Rena D. Malik

Survey of pediatric urologists on the preoperative use of testosterone in the surgical correction of hypospadias

OBJECTIVE To better characterize the current state of testosterone use in the surgical correction of hypospadias among pediatric urologists. METHODS An email was sent via the pedsurology research listserv through the American Academy of Pediatrics, inviting members to participate in an anonymous survey regarding their use of preoperative testosterone in hypospadias correction. RESULTS Twenty-seven responses were obtained for a response rate of 53%. Almost all responders practiced in North America, had exclusively pediatric patients in their practice, and had been in practice for 30 years or less. 55% were classified as high-volume surgeons, completing >50 cases yearly, 87% of whom use preoperative androgen therapy currently, compared with 67% of low-volume surgeons. Testosterone was prescribed primarily for a small appearing penis, reduced glans circumference, reduced urethral plate width, and/or proximal hypospadias. The effect of testosterone was determined primarily by evaluating penile appearance (59%). However, the majority (56%) of physicians stopped giving testosterone when they completed a predetermined regimen. CONCLUSIONS While many pediatric urologists use testosterone prior to hypospadias repair, the practice patterns are variable. It appears that the use of testosterone is primarily limited to patients with proximal hypospadias, small appearing penis, reduced glans circumference or reduced urethral plate.

Prospective Health-related Quality of Life Analysis for Patients Undergoing Radical Cystectomy and Urinary Diversion

OBJECTIVE To better define health-related quality of life (HRQOL) for patients undergoing radical cystectomy (RC) and urinary diversion. MATERIALS AND METHODS Patients undergoing RC and urinary diversion for urothelial carcinoma by 1 of 2 surgeons (G.D.S. or N.D.S.) had a HRQOL assessment at baseline and at follow-up using the validated, bladder cancer-specific Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index questionnaire. The primary outcome was change in HRQOL between baseline and follow-up. RESULTS From September 15, 2011, to July 23, 2012, 74 of 103 eligible patients were enrolled, and all but 1 completed the baseline Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index leaving 73 patients in the study. Median age was 68 years (interquartile range, 60-74 years), 58 (78%) were Caucasian, 53 (73%) were ≥ cT2, 45 (62%) underwent incontinent diversion, and the mean age-adjusted Charlson Comorbidity Index score was 2.4 ± 1.8, with no significant differences among the 73 participants and 30 nonparticipants. The median time from surgery to response was 175 days (interquartile range, 102-232 days), and the response rate was 67%, with 9 deaths during follow-up. Baseline HRQOL scores did not significantly differ between respondents and nonrespondents or between those living vs deceased. Overall, RC-specific, physical, social, and functional HRQOL scores did not differ from baseline to follow-up, whereas emotional HRQOL scores were significantly improved (15.7 ± 5.8 vs 18.1 ± 3.9, P = .03). Overall or domain-specific HRQOL measures did not differ significantly between patients undergoing incontinent (n = 27) vs continent (n = 16) diversions. CONCLUSION Overall, HRQOL scores did not statistically differ from baseline to the median 6-month follow-up for patients undergoing RC and urinary diversion for urothelial carcinoma. Patients undergoing continent vs incontinent urinary diversions had similar overall HRQOL scores at follow-up.

Urinary Retention in Elderly Women: Diagnosis & Management

The management of urinary retention in the elderly female can present a challenging conundrum for primary care physicians, geriatricians, and urologists. It is often difficult to diagnose due to concomitant comorbidities and potential cognitive impairments. Evaluation should include a comprehensive history and physical examination, post-void residual, and urinalysis with consideration given to urodynamic testing in select patients. Management varies from conservative to invasive and should be tailored to the individual patient. Primary goals of care include symptom reduction, prevention of urinary tract infection, and upper tract deterioration. This presents an up-to-date review of the presentation, diagnosis, and management options available for elderly women with urinary retention.

Comparison of patients undergoing laser vaporization of the prostate versus TURP using the ACS-NSQIP database

BACKGROUND:The introduction of laser therapies for the management of bladder outlet obstruction in men with BPH has challenged the gold standard treatment, TURP. We sought to compare the changing clinical characteristics of patients undergoing TURP and laser vaporization of the prostate (LVP) over time.METHODS:The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for men who underwent TURP and LVP from 2007 to 2012. Patient demographics, clinical and intraoperative characteristics and 30-day postoperative outcomes were analyzed.RESULTS:In all, 12 645 men met inclusion criteria, of whom 65% underwent TURP and 35% underwent LVP. Overall, men undergoing TURP were more likely to be scheduled as an emergency (3% vs 1%, P<0.001), have shorter operative times (53 vs 56 min, P<0.001), longer hospital stays (2.4 vs 1.0 days, P<0.001), more frequent blood transfusions (2.1% vs 0.6%, P<0.001) and more postoperative complications including: pneumonia (0.5% vs 0.3%, P=0.02), septic shock (0.3% vs 0.1%, P=0.045), and reoperation within 30 days (2.2% vs 1.4%, P=0.06). However, between 2007 and 2012, there was a significant trend for men undergoing TURP to have increased functional independence (93–96%, P<0.01) and American Society of Anesthesiology (ASA) Physical Class I categorization (0.6–5.1%, P<0.001). In contrast, over the same time period, there was a trend for men undergoing LVP to be significantly older (71–73 years, P<0.001) and have an increased hospital stay (0.50 days to 1.30 days, P=0.03).CONCLUSIONS:Statistically significant differences in clinical characteristics of patients undergoing TURP and LVP have historically existed. However, since 2007, the characteristics of patients undergoing LVP and TURP have changed significantly. Further studies are required to compare these patient characteristics with specific urologic variables and to evaluate clinically significant changes in these cohorts.

