Nabeel Shakir

Equivocal Ureteropelvic Junction Obstruction on Diuretic Renogram—Should Minimally Invasive Pyeloplasty be Offered to Symptomatic Patients?

PURPOSE Equivocal ureteropelvic junction obstruction refers to clinical symptoms and/or other radiological suggestions of possible ureteropelvic junction obstruction but with inconclusive results of obstruction on diuretic renogram. We evaluated long-term outcomes in patients with equivocal ureteropelvic junction obstruction treated with minimally invasive pyeloplasty. MATERIALS AND METHODS We retrospectively analyzed the records of 125 consecutive patients who underwent minimally invasive pyeloplasty as performed by a single surgeon from May 2004 to July 2013. Of 98 patients with followup those with more than 6-month followup were included in analysis. Equivocal ureteropelvic junction obstruction, defined as half-life less than 20 minutes on diuretic renogram, was identified in 23 patients. All patients underwent transperitoneal minimally invasive pyeloplasty. We evaluated patient demographics, preoperative and postoperative symptoms and renal function. RESULTS The 16 female and 7 male patients with equivocal ureteropelvic junction obstruction had flank pain and associated hydronephrosis on imaging. At a median followup of 20.2 months (range 7 to 75) 95.7% of patients with equivocal obstruction achieved complete symptom resolution. Mean ± SD preoperative and postoperative half-life was 14.1 ± 3.7 and 7.4 ± 4.2 minutes, respectively, for an improvement of 6.7 minutes (p < 0.001). In 1 patient (4.3%) with equivocal obstruction of a complicated iatrogenic etiology treatment ultimately failed postoperatively and endopyelotomy was required. There was no statistically significant difference in clinical or radiological success between the equivocal obstruction group and the 75 patients treated with minimally invasive pyeloplasty for definitive ureteropelvic junction obstruction (p = 0.44 and 0.07, respectively). CONCLUSIONS In patients with radiographic equivocal ureteropelvic junction obstruction and flank pain minimally invasive pyeloplasty efficaciously provides symptomatic relief and functional preservation. Results are comparable to those in patients with high grade obstruction.

Comparative Effects of Irreversible Electroporation, Radiofrequency Ablation, and Partial Nephrectomy on Renal Function Preservation in a Porcine Solitary Kidney Model

OBJECTIVE To evaluate kidney function preservation or regeneration and pathological changes post-irreversible electroporation (IRE) in comparison with partial nephrectomy and radiofrequency ablation (RFA) in a solitary kidney porcine model. Tissue ablation using IRE has been reported to spare critical anatomic structures within or near the ablation zone with associated regeneration of adjacent parenchyma, possibly offering functional preservation. METHODS Fifteen pigs initially underwent laparoscopic nephrectomy. The lower third of the remaining kidney was then ablated or removed with either IRE, RFA, or partial nephrectomy. Serum creatinine (SCr) was measured at baseline, 24 hours, 3, 7, 14, and 28 days postoperatively. The impact of the type of procedure on SCr over time was evaluated. Acute and chronic histological changes were analyzed and cellular viability was assessed using nicotinamide adenine dinucleotide staining in the IRE ablations. RESULTS Ten ablations (5 IRE, 5 RFA) and 5 partial nephrectomies of the entire lower third of a solitary kidney were performed. The type of procedure did not affect SCr significantly at baseline (P = .14) or change in SCr over time (P = .48). Histologically, IRE and RFA lesions showed similar findings including coagulative necrosis that progressively was replaced by reparative stromal changes and fibrous tissue. Nicotinamide adenine dinucleotide staining of the IRE lesions at 14 and 28 days showed no viability in the necrotic areas with viable tissue at the margins demonstrating reparative changes. CONCLUSION Large volume IRE ablation of normal renal parenchyma in the porcine model does not provide a functional advantage as compared with conventional renal tumor treatments.

