who experienced postoperative complications (P 1⁄4 0.832). In Group 1, 26.0% of patients experienced postoperative complications while 28.6% of patients in Group 2 experienced postoperative complications. While the number of pads per day decreased significantly from before AUS placement to after AUS placement, there was no significant difference in the average number of pads used per day between Group 1 and Group 2 (P 1⁄4 0.907). The number of pads used per day in Group 1 before AUS placement was 5.24 3.12 which decreased to 1.13 1.31 (P < 0.001). In Group 2, the number of pads used per day before surgery was 6.09 1.97 which decreased to 1.53 0.99 pads per day after AUS placement (P < 0.001). The percentage of men requiring revision in Group 1 was 31.2%, while the percentage of revisions in Group 2 was 14.3%(P 1⁄4 0.028). The median time to revision was 14 months and 18.5 months for Group 1 and Group 2, respectively. The presence of peripheral vascular disease (PVD) and coronary artery disease (CAD) was associated with increased incidence of AUS-related complications (primarily refractory incontinence and cuff erosion) in both Groups (P 1⁄4 0.032). The following factors were not significant: age, race, smoking, hypertension, diabetes mellitus, dyslipidemia, BMI, AUS device specifications, type of radiation therapy. CONCLUSIONS: The timing of radiation therapy does not have a significant impact on complication rates or urinary continence as represented by number of pads used post-AUS placement. There is a non-statistical association between lower revision rates in patients who underwent radiation after AUS placement, as compared to before AUS placement. Patients with pre-existing PVD or CAD may experience more frequent postoperative complications, but this study is underpowered. Further research is needed to confirm these findings.