Nathan C. Wong

The contemporary role of 1 vs. 2-stage repair for proximal hypospadias

This review discusses the most commonly employed techniques in the repair of proximal hypospadias, highlighting the advantages and disadvantages of single versus staged surgical techniques. Hypospadias can have a spectrum of severity with a urethral meatus ranging from the perineum to the glans. Associated abnormalities are commonly found with proximal hypospadias and encompass a large spectrum, including ventral curvature (VC) up to 50 degrees or more, ventral skin deficiency, a flattened glans, penile torsion and penoscrotal transposition. Our contemporary understanding of hypospadiology is comprised of a foundation built by experts who have described a number of techniques and their outcomes, combined with survey data detailing practice patterns. The two largest components of hypospadias repair include repair of VC and urethroplasty. VC greater than 20 degrees is considered clinically relevant to warrant surgical correction. To repair VC, the penis is first degloved—a procedure that may reduce or remove curvature by itself in some cases. Residual curvature is then repaired with dorsal plication techniques, transection of the urethral plate, and/or ventral lengthening techniques. Urethroplasty takes the form of 1- or 2-stage repairs. One-stage options include the tubularized incised urethroplasty (TIP) or various graft or flap-based techniques. Two-stage options also include grafts or flaps, including oral mucosal and preputial skin grafting. One stage repairs are an attractive option in that they may reduce cost, hospital stay, anesthetic risks, and time to the final result. The downside is that these repairs require mastery of multiple techniques may be more complex, and—depending on technique—have higher complication rates. Two-stage repairs are preferred by the majority of surveyed hypospadiologists. The 2-stage repair is versatile and has satisfactory outcomes, but necessitates a second procedure. Given the lack of clear high-quality evidence supporting the superiority of one approach over the others, hypospadiologists should develop their own algorithm, which gives them the best outcomes.

The Influence of Pre-Operative Hormonal Stimulation on Hypospadias Repair

Androgen stimulation to temporarily promote penile growth has been commonly used to facilitate hypospadias repair. Although some series suggest improvement in both functional and cosmetic outcomes, a recent systematic review and meta-analysis showed a possible relationship between pre-operative hormonal stimulation and higher complications. As a result, indications and treatment regimens remain controversial. Here, we review the available literature and present our clinical practice.

Can it wait? A systematic review of immediate vs. delayed surgical repair of penile fractures

INTRODUCTION Penile fractures have classically been thought to require immediate surgical intervention; however, recent series have described acceptable outcomes with delayed repair. In this systematic review, we compared complication rates between immediate and delayed repair of penile fractures. METHODS A systematic search of MEDLINE, Embase, CENTRAL, and Web of Science was performed with predefined search terms between 1974 and 2015. Titles and abstracts were screened prior to full-text review and quality appraisal by two independent investigators. Abstracted outcomes included postoperative erectile dysfunction (ED), tunical scar formation, and penile curvature. Only studies reporting a direct comparison of complications following immediate (<24 hours from injury to presentation/surgery) and delayed (>24 hours) repair of penile fractures were included. RESULTS A total of 12 studies met inclusion criteria. All were retrospective, observational studies of low or moderate methodological quality. Of the reported 502 patients, 391 underwent immediate repair and 111 delayed repair. In the immediate repair group, the percent of patients with postoperative ED, tunical scars, and curvature were 6.6%, 5.4%, and 1.8%, respectively, while in the delayed group, the rates of ED, tunical scars, and curvature were 4.5% across the board. Rates of ED and tunical scar formation following immediate compared to delayed repair trended towards favouring immediate repair, but did not differ significantly, while rates of curvature significantly favoured immediate repair. However, cases of curvature were typically reported as mild and none affected sexual functioning. CONCLUSIONS In this systematic review, we demonstrated that ED and tunical scar formation rates between immediate and delayed repair of penile fractures were statistically similar, while immediate repair had a lower rate of penile curvature. Although this suggests that a brief delay in repair may be acceptable in select patients, the results should be interpreted with caution, as the included studies were of low or moderate methodological quality. Most importantly, this review highlights the deficiencies in the current penile fracture literature, setting the stage to improve the quality of future studies.