Delayed Reconstruction of Bulbar Urethral Strictures is Associated with Multiple Interventions, Longer Strictures and More Complex Repairs

Purpose: Prior to urethral reconstruction many patients with stricture undergo a variable period during which endoscopic treatments are performed for recurrent obstructive symptoms. We evaluated the association among urethroplasty delay, endoscopic treatments and subsequent reconstructive outcomes. Materials and Methods: We reviewed the records of men who underwent primary bulbar urethroplasty from 2007 to 2014. Those with prior urethroplasty, penile and/or membranous strictures and incomplete data were excluded from analysis. Men were stratified by a urethroplasty delay of less than 5, 5 to 10 or greater than 10 years from diagnosis. Results: A total of 278 primary bulbar urethroplasty cases with complete data were evaluated. Median time between stricture diagnosis and reconstruction was 5 years (IQR 2–10). Patients underwent an average ± SD of 0.9 ± 2.4 endoscopic procedures per year of delay. Relative to less than 5 and 5 to 10 years a delay of greater than 10 years was associated with more endoscopic treatments (median 1 vs 2 vs 5), repeat self‐dilations (13% vs 14% vs 34%), strictures longer than 2 cm (40% vs 39% vs 56%) and complex reconstructive techniques (17% vs 17% vs 34%). An increasing number of endoscopic treatments was independently associated with strictures longer than 2 cm (OR 1.06, p = 0.003), which had worse 24‐month stricture‐free survival than shorter strictures (83% vs 96%, p = 0.0003). Each consecutive direct vision internal urethrotomy was independently associated with the risk of urethroplasty failure (HR 1.19, p = 0.02). Conclusions: Urethroplasty delay is common and often associated with symptomatic events managed by repeat urethral manipulations. Endoscopic treatments appear to lengthen strictures and increase the complexity of repair.

Use of an Electronic Medical Record to Assess Patient-Reported Morbidity Following Ureteroscopy.

BACKGROUND AND PURPOSE With the extensive documentation afforded by our electronic medical record (EMR), we observed an unusually high number of patient-initiated encounters following ureteroscopy (URS). We sought to quantify and categorize patient encounters following URS to determine if we could identify avoidable common problems. MATERIALS AND METHODS Following IRB approval, we reviewed the records of 298 consecutive patients with stones who underwent 314 URS procedures between July 2013 and November 2014. Patient demographics, stone characteristics and operative details, as well as telephone encounters, secure online patient-initiated (MyChart) messages, and emergency department (ED) visits following URS were extracted from our EMR (Epic, Verona, WI). We performed univariate (UVA) and multivariate (MVA) analysis to identify factors predictive of postoperative patient encounters and compared URS patients to a group of 56 patients undergoing transurethral resection of bladder tumor (TURBT) for number and type of encounters. RESULTS We identified 443 encounters generated by 201 URS patients, including 334 telephone calls, 71 MyChart messages, and 38 ED visits. Among these encounters, 352 (79%) were medically related (pain comprised 45%) and the remainder involved scheduling issues. By UVA age, bilateral versus unilateral URS, stone location (both kidney and ureter), ureteral access sheath size, and total number of stones predicted a postoperative encounter. By MVA, only younger age and larger UAS size were independent predictors. When compared with TURBT patients, URS patients had a 2.5-fold higher risk of having a pain-related postoperative encounter (OR 2.54, 95% CI 1.08-7.04, P=0.03). CONCLUSIONS Among patients undergoing URS for stones, two-thirds made unprompted contact with a healthcare provider and 80% of contacts involved postoperative pain, a finding that is distinct from another endoscopic procedure that does not involve upper tract manipulation. Patients do not perceive URS as the benign procedure doctors do.

Preconditioning effect on cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND Recent experimental evidence indicates that endogenous mechanisms against cerebral vasospasm can be induced via preconditioning. OBJECTIVE To determine whether these vascular protective mechanisms are also present in vivo in humans with aneurysmal subarachnoid hemorrhage. METHODS A multicenter retrospective cohort of patients with aneurysmal subarachnoid hemorrhage was examined for ischemic preconditioning stimulus: preexisting steno-occlusive cerebrovascular disease (CVD) and/or previous cerebral infarct. Generalized estimating equation models were performed to determine the effect of the preconditioning stimulus on the primary end points of radiographic vasospasm, symptomatic vasospasm, and vasospasm-related delayed cerebral infarction and the secondary end point of discharge modified Rankin Scale score. RESULTS Of 1043 patients, 321 (31%) had preexisting CVD and 437 (42%) had radiographic vasospasm. Patients with preexisting CVD were less likely to develop radiographic vasospasm (odds ratio = 0.67; 95% confidence interval = 0.489-0.930; P = .02) but had no differences in other end points. In terms of the secondary end point, patients with preexisting CVD did not differ significantly from patients without preexisting CVD in mortality or unfavorable outcome in multivariate analyses, although patients with preexisting CVD were marginally more likely to die (P = .06). CONCLUSION This retrospective case-control study suggests that endogenous protective mechanisms against cerebral vasospasm-a preconditioning effect-may exist in humans, although these results could be the effect of atherosclerosis or some combination of preconditioning and atherosclerosis. Additional studies investigating the potential of preconditioning in aneurysmal subarachnoid hemorrhage are warranted.

