Matthew D. Lyons

Surgical bladder-preserving techniques in the management of muscle-invasive bladder cancer

PURPOSE Bladder preservation surgical strategies for the treatment of invasive bladder cancer have been developed to provide options to those patients who are medically unfit to undergo radical extirpative surgery or prefer conservative therapy for limited disease. The purpose of this manuscript is to review the available bladder-preserving surgical techniques for treatment of muscle-invasive bladder cancer. METHODS We performed a thorough literature search to determine the available bladder-preserving treatments for muscle-invasive bladder cancer as well as their corresponding outcomes. RESULTS Available surgical strategies include radical transurethral resection (TUR) with or without neoadjuvant chemotherapy, partial cystectomy and multi-modal therapy. Patient selection is critical in determining which patients can safely be offered bladder preservation therapies. Disease characteristics that portend more favorable outcomes in the setting of bladder preservation include cT2 stage, unifocal tumor, the absence of carcinoma in situ and hydronephrosis, and complete TUR. Several new technologies, including fluorescence and cryoablation treatment, have been incorporated into existing treatment modalities to improve surgical precision and margins. Ongoing studies aimed at improving the accuracy of clinical staging can further refine patient selection and improve clinical outcomes. CONCLUSIONS Surgical bladder preservation techniques for treatment of invasive bladder cancer requires careful, long-term follow-up. Prospective, randomized studies comparing bladder sparing treatment modalities with radical cystectomy are needed, but ultimately will be difficult to accrue due to a variety of factors.

Lisdexamfetamine Dimesylate (Vyvanse) for the Treatment of Neurogenic Anejaculation

Dear Editor: We report the first successful pharmacologic treatment of neurogenic anejaculation with lisdexamfetamine dimesylate (Vyvanse) in a 22 year-old Caucasian male with a history of pediatric pelvic neuroblastoma. At 2 years of age, the patient was found to have a pelvic mass abutting the sacrum and iliac vessels. Surgical excision required dissection along the sacral prominence and sacral nerve roots. He did not undergo chemotherapy or radiation as part of his treatment course for neuroblastoma. The patient was referred to our fertility clinic for a lifelong history of anejaculation and aspermia with normal sensation of climax. The patient described a single small volume ejaculation several years prior following administration of lisdexamfetamine dimesylate (Vyvanse). The patient denied problems with libido, erectile dysfunction, and orgasm. Physical exam was unremarkable and revealed normal testicular volume of 20 cc bilaterally. He underwent hormonal evaluation and was found to have normal serum total testosterone of 720 ng/dL, follicle-stimulating hormone 5.8 mIU/mL, and luteinizing hormone 3.8 mIU/mL. A postejaculate urinalysis did not reveal sperm. A pelvic magnetic resonance imaging study was unremarkable. Given his history, we elected to try a short course of intermittent dosing of lisdexamfetamine dimesylate (Vyvanse) 60 mg 2 hours prior to masturbation. With the first use of the medication he produced an antegrade ejaculate. Following a short trial of lisdexamfetamine dimesylate, he returned to clinic for a semen analysis, which demonstrated low volume asthenoteratospermia (Table 1). He reported no adverse events, but did note a subjective temporary decrease in his erectile rigidity, which reversed after the drug was metabolized. This case is the first reported use of lisdexamfetamine dimesylate (Vyvanse) for the treatment of neurogenic anejaculation. Anejaculation is a rare cause of male factor infertility and can result in significant psychoemotional distress. Etiologies of neurogenic anejaculation include spinal cord injury, low abdominal or pelvic surgery such as retroperitoneal lymph node dissection, diabetes mellitus, and other diseases causing peripheral neuropathy, myelodysplasia, multiple sclerosis, and stroke or traumatic brain injury. Treatment approaches include pharmacologic strategies, penile vibratory stimulation, and electroejaculation, often tried in that order. Off-label pharmacologic treatments have been attempted based on knowledge of anatomic and physiologic considerations. Emission is under neural control originating from the thoracolumbar spine at the T10-L2 level. Sympathetic efferent fibers form the lumbar sympathetic trunk ganglia then travel posterior to the inferior vena cava in the interaortocaval region and continue inferiorly and coalesce to form the superior hypogastric plexus anterior to L5 and the sacrum. Ultimately, postganglionic fibers travel to their target organs including the seminal vesicles, bladder neck, prostate, and vasa deferentia to combine to mediate sympathetic control during the emission phase (Safarinejad, 2009). While the exact mechanisms of neurotransmitter control over ejaculation have not been fully elucidated, dopaminergic pathways have frequently been associated with ejaculatory function. Parkinson’s disease patients treated with L-DOPA have reported hypersexuality with more frequent masturbation, sexual hallucinations, and 658640 JMHXXX10.1177/1557988316658640American Journal of Men’s HealthLyons et al. letter2016

Special considerations for placement of an inflatable penile prosthesis for the patient with Peyronie's disease: techniques and patient preference.