Misuse of ultrasound for palpable undescended testis by primary care providers: A prospective study

INTRODUCTION Although previous evidence has shown that ultrasound is unreliable to diagnose undescended testis, many primary care providers (PCP) continue to misuse it. We assessed the performance of ultrasound as a diagnostic tool for palpable undescended testis, as well as the diagnostic agreement between PCP and pediatric urologists. METHODS We performed a prospective observational cohort study between 2011 and 2013 for consecutive boys referred with a diagnosis of undescended testis to our tertiary pediatric hospital. Patients referred without an ultrasound and those with non-palpable testes were excluded. Data on referring diagnosis, pediatric urology examination and ultrasound reports were analyzed. RESULTS Our study consisted of 339 boys. Of these, patients without an ultrasound (n = 132) and those with non-palpable testes (n = 38) were excluded. In the end, there were 169 pateints in this study. Ultrasound was performed in 50% of referred boys showing 256 undescended testis. The mean age at time of referral was 45 months. When ultrasound was compared to physical examination by the pediatric urologist, agreement was only 34%. The performance of ultrasound for palpable undescended testis was: sensitivity = 100%; specificity = 16%; positive predictive value = 34%; negative predictive value = 100%; positive likelihood ratio = 1.2; and negative likelihood ratio = 0. Diagnosis of undescended testis by PCP was confirmed by physical examination in 30% of cases, with 70% re-diagnosed with normal or retractile testes. CONCLUSION Ultrasound performed poorly to assess for palpable undescended testis in boys and should not be used. Although the study has important limitations, there is an increasing need for education and evidence-based guidelines for PCP in the management of undescended testis.

A Randomized Comparison of 2 Robotic Virtual Reality Simulators and Evaluation of Trainees' Skills Transfer to a Simulated Robotic Urethrovesical Anastomosis Task

OBJECTIVE To determine, via a randomized comparison study, whether robotic simulator-acquired skills transfer to performance of a urethrovesical anastomosis (UVA) on a 3-dimensional-printed bladder model using the da Vinci Robot. MATERIALS AND METHODS Medical students, surgical residents, and fellows were recruited and divided into 2 groups: Group 1 (G1) (junior trainees) and Group 2 (G2) (senior trainees). Participants were randomized to identical simulator training curricula on the dV-Trainer (dV-T) or da Vinci Surgical Skills Simulator (dVSSS). Participants then completed a UVA task on a 3-dimensional-printed bladder model using the da Vinci robot. Three blinded expert robotic surgeons rated videotaped performances of the UVA task using validated assessment tools, namely, the Global Evaluative Assessment of Robotic Skills (GEARS; overall procedure) and Robotic Anastomosis Competence Evaluation (RACE; specific to UVA). RESULTS Thirty-nine participants (G1 = 23 and G2 = 16) completed the study. Participants in G2 had significantly more simulation and surgical experience compared with G1 (P <.05). UVA scores of the dVSSS group were higher compared with dV-T (GEARS: P = .09; RACE: P = .01). In the G1 cohort, dVSSS scores were significantly higher than dV-T (GEARS: P = .01; RACE: P <.01). In the G2 cohort, scores were statistically similar (GEARS: P = .32; RACE: P = .91). CONCLUSION Compared with the dV-T, the dVSSS training led to superior GEARS and RACE scores for performance of the UVA task in junior trainees, but not in senior trainees. The dVSSS can be used to improve surgical skills acquisition in less experienced trainees in a safe and effective manner.

Use of machine learning to predict early biochemical recurrence after robot-assisted prostatectomy

To train and compare machine‐learning algorithms with traditional regression analysis for the prediction of early biochemical recurrence after robot‐assisted prostatectomy.

Techniques: Utility of a 3D printed bladder model for teaching minimally invasive urethrovesical anastomosis

The urethrovesical anastomosis (UVA) is one of the most challenging steps during a minimally invasive radical prostatectomy. Not surprisingly, minimally invasive, in particular laparoscopic, prostatectomy is associated with a steep learning curve.1 With competency-based training on the horizon, as well as the recent reduction in resident work hours, surgical educators have shifted some training outside of the operating room into surgical skills labs. To reduce learning curves and improve resident education at our centre, we use a hands-on 3D printed bladder bench model to emulate the UVA task during a minimally invasive prostatectomy.