Assessing variability of the 24-hour pad weight test in men with post-prostatectomy incontinence

ABSTRACT Purpose: Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity. Materials and Methods: 25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used. Results: Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74–0.93), p<0.001). The mean difference between the minimum pad weight leakage and maximum leakage per patient was 133.4g (95% CI 80.4–186.5). The mean increase in 24-hour leakage for a one-point increase in self-reported activity level was 118.0g (95% CI 74.3–161.7, p<0.001). Pad weights also varied significantly when self-reported activity levels did not differ (mean difference 51.2g (95% CI 30.3–72.1), p<0.001). Conclusions: 24-hour pad weight leakage may vary significantly on different days of collection. This variation is more pronounced with changes in activity level. Taking into account patient activity level may enhance the predictive value of pad weight testing.

Characteristics of Men Undergoing Testosterone Replacement Therapy and Adherence to Follow-up Recommendations in Metropolitan Multicenter Health Care System

OBJECTIVE To identify the frequencies of treatment and recommended laboratory follow-up for men with low serum testosterone levels. METHODS The Electronic Data Warehouse was queried to identify men of ages 18-85 years, who obtained a testing for serum total testosterone level from 2009 to 2012. The frequency of testosterone replacement therapy (TRT), patient demographics, and clinical characteristics were collected. The frequency of follow-up with serum total testosterone and complete blood count levels was documented. RESULTS Among 9176 men who underwent testing for low testosterone levels, 3320 (36%) of them were hypogonadal with a mean serum total testosterone level of 194.3 ± 64.9 ng/dL. Of them, 17.7% men were treated with TRTs. The treatment frequency significantly increased from 8.3% in 2009 to 24% in 2012. A total of 4.8% of men of reproductive ages (age, 18-35 years) were placed on TRTs. Within 180 days of initial testing, only 40% of treated men received follow-up with liver function tests and/or complete blood count, and only 49% had a follow-up serum testosterone level. CONCLUSION Although the frequency of TRT is increasing, only a small percentage of hypogonadal men are actively undergoing treatment. A significant proportion of men of reproductive age are being treated with significant impacts on potential fertility. Less than half of the patients treated are being monitored appropriately after testosterone replacement. This highlights the importance of further education for providers prescribing testosterone replacement.

Perspectives on International Urological Volunteerism: A Survey of IVUmed Resident Scholar Alumni

Introduction: The primary intentions of international surgical programs are to directly benefit those receiving medical care, educate local physicians and staff, and improve care delivery models. IVUmed, a nonprofit organization dedicated to providing urological care to resource poor areas of the world, provides scholarship opportunities for urology trainees. We assessed the motivations and barriers of IVUmed traveling resident scholars regarding continuing international surgical work after completion of the program. Methods: An Internet based survey was sent to all previous IVUmed resident scholars assessing potential factors associated with repeat international service. Logistic regression was used to examine the association between survey responses and the likelihood of repeating an international service trip after completion of training. Results: Of 196 IVUmed resident scholar participants 100 (51%) responded to the survey. Of the 69 attending surgeons 17 (25%) had repeated an international service trip. Altruism (100%), personal fulfillment (99%) and practicing in a resource limited setting (94%) were the most frequently cited motivating factors for repeat participation, while lack of time (96%) was the most commonly reported barrier. Respondents in private practice were less likely to participate in a subsequent trip compared to those in an academic setting (OR 0.16, CI 0.03–0.80, p = 0.03). No other factors were associated with the likelihood of repeating an international service trip. Conclusions: Among urologists who participated in a funded international scholarship program during residency repeat participation during the subsequent 7 years was modest. Private practitioners were less likely to repeat international service compared to academic urologists.

V2-10 SURGICAL TECHNIQUE: TOTAL COLPOCLEISIS

Postoperative, all women had POP-Q stage 0. A 74% continence rate for urinary incontinence was noted. CONCLUSIONS: The LACESA and LAVASA techniques yielded excellent anatomical correction of prolapse. The mesh used is made of PVDF, which cause milder tissue reaction and minimizing the risk of mesh shrinkage/erosions. The unique design of the PVDF structure allows restoration of the USLs with clearly defined surgical steps, making the procedure standardised and reproducible.

Outcomes following Thulium vapoenucleation of large prostates

ABSTRACT Introduction: Thulium laser VapoEnucleation of the prostate (ThuVEP) is an evolving surgical technique for BPH. Most studies have focused on outcomes in small to medium sized prostates and have originated from Europe and Asia. We sought to describe our experience with ThuVEP for very large prostates in a North American cohort. Materials and Methods: From December 2010 to October 2014, 25 men underwent ThuVEP using the CyberTM® (Quantastem, Italy) thulium laser, all with prostate volume >75mL. Data collected included patient demographics, comorbidities, intraoperative parameters, complications, and post-operative outcomes including maximum flow rate (Qmax), post-void residual (PVR), International Prostate Symptom Score (IPSS), and quality of life score (QoL) in one year of follow-up. Statistical analysis was done using Wilcoxon signed-rank test. Results: At baseline, mean age was 70±9 years and prostate size was 163±62g. Most patients (84%) were in retention and 10 (40%) patients were on anticoagulation. Seven (28%) patients went home the day of surgery (mean hospital stay: 1.2±1.2d). There were 2 intraoperative complications (8%), both cystotomies related to morcellation. Nine patients (36%) experienced a complication, all within 30 days. There were no Clavien ≥III complications. Significant improvements were seen in Qmax, PVR, IPSS, and QoL score at each time interval to 12-months following surgery (all p<0.05). Of 21 patients initially in retention, all were voiding at last follow-up. Conclusions: Our findings suggest that ThuVEP is an effective treatment for BPH in patients with large prostates with sustained results for one year.