Permanent Bulbar Urethral Ligation: Emerging Treatment Option for Incontinent Men With End-stage Urethra

OBJECTIVE To report our experience with permanent urethral ligation for severe incontinence among men with end-stage urethra. MATERIALS AND METHODS From our institutional artificial urinary sphincter database of 512 patients from 2010 to 2016, 10 men underwent permanent urethral ligation with concurrent suprapubic tube diversion following recurrent artificial urinary sphincter cuff erosion. Clinical characteristics and outcomes were evaluated. Quality of life was assessed using the Michigan Incontinence Symptom Index and the Patient Global Index of Improvement. RESULTS Urethral ligation resulted in resolution of incontinence in 8 men (80%), including 7 (70%) after 1 surgery and in 1 (10%) after a single revision. The average American Society of Anesthesiologists physical status rating was 2.7 (range 2-3). Seven patients (70%) experienced postoperative complications (4 Clavien-Dindo grade II complications [1 Clostridium difficile infection, 3 refractory bladder spasms) and 5 grade III complications (2 abscesses, 2 urethrocutaneous fistula, and 1 bladder stone formation]). Overall, satisfactory Michigan Incontinence Symptom Index urinary scores were reported in 8 (80%) men. On the Patient Global Index of Improvement, 6 (60%) men reported improvement in overall condition following surgery. All men (10/10) stated that they would recommend this procedure to others. CONCLUSION For debilitated men with end-stage urethra and severe refractory stress urinary incontinence, permanent urethral ligation with chronic suprapubic tube drainage can restore continence and improve quality of life without the need for more invasive formal urinary diversion, though with a high risk of complication.

CHANGING TRENDS IN RECONSTRUCTION OF COMPLEX ANTERIOR URETHRAL STRICTURES: FROM SKIN FLAP TO PERINEAL URETHROSTOMY

OBJECTIVE To evaluate procedural trends and outcomes for reconstruction of complex strictures at our tertiary center over the last decade. METHODS We retrospectively reviewed complex urethral reconstruction comparing 3 techniques: (1) buccal mucosal graft (BMG), (2) penile skin flap, or (3) perineal urethrostomy (PU) at our center (2007-2017) with ≥6 months follow-up. Strictures amenable to anastomotic repair were excluded. Success was defined as no need for further operative management. RESULTS Among 1129 strictures cases, 403 complex strictures were identified for analysis (median length 4.5 cm). Median age was 53.2 years (standard deviation ± 14.9). Reconstruction was most commonly performed using BMG (61.3%), followed by penile skin flap (21.6%) and PU (19.1%). PU use has increased steadily over the past decade, rising from 4.3% of case volume in 2008 to 38.7% in 2017 (P = .01). Over time, the proportion of reconstruction using BMG has remained stable, while penile skin flaps are now less commonly utilized. Over a median follow-up of 50.7 months, 16.9% (68/403) patients failed at a median of 13.9 months. Success rates were higher following PU (94.8%) compared to BMG and skin flaps (78.5% and 78.2%, respectively) (P = .003) despite PU patients being older (median age 62.6 years), having longer strictures (median 5.0 cm) and more commonly having lichen sclerosus (LS) (22.1%). CONCLUSION Over a decade of a urethral reconstructive practice, PU has increasingly become preferred for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for these complex strictures are markedly higher than those of grafts and flaps.

Improving Male Sling Selectivity and Outcomes—A Potential Role for Physical Demonstration of Stress Urinary Incontinence Severity?

