Joshua A. Broghammer

Fournier’s Gangrene: Population Based Epidemiology and Outcomes

PURPOSE Case series have shown a Fourniers gangrene mortality rate of 20% to 40% with an incidence of as high as 88% in some studies. Because to our knowledge there are no population based data, we used a national database to investigate the epidemiology of Fourniers gangrene. MATERIALS AND METHODS We used the State Inpatient Databases, the largest hospital based database available in the United States, which includes 100% of hospital discharges from participating states. Inpatients diagnosed with Fourniers gangrene (ICD-9 CM 608.83) who underwent genital/perineal débridement or died in the hospital were identified from 13 participating states in 2001 and from 21 in 2004. Population based incidence, regional trends and case fatality rates were estimated. RESULTS We identified 1,641 males and 39 females with Fourniers gangrene. Cases represented less than 0.02% of hospital admissions. The overall incidence was 1.6/100,000 males, which peaked in males who were 50 to 79 years old (3.3/100,000) with the highest rate in the South (1.9/100,000). The overall case fatality rate was 7.5%. Patients with Fourniers gangrene were rarely treated at hospitals (mean +/- SD 0.6 +/- 1.2 per year, median 0, range 0 to 23). Overall 0 to 4 and 5 or greater cases were treated at 66%, 17%, 10%, 4%, 1% and 1% of hospitals, respectively. CONCLUSIONS Patients with Fourniers gangrene are rarely treated at most hospitals. The population based mortality rate of 7.5% was substantially lower than that reported in case series from tertiary care centers.

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.

Multi-institutional 1-Year Bulbar Urethroplasty Outcomes Using a Standardized Prospective Cystoscopic Follow-up Protocol

OBJECTIVE To evaluate multi-institutional outcomes of bulbar urethroplasty utilizing a standardized cystoscopic follow-up protocol. METHODS Eight reconstructive surgeons prospectively enrolled urethral stricture patients in a multi-institutional study and performed postoperative cystoscopy at 3 and 12 months. Anatomic failure was defined as the inability to pass a flexible cystoscope without force. Functional failure was defined as the need for a secondary procedure. Men not compliant with the 12-month cystoscopy were called and asked if any interval secondary procedures had been performed. Patients with bothersome voiding complaints at cystoscopy were considered symptomatic. RESULTS Of 213 men in study, 136 underwent excisional urethroplasty (excision and primary anastomosis [EPA]) and 77 underwent repair with buccal grafts. Cystoscopy compliance was 79.8% at 3 months and 54.4% at 12 months. Anatomic success rates were higher at 3 vs 12 months for EPA repairs (97.2% [106 of 109] vs 85.5% [65 of 76; P=.003] but not buccal repairs (85.5% [53 of 62] vs 77.5% [31 of 40]; P=.30). Functional success rates at a year were higher but statistically similar to anatomical success rates (EPA-90.3% [93 of 103]; P=.33; buccal-87% [47 of 54]; P=.22). Of the 20 anatomic recurrences, only 13 (65%) were symptomatic at the time of cystoscopic diagnosis. CONCLUSION Rates of success are lower when using the anatomic vs traditional definition. Of recurrences found by cystoscopy, only 65% were symptomatic. One-year patient cystoscopy compliance was poor and its ability to be used as the gold standard screening methodology for recurrence is questionable.

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.

Penile fracture and magnetic resonance imaging

A thirty-three-year-old male presented to an outside emergency department with scrotal swelling and pain after intercourse. A scrotal ultrasound revealed hematoma, with no other abnormalities and the patient was discharged. He then presented to our institution where examination showed diffuse ecchymosis through the shaft of the penis, suprapubic region, and scrotum without a palpable cavernosal defect. Magnetic resonance imaging (MRI) without contrast was obtained after the injection of 10 micrograms of intracavernosal alprostadil. The low signal tunica albuginea is easily demarcated compared to the high T2 and intermediate T1 signal of the corpora cavernosum (Figures 1-3) (1,2). Hematoma shows heterogeneous intermediate T1 and T2 signal (Figures 2 and 3) (1). Penile fracture is rupture of the corpus cavernosum from blunt trauma to the erect penis (3,4). Typical presentation is a pop during intercourse, immediate detumescence with edema, hematoma and penile deformity (3,4). In atypical presentations, radiological studies may be useful to determine the diagnosis. MRI provides the ability to identify disruption of the corpus cavernosum due to excellent tissue contrast and Penile Fracture and Magnetic Resonance Imaging _______________________________________________

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.