Placement of an inflatable penile prosthesis (IPP) is the mainstay of surgical treatment for patients with Peyronie’s disease (PD) and concomitant medication-refractory erectile dysfunction. Special considerations and adjunctive surgical techniques during the IPP procedure are often required for patients with PD to improve residual penile curvature, as well as postoperative penile length. The surgical outcomes and various adjunctive techniques are not significantly different from one another, and selection of the appropriate technique must be tailored to patient-specific factors including the extent of the deformity, the degree of penile shortening, and preoperative patient expectations. The aims of this review were to assess the current literature on published outcomes and surgical techniques involving IPP placement in the treatment of PD. Patient satisfaction and preferences are reported, along with the description and patient selection for surgical techniques that include manual penile modeling, management of refractory curvature with concurrent plication, and correction of severe residual curvature and penile shortening with tunica release and plaque incision and grafting. A thorough description of the available techniques and their associated outcomes may help guide surgeons to the most appropriate choice for their patients.

Patient Selection and Counseling for Urinary Diversion

Patient selection and preoperative counseling are critical aspects of determining which urinary diversion to perform and should be emphasized at each stage of preoperative planning. The surgeon must have a thorough understanding of the patients disease process, functional and psycho-emotional status, and social support network so that they can set appropriate expectations. It is also crucial to have a multidisciplinary team of individuals who are experienced with all aspects of urinary diversion care, including ostomy nurses, nurse navigators, and urologic surgeons skilled at teaching and trouble-shooting self-catheterization for continent cutaneous diversion and orthotopic diversion in the setting of hypercontinence.

MP90-17 ASSESSING THE CARE OF KIDNEY STONE PATIENTS IN THE PRIMARY CARE SETTING

on stone activity is not well studied. Our goal was to determine if SI CaOx correlates with stone activity in calcium oxalate (CaOx) stone formers. METHODS: We reviewed the charts of 604 patients from our stone clinic between 2005 and 2016 and identified CaOx stone formers who had a baseline 24-hour urine collection and at last one follow-up urine collection after the initiation of drug and/or dietary therapy. Patient demographics, imaging studies, serum chemistries, and 24-hour urine studies were recorded in a timeline for each patient. SI was calculated using JESS for each 24-hour urine study. Stone recurrence (SR) was defined as stone growth or new stone formation and no recurrence (NR) indicated no new stone formation. Absolute SI values were compared between times of SR and times of NR, and change in SI from baseline to time of SR were correlated with SI. Statistical analysis was performed with SAS, and significance was set at p<0.05. RESULTS: In total, 255 patients with 358 events were included in the analysis. Mean patient age was 51 13 SD years, with a male:female ratio of 1.3. Comparing NR (98 patients with 97 events) to SR (157 patients with 113) demonstrated no significant difference in mean SI CaOx values (5.6 2.8 versus 5.6 2.9, p1⁄40.6). In addition, in patients who experienced SR (n1⁄4157) no significant difference was seen comparing mean SI CaOx values during NR (n1⁄4148) or SR (n1⁄4113) events (5.9 2.8 versus 5.6 2.9, respectively, p1⁄40.08). For all patients with SR, 65 were identified who experienced both changes from SR to NR (median DSI CaOx 0.20, IQR -1.46-1.21) and NR to SR (median DSI CaOx 0.52, IQR -1.55-1.47). No significant difference was seen (p1⁄40.84). CONCLUSIONS: At first evaluation, neither absolute nor change in SI correlates with stone recurrence and may not be a reliable way to follow effectiveness of medical therapy.

Understanding the Relationship Between 30- and 90-Day Emergency Room Visits, Readmissions, and Complications after Radical Cystectomy

comorbidity status, non-Medicaid insurance, discharge to home, and Hartmann’s resection performed by a high-volume colorectal surgeon or hospital. After controlling for patient, surgeon, and hospital characteristics, high surgeon and/or hospital volume were independently associated with a laparoscopic approach, shorter length of stay, and lower rates of ICU admission, 30-day readmission, and 90day mortality after stoma reversal (Table).