Ram Pathak

Urologic-Induced Complications of Prophylactic Ureteral Localization Stent Placement for Colorectal Surgery Cases

PURPOSE A prophylactic ureteral localization stent (PULSe) placed by urologists aids in intraoperative localization and detection of suspected ureteral injury during complex colorectal surgery (CRS) cases. We evaluated the incidence and management of urologic-induced complications secondary to PULSe placement during CRS cases at a single center. MATERIALS AND METHODS We performed a retrospective review of all patients who underwent cystoscopy and PULSe placement at the time of CRS over a 12-month period. Bilateral 5 French ×70-cm TigerTail® (Bard Medical Division, Covington, GA) PULSe devices were placed without assistance of routine fluoroscopy. RESULTS Ninety-nine patients (mean age, 58.1 years; range, 17-88 years) underwent bilateral PULSe placement, with a male:female ratio of 44:55 and a mean body mass index of 26.8 (17.0-38.6) kg/m(2). Mean pre- and postprocedural creatinine levels were 0.91 and 1.01 mg/dL, respectively. Twenty-two of 99 (22%) cases utilized a guidewire to aid in placement of PULSe. Four Clavien grade IIIb complications occurred: mucosal edema, reflex anuria, ureteral perforation, and ureteral obstruction secondary to significant clot burden. Three of the grade IIIb complications were managed endoscopically with double-J stent placement. The ureteral perforation case required percutaneous nephrostomy tube placement. Subgroup analysis of the four grade IIIb complications revealed a mean age of 62.3 years, body mass index of 26.98 kg/m(2), and pre- and postprocedural creatinine levels of 0.95 and 4.83 mg/dL, respectively. Only one of the four grade IIIb complications utilized a guidewire prior to PULSe placement. CONCLUSIONS The incidence of Clavien grade III urologic-induced complications during PULSe placement is approximately 2% (4/188). Mandatory adoption of fluoroscopy and guidewires may be required to minimize complications of PULSe placement.

Impact of Minimally Invasive Benign Prostatic Hyperplasia Therapies on 30- and 90-Day Postoperative Office Encounters

OBJECTIVE To compare the frequency of postoperative encounters in the 30-day and 90-day postoperative periods for various bladder outlet obstruction surgical therapies. MATERIALS AND METHODS All patients who underwent transurethral resection of the prostate (TURP), GreenLight laser photovaporization of the prostate (GL-PVP) (American Medical Systems Inc.), and holmium laser enucleation of the prostate (HoLEP) from January 1, 2012 to December 31, 2014 were followed for 6 months postoperatively. All postoperative encounters such as patient calls or questions, catheter exchanges or removals, and hospital-based readmissions or emergency department visits were recorded in the electronic medical record. RESULTS Two hundred and ninety-one consecutive patients underwent outlet procedures during the study period: TURP (N = 199; mean age, 71 years; mean body mass index [BMI], 28.5), HoLEP (N = 60; mean age, 68 years; mean BMI, 28.1), or GL-PVP (N = 32; mean age, 72 years; mean BMI, 29.3). No statistically significant difference was observed for age, BMI, preoperative American Urological Association symptom score, or preoperative maximum flow velocity between the 3 groups. Thirty-day postoperative encounters differed significantly between the 3 surgery types (P < .001). Specifically, there were fewer encounters within 30 days of surgery for TURP compared to both HoLEP (≥1 encounter: TURP = 48.7%, HoLEP = 66.7%; P = .006) and GL-PVP (≥1 encounter: TURP = 48.7%, GL-PVP = 93.7%; P < .001). The number of encounters within 90 days postoperatively was also significantly lower for TURP patients (P < .001). CONCLUSION TURP results in fewer postoperative encounters in both the 30-day and 90-day postoperative periods compared to HoLEP and GL-PVP. Laser prostate therapies may place increased burden on clinic staff during the 30-day and 90-day postoperative periods.

Vasectomy Simulation Curriculum and Trainer with Enhanced Face, Content, and Construct Validity

Introduction: We assessed the face, content and construct validity of a newly created vasectomy simulation module. Methods: Pre-simulation and post-simulation surveys quantifying simulation effectiveness, impact on confidence level and critiques of the overall design were obtained in July 2015 to assess face and content validity. Residents were subdivided based on year of residency and construct validity was ascertained via a 20-objective checklist and individual Likert score as graded by a single attending physician in a blinded fashion. Results: Two medical students and 8 residents (2 Pre-Urology, 2 Uro-1, 2 Uro-2 and 2 Uro-3) were included in the analysis. The response rate was 100% (10 of 10) for the simulation exercise and all residents (100%, 8 of 8) were used in the metric data analysis. Simulation increased the confidence to perform a vasectomy independently on average 1.58 points based on pre-simulation and post-simulation questionnaire analysis (95% CI 1.09–2.89, p=0.02). Training year had a significantly positive association (overall p <0.01) with number of objectives completed. Conclusions: Our enhanced vasectomy simulation module demonstrated excellent face, content and construct validity.

Developing a personalized template for lymph node dissection during radical prostatectomy

Lymph node dissection (LND) represents a critical step in order to determine lymph node invasion (LNI), not only for prognostic means but also as a therapeutic strategy in the management of patients with prostate cancer (CaP). Indications for performing LND are inconsistent with the American Urologic Association (AUA), European Association of Urology (EAU), and National Comprehensive Cancer Network (NCCN) recommendations differing. A thorough appreciation of lymph node drainage patterns and extent of LND has reshaped our understanding of this disease. Moreover, newer research into this field has directly resulted in refinements to current nomograms with utilization of various prostate-specific antigen (PSA) parameters and genomic medicine. Lastly, the application of newer imaging modalities in combination with molecular-guided robotic surgery has personalized the approach of LND espousing excellent safety, efficacy, and oncologic outcomes in these patients.