High-grade Renal Injuries: Radiographic Findings Correlated with Intervention for Renal Hemorrhage

With the advent of advanced trauma critical care, and precise methods of assessing renal trauma with computed tomography, most patients with high-grade renal trauma can be managed conservatively. Some patients, however, do not do well with conservative management. This article evaluates specific radiographic characteristics that have recently been associated with intervention for renal hemorrhage after trauma.

Urethral Stricture Outcomes After Artificial Urinary Sphincter Cuff Erosion: Results From a Multicenter Retrospective Analysis

OBJECTIVE To evaluate the influence of both repair type and degree of cuff erosion on postoperative urethral stricture rate. Sparse literature exists regarding patient outcomes after artificial urinary sphincter (AUS) cuff erosion. Surgeons from 6 high-volume male continence centers compiled a comprehensive database of post-erosion patients to examine outcomes. MATERIALS AND METHODS This retrospective multi-institution study included 80 patients treated for AUS cuff erosions. Seventy-eight patients had specific information regarding post-cuff erosion urethral strictures. Erosion patients were categorized into 1 of 3 repair types at the time of explant surgery: catheter only, single-layer capsule-to-capsule repair (urethrorrhaphy), and formal urethroplasty. Operative notes and available medical records were extensively reviewed to collect study data. RESULTS Twenty-five of 78 patients manifested a urethral stricture after AUS cuff erosion (32%). More strictures occurred among patients who underwent urethrorrhaphy (40% vs 29% for catheter only and 14% for urethroplasty). Stricture rates did not vary significantly by repair type (P = .2). Strictures occurred significantly more frequently in patients with complete cuff erosions (58%) as compared to partial erosions (25%, P = .037). A trend was detected regarding increased percentage of erosion correlating with increased stricture rate, but this did not reach statistical significance (P = .057). Partially eroded patients were more likely to undergo urethrorrhaphy repair (60%, P = .002). CONCLUSION Urethral stricture was more likely to occur after complete cuff erosion as opposed to partial erosion in this multicenter retrospective population. Repair type, whether catheter only, urethrorrhaphy, or formal urethroplasty, did not appear to influence postoperative stricture rate.

Prior Radiation Therapy Decreases Time to Idiopathic Erosion of Artificial Urinary Sphincter: A Multi-Institutional Analysis

Purpose: Substantial controversy and conflicting data exist regarding the survival of the artificial urinary sphincter in patients with prior radiation therapy. We present data from a multi‐institutional analysis examining the effect of prior radiation for prostate cancer on device survival. Materials and Methods: A database was compiled of patients with artificial urinary sphincter cuff erosion, which included demographic and comorbid patient characteristics, functional analyses and interventions. We identified 80 patients with iatrogenic or idiopathic artificial urinary sphincter erosion. Idiopathic erosion cases were further analyzed to determine factors influencing device survival with specific stratification for radiation therapy. Results: A total of 56 patients were identified with idiopathic artificial urinary sphincter erosion. Of those men 33 (58.9%) had not undergone radiation treatment while 23 (41.1%) had a history of brachytherapy or external beam radiotherapy. In patients without radiation erosion‐free median device survival was 3.15 years (95% CI 1.95–5.80), in contrast to the median device survival of only 1.00 year (95% CI 0.36–3.00) in irradiated patients. The erosion‐free survival experience of patients with vs without radiation differed significantly (Wilcoxon‐Breslow test for equality of survivor functions p = 0.03). Conclusions: Radiation therapy in patients with known idiopathic cuff erosion in this contemporary analysis correlated with significantly increased time to erosion. Mean time to idiopathic cuff erosion was accelerated by approximately 2 years in irradiated cases. To our knowledge these data represent the first demonstration of substantial outcome differences associated with radiation in patients with an artificial urinary sphincter who present specifically with cuff erosion.