Management of pelvic fracture-associated urethral injuries: A survey of Canadian urologists

INTRODUCTION The management of pelvic fracture-associated urethral injuries (PFUI) is not standardized and optimal management is controversial. We surveyed Canadian urologists about their experiences and opinions regarding optimal management of PFUI. METHODS Canadian urologists were surveyed via an anonymous, bilingual, web-based, 12-item questionnaire. A total of 735 Canadian urologists were invited to participate via email distributed by the Canadian Urological Association. RESULTS Of the 146 urologists who participated (19.9% response rate), the majority practice at a trauma centre (53.2%), but manage only 1-5 PFUI/year (71.5%). Most participants (82.6%) favour primary realignment compared to suprapubic (SP) tube with delayed repair (15.3%) and immediate reconstruction (2.1%). Compared to SP diversion and delayed repair, the majority of participants believe primary realignment is associated with equivocal incontinence (61.2%) and erectile dysfunction rates (75.8%), but has lower stricture rates (73.0%). Among respondents who perform primary realignment, 45.4% concurrently place a SP tube, while 54.6% do not. While 91% believe SP tubes do not increase the risk of pelvic hardware infections, 31.6% report that orthopedic surgeons alter their management of pelvic fractures in the presence of a SP tube. CONCLUSIONS Most Canadian urologist respondents - even those practicing at trauma centres - manage very few PFUIs/year. There is reasonable consensus among respondents that primary realignment is favourable to delayed or immediate reconstruction, but discordance on whether or not to place concurrent SP tubes. The urological and orthopedic consequences of SP tubes in the management of traumatic urological injuries warrant further investigation.

Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon

INTRODUCTION Since its introduction, robot-assisted laparoscopic radical prostatectomy (RARP) has gained widespread popularity, but is associated with a variable learning curve. Herein, we report the positive surgical margin (PSM) rates during the RARP learning curve of a single surgeon with significant previous laparoscopic radical prostatectomy (LRP) experience. METHODS We performed a prospective cohort study of the first 400 men with prostate cancer treated with RARP by a single surgeon (BS) with significant LRP experience. Our primary outcome was the impact of case timing in the learning curve on margin status. Our analysis was conducted by dividing the case numbers into quartiles (Q1-Q4) and determining if a case falling into an earlier quartile had an impact on margin status relative to the most recent quartile (Q4). RESULTS The Q1 cases had an odds ratio for margin positivity of 1.74 compared to Q4 (p=0.1). Multivariate logistic regression did not demonstrate case number to be a significant predictor of PSM. The mean Q1 operative time was 207.4 minutes, decreasing to 179.2 by Q4 (p<0.0001). The mean Q1 estimated blood loss was 255.1 ml, decreasing to 213.6 by Q4 (p=0.0064). There was no change in length of hospitalization within the study period. CONCLUSIONS Even when controlling for copredictors, a statistically significant learning curve for PSM rate of a surgeon with significant previous LRP experience was not detected during the first 400 RARP cases. We hypothesize that previous LRP experience may reduce the RARP PSM learning curve.

MP55-04 REVISITING THE ROLE OF GENDER ON EARLY DIAGNOSED PRIMARY VESICOURETERAL REFLUX IN INFANTS WITH PRENATAL HYDRONEPHROSIS

characterize the inter-rater reliability of VUR grade and UDR in children with VUR. METHODS: Voiding cystourethrograms (VCUG) of 20 pediatric patients (31 VUR-affected kidneys) were independently reviewed by four pediatric urologists in a blinded fashion. For each renal unit, grade was assigned according to the standardized international scale. UDR was calculated by dividing the largest ureteral diameter within the false pelvis by the distance between the L1-L3 vertebral bodies. The mean grade and mean UDR was calculated for each affected kidney. Correlation within each rater was determined using a Pearson’s correlation coefficient. Reliability of VUR grade and UDR was calculated using intraclass correlation coefficients (ICC) using a two-way ANOVA model interrater agreement. RESULTS: VUR grade (ICC 1⁄4 0.87, 95% CI 1⁄4 0.78-0.93) and UDR (ICC 1⁄4 0.95, 95% CI 1⁄4 0.92-0.97) were reliably measured by four independent raters. While UDR and grade were equally reliable measures, UDR had a tighter confidence interval. For each rater, grade and UDR were well-correlated (r 1⁄4 0.73-0.84; p <0.0001). In the upper ranges of measurements, grade was more variable than UDR [Figure]. Using an empirical threshold, the increased variability with grade may lead to significantly more differences in clinical decision-making among physicians (p 1⁄4 0.022). CONCLUSIONS: UDR has good inter-rater reliability among pediatric urologists. There was significantly more clinically relevant variability with grade than with UDR. Our study demonstrates that UDR is a more objective and reliable measure than grade, and may be a useful adjunct in clinical decision making and categorizing VUR.