MP43-19 A CONTEMPORARY ASSESSMENT OF NORMAL ERECTION PHYSIOLOGY

INTRODUCTION AND OBJECTIVES: To investigate the detailed mechanism of erectile dysfunction (ED) induced by hyperhomocysteinaemia (HHcy) in rats and determine whether the Human Tissue Kallikrein 1 (hKLK1) might improve it, as we have proved the protective role of hKLK1 on erectile function in aged rats. METHODS: We established a rat model of HHCy through dietary-rich methionine (Met) in male Sprague-Dawley (SD) rats. Male wild-type SD rats (WTR) and transgenic rats harboring the hKLK1 gene (TGR) were fed to 10 weeks of age. Then 24 WTRs were divided into control (n1⁄48), the low-dose (4% Met, n1⁄48), and the highdose (7% Met, n1⁄48). Another 8 age-matched TGRs with the highdose formed the TGR+7%Met group. 30 days later, erectile function, level of total homocysteinaemia (tHcy), oxidative stress, endothelial function, cavernous nerve function and fibrosis of all groups were determined. RESULTS: hKLK1 in the TGR+7%Met group could greatly decrease the tHcy levels and improve ED induced by HHcy in rats. For the endothelial function, hKLK1 could preserve the endothelial cell-cell junction, enhance endothelial regeneration and activated the Akt/eNOS signaling pathway. Together with the promotion of hKLK1 on nNOS expression, the NO/cGMP signaling pathway activity was also increased. For the fibrosis, hKLK1 could preserve normal corpus cavernosum structure through inhibiting apoptosis and promoting autophagy on corpus cavernosum smooth muscle cells. In addition, hKLK1 also inhibited the fibrosis-related signaling pathway activity. CONCLUSIONS: hKLK1 might effectively improve ED induced by HHcy in rats by protecting endothelial function, promoting cavernous nerve function and inhibiting fibrosis, which suggested hKLK1 might be a potential treatment method for ED.

Multispecialty retrospective review of the clinical utility of pelvic magnetic resonance imaging in the setting of pelvic pain

Background Pelvic pain is a common complaint, and management of it is often difficult. We sought to evaluate the utility of magnetic resonance imaging (MRI) in the diagnosis of male pelvic pain. Though MRIs are commonly ordered to evaluate pelvic pain, there are very few studies obtaining the efficacy of pelvic MRI in determining a definitive diagnosis. The primary aim of our study was to evaluate the clinical utility of pelvic MRI for a diagnosis code that included pain. Methods After receiving institutional review board approval, a retrospective study was performed of all pelvic MRIs completed at our institution from January 2, 2010 to December 31, 2014. These were further delineated into ordering providers by specialty and urology-specific International Classification of Diseases, Ninth Revision (ICD-9) code diagnoses (male pelvic pain, prostatitis, groin pain, scrotal pain, testicular pain, and penile pain). Clinical utility was defined as positive if MRI findings resulted in a change in management. Subanalysis was performed on patients with an ICD-9 co-diagnosis of previous oncologic concern. Results A total of 2,643 pelvic MRIs were ordered at our institution over a 5-year period. Of these, 597 pelvic MRIs (23%) were ordered for a diagnosis code that included pain (hip pain, rectal pain, joint pain, penile pain, scrotal pain, male pelvic pain and orchitis). Total utility for MRIs to find anatomic abnormalities potentially responsible for the present pain was 34% (205/597). When ordered by urologic providers, utility was 23%. Oncologists represented the highest positivity rate at 57%. Conclusions Chronic pelvic pain is a multispecialty complaint that is difficult to treat. We were surprised to find the large number of both specialists and generalists invested in the management of pelvic pain. The increasing availability of MRI technology makes it a likely candidate to test for a clinically significant anatomic reason for pain. Though MRI is a test with minimal adverse effect and no increased risk of radiation exposure, the cost on the healthcare system should be offset by a clear clinical utility. We found total utility to be 34% across all ordering providers and an increase in positivity with concern of oncologic disease. Therefore, we would recommend pelvic MRIs in the evaluation of patients with refractory pelvic pain.

MP92-17 USE OF GUIDEWIRE DURING PLACEMENT OF PROPHYLACTIC URETERAL LOCALIZATION STENTS (PULSE) FOR COLORECTAL SURGERY (CRS) CASES DECREASES UROLOGIC-INDUCED OPERATIVE COMPLICATIONS

RESULTS: Minimization of healthcare waste, use of high value care, and standardization of clinical processes scored the highest on importance and impact, while panelists felt that quality measurement tools (i.e., patient satisfaction measures, Physician Quality Reporting System) were less important to teach and unlikely to substantially improve patient care. Expert panelists clearly distinguish quality measurement (i.e. reporting systems) and quality improvement activities (Table). CONCLUSIONS: These results broadly support a QI curriculum focused on methods to eliminate waste, standardize care pathways, and strengthen processes of urologic patient care. Educating residents about quality measurement and reporting may not meaningfully improve patient outcomes. Future research will assess methods to improve resident engagement in QI education.