Jordan Siegel

Does Pressure Regulating Balloon Location Make a Difference in Functional Outcomes of Artificial Urinary Sphincter

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.

Malleable Penile Prosthesis Is a Cost-Effective Treatment for Refractory Ischemic Priapism

INTRODUCTION Refractory ischemic priapism (RIP) can be difficult to treat, consuming significant healthcare-related resources. Acute insertion of a malleable penile prosthesis (MPP) has been reported as an effective therapy that treats the priapism and restores sexual function. AIM We report our 6-year, urban public hospital experience with acute insertion of MPP in patients with RIP. METHODS We retrospectively reviewed the records of patients receiving MPPs for RIP from 2007 to 2013. Data analyzed included duration of erection, number of emergency room (ER) visits, hospital admissions, days of hospitalization, and postoperative course. Costs were estimated using standard Medicare reimbursement rates. MAIN OUTCOME MEASURE Healthcare-related costs of treatment of RIP episodes in men presenting to our institution. RESULTS During the study period, 14 men underwent MPP placement acutely for refractory priapism. Thirteen presented with RIP, and one had stuttering priapism over a 14-day hospitalization. Etiologies included sickle cell anemia (4/13, 29%), medication-induced (3/14, 21%), and idiopathic (7/14, 50%). Average preoperative duration of RIP was 82 hours with considerable consumption of health-care resources (average US

Ventral Slit Scrotal Flap: A New Outpatient Surgical Option for Reconstruction of Adult Buried Penis Syndrome

83,818 estimated cost, 4 ER visits [range 1-27], 2 hospital admissions [range 1-5], 1.5 shunt procedures [range 1-3], 5 irrigation and drainage procedures using phenylephrine injection [range 2-20], and 5 hospital admission days [range 2-14]). All patients were discharged within 24 hours of MPP surgery. CONCLUSIONS The management of RIP is associated with multiple ER visits, prolonged hospital admissions, and significant resource utilization. MPP insertion is efficacious for the immediate resolution of refractory priapism, with potential cost and resource benefits.

Low Serum Testosterone Level Predisposes to Artificial Urinary Sphincter Cuff Erosion

INTRODUCTION We present a novel technique using ventral slit with scrotal skin flaps (VSSF) for the reconstruction of adult buried penis without skin grafting. TECHNICAL CONSIDERATIONS An initial ventral slit is made in the phimotic ring, and the penis is exposed. To cover the defect in the ventral shaft skin, local flaps are created by making a ventral midline scrotal incision with horizontal relaxing incisions. The scrotal flaps are rotated to resurface the ventral shaft. Clinical data analyzed included preoperative diagnoses, length of stay, blood loss, and operative outcomes. Complications were also recorded. Fifteen consecutive patients with a penis trapped due to lichen sclerosus (LS) or phimosis underwent repair with VSSF. Each was treated in the outpatient setting with no perioperative complications. Mean age was 51 years (range, 26-75 years), and mean body mass index was 42.6 kg/m(2) (range, 29.8-53.9 kg/m(2)). The majority of patients (13 of 15, 87%) had a pathologic diagnosis of LS. Mean estimated blood loss was 57 cc (range, 25-200 cc), mean operative time was 83 minutes (range, 35-145 minutes), and all patients were discharged on the day of surgery. The majority of patients (11 of 15, 73.3%) remain satisfied with their results and have required no further intervention. Recurrences in 3 of 15 (20.0%) were due to LS, panniculus migration, and concealment by edematous groin tissue; 2 of these patients underwent subsequent successful skin grafting. CONCLUSION VSSF is a versatile, safe, and effective reconstructive option in appropriately selected patients with buried penis, which enables reconstruction of penile shaft skin defects without requiring complex skin grafting.

Classification System for Individualized Treatment of Adult Buried Penis Syndrome.

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 testosterone 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.

In situ urethroplasty after artificial urinary sphincter cuff erosion

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.

The case for excision and primary anastomotic urethroplasty for bulbar urethral stricture

Artificial urinary sphincter (AUS) cuff erosion is a challenging complication traditionally managed with device removal and Foley catheter drainage. Urethral stricture can result secondary to the healing process, delaying AUS reimplantation. In situ urethroplasty (ISU) technique is a definitive repair at the time of device removal. Early results demonstrate a decreased rate of stricture formation compared to traditional management with little additional operative time and no additional complications. Patients undergoing ISU have less delay prior to AUS reimplantation, leading to possible benefit in health-related quality of life (HRQL) outcomes.

Opinion: Anastomotic urethroplasty

With an estimated prevalence of 296 to 627 per 100.000 men, male urethral stricture disease imposes a significant burden on the health care system (1, 2). Urethroplasty has demonstrated durable, high success rates in the management of a wide spectrum of stricture disease, far exceeding that of the more commonly performed but less successful direct vision internal urethrotomy (DVIU) (1, 3-5). While procedure selection depends on stricture characteristics (length, location, and etiology), the high success rate of excision and primary anastomotic (EPA) urethroplasty makes it the procedure of choice for most strictures of the bulbar urethra (6). However, concerns regarding the effect of urethral transection on male sexual health has led some centers to advocate for substitution urethroplasty (7), likely contributing to an increase in these procedures (8). Our objective is to review the literature supporting EPA urethroplasty in strictures of the bulbar urethra.

Role of Penile Prosthesis Insertion in the Treatment of Acute Priapism

With an estimated prevalence of 296 to 627 per 100,000 men, male urethral stricture disease imposes a significant burden on the health care system (1, 2). Urethroplasty has demonstrated durable, high success rates in the management of a wide spectrum of stricture disease, far exceeding that of the more commonly performed but less successful direct vision internal urethrotomy (DVIU) (1, 3-5). While procedure selection depends on stricture characteristics (length, location, and etiology), the high success rate of excision and primary anastomotic (EPA) urethroplasty makes it the procedure of choice for most strictures of the bulbar urethra (6). However, concerns regarding the effect of urethral transection on male sexual health has led some centers to advocate for substitution urethroplasty (7), likely contributing to an increase in these procedures (8). Our objective is to review the literature supporting EPA urethroplasty in strictures of the bulbar urethra.

Repeat Excision and Primary Anastomotic Urethroplasty for Salvage of Recurrent Bulbar Urethral Stricture

Ischemic priapism must be expeditiously treated to prevent corporal fibrosis, penile shortening, and erectile dysfunction. Medical therapy with corporal aspiration and irrigation is a useful first-line therapy, but in refractory cases, invasive procedures are typically necessary. Though sometimes effective, shunt surgeries are not universally successful in achieving detumescence and exacerbate corporal scarring, which makes subsequent penile prosthesis insertion more difficult. Insertion of a penile prosthesis during an acute episode of refractory, ischemic priapism alleviates pain and allows the patient to resume sexual function earlier. It also obviates the corporal scarring that may significantly shorten the penis and complicate subsequent prosthesis insertion.