Introduction: We reviewed our 9‐year experience with AdVance™ Male Sling System cases to determine clinical features associated with treatment success and to refine procedure selectivity. We hypothesized that preoperative physical demonstration of stress urinary incontinence by the standing cough test improves patient selection for male sling surgery. Methods: Retrospective review of primary AdVance sling surgeries between 2008 and 2016 was performed. Patients without standing cough test results were excluded from study. Success was defined as 1 pad per day or less postoperatively and no further intervention. Standing cough test was performed during preoperative consultation and objectively graded using the MSIGS (Male Stress Incontinence Grading Scale). Results: Of the 203 male patients who underwent sling placement 80 (39%) experienced treatment failure during a median followup of 63.5 months. From 2008 to 2016 the proportion of AdVance slings performed as a surgical treatment modality for stress urinary incontinence decreased from 66% to 13%. Increasing selectivity correlated with greater treatment success. Success was greater among men using 2 pads per day or less preoperatively (77% vs 36%, p <0.0001), having physical findings of mild stress urinary incontinence (MSIGS grade 0‐2 on standing cough test, 67% vs 26%, p <0.0001) and without a history of radiation (64% vs 41%, p=0.02). In combination, men without prior radiation with mild stress urinary incontinence and favorable standing cough test were “ideal patients” with an 81% success rate. Incremental increases in pad per day use (OR 1.8 per pad, p <0.0001) and MSIGS grade (OR 1.7 per grade, p=0.005) were independently associated with treatment failure. Conclusions: Increasing selectivity has improved sling outcomes for men with stress urinary incontinence. Ideal sling candidates have not received radiation therapy, and have history and physical findings suggestive of mild stress urinary incontinence.

Oxidized Regenerated Cellulose (Fibrillar™) Reduces Risk of Postoperative Corporal Bleeding Following Inflatable Penile Prosthesis Surgery

OBJECTIVE To report our initial experience with oxidized regenerated cellulose (ORC; Surgicel Fibrillar) as a hemostatic adjunct during inflatable penile prosthesis (IPP) surgery. MATERIALS AND METHODS Beginning in April 2016, ORC pledgets were placed within the corporotomy closures of all men undergoing IPP insertion. Perioperative characteristics and outcomes including cumulative postoperative drain output were evaluated among consecutive cases with (April 2016 to October 2016) and without ORC (December 2015 to March 2016) using an identical surgical technique by a single surgeon. RESULTS During the study period, 64 men underwent IPP implantation, of whom 32 (50%) received ORC. There was a significant reduction in median drain output relative to controls (33 mL vs 65 mL; P = .01). Postoperatively, ORC use was associated with a reduction in the number of patient phone calls for scrotal-related concerns in the immediate postoperative period (average 0.5 vs 1.1; P = .03). There were 3 IPP explantations in the non-ORC group (2/3 for infection)-one of which was directly related to an infected hematoma. After controlling for other clinical features, the use of ORC (β -32, 95% confidence interval: -61 to -5; P = .02) was independently associated with a reduction in drain output. CONCLUSION ORC use during IPP corporotomy closure reduces postoperative drain output, a known risk factor for hematoma-related complications.

Low Serum Testosterone is Present in Nearly Half of Men Undergoing Artificial Urinary Sphincter Placement

OBJECTIVES To report the prevalence of low serum testosterone (LST) in men undergoing artificial urinary sphincter (AUS) placement at a single high-volume institution. METHODS We retrospectively reviewed all men undergoing AUS procedures by a single surgeon from January 2015 to January 2018 to identify men with pretreatment total serum testosterone levels. LST was defined as less than 280 ng/dL. Patients with only posttreatment testosterone levels were excluded. Demographic characteristics and clinical outcomes were compared between men with and without LST. RESULTS Among 113 patients who underwent AUS with pretreatment serum testosterone levels drawn an average of 2.2 months before AUS surgery, 45.1% (51 of 113) met criteria for LST, including 18 patients on androgen deprivation therapy. The rate of primary LST was 34.7% (33 of 95). The median total serum testosterone level among men with LST was 118 ng/dL (interquartile range 6-211), and 413 mg/dL (interquartile range 333-550) in the normal serum testosterone group. There were no differences in patient age, history of radiation, erectile dysfunction, or other comorbidities between the groups. Body mass index was higher in the LST group compared to normal serum testosterone (30 vs 27 kg/m2, P = .001). Cuff size and rates of transcorporal cuff placement were similar between groups. CONCLUSION Nearly one-half of men with stress urinary incontinence undergoing AUS placement present with LST. While AUS cuff erosion appears to be more common in men with LST, further study is needed to determine if treating LST will reduce cuff erosion rates.