Robert C. Kovell

Pelvic Anatomy on Preoperative Magnetic Resonance Imaging Can Predict Early Continence After Robot-Assisted Radical Prostatectomy

BACKGROUND AND PURPOSEnPostoperative incontinence is multifactorial after radical prostatectomy. Using endorectal coil MRI, we examined features of the male urethra and accompanying muscular sphincter to predict continence after robot-assisted radical prostatectomy (RARP).nnnPATIENTS AND METHODSn80 patients underwent preoperative 1.5 Tesla endorectal coil MRI. Urethral length was measured in the coronal plane. All patients underwent RARP. Questionnaires were completed by patients at monthly intervals. The primary end point was time to continence defined as necessitating 0 to 1 pad per day (PPD). Statistical analysis was performed using Cox regression models to create both univariate and multivariate survival models.nnnRESULTSnMean age was 59.7 (standard deviation [SD] 7.1); 98% had bilateral nerve sparing. Mean urethral length was 17.1 mm (SD 4.5 mm). Mean prostate size was 34.7 g (SD 17.8). By 3 months, 60 patients achieved 1 PPD (mean 8.1 weeks, SD 9.4) and 34 patients achieved 0 PPD (mean 10.5 weeks, SD 8.0). Time to social continence was significantly related to prostate size both as a continuous variable (P=0.01), and as a dichotomized variable of ≥ 50 vs<50 g (P=0.02). Increased urethral length was related to decreased time to continence both as a continuous variable (P=0.06), and when dichotomized to ≥ 20 vs<20 mm (P=0.08). In addition to larger prostate size (hazard ratio [HR] 0.97, P<0.04), older age (0.95 P<0.025) was also associated with a longer time to achieve 0 PPD. Multivariate analysis revealed that longer urethral length was associated with a faster recovery of continence (HR 1.11, P<0.01). After controlling for age and urethral length, patients with a prostate size ≥ 50 g had 75% lower likelihood of achieving continence at all time points when compared with patients with prostate size <50 g (HR 0.25; 95% confidence interval: 0.06, 1.06; P=0.06).nnnCONCLUSIONSnLonger urethral length increased the likelihood of achieving continence at all time points postoperatively. Advanced age and larger prostate size were negatively associated with continence outcomes.

Tissue Preservation Techniques at the Time of Urethroplasty for Urethral Stricture Disease

Reconstructive surgery for urethral stricture disease seeks to re-establish long-lasting urethral patency while minimizing associated adverse effects. In recent years, genitourinary reconstructive surgeons have developed and refined a number of techniques that seek to decrease the impact of urethroplasty on local tissues including blood supply and innervation. This review presents an outline of recent advances in urethral reconstructive techniques that seek to minimize surgical impact, including tissue preservation, tissue engineering, and minimally invasive approaches and reviews the current state of the literature related to these techniques.

Primary Seminal Vesicle Adenocarcinoma Presenting With Bilateral Orbital Metastasis: A Case Report

Seminal vesicle (SV) adenocarcinoma is a rare and poorly understood malignancy. Symptoms are non-specific and prognosis is extremely poor. Herein we present a case report of a primary SV clear cell adenocarcinoma with bilateral orbital metastases at the time of initial presentation treated with multimodal therapy including radiotherapy and multi-drug chemotherapy.

Advances and Challenges in Transitional Urology: Caring for Adolescents and Young Adults with Lifelong Complex Genitourinary Conditions

Purpose of ReviewAs long-term survival with complex congenital and pediatric diseases has improved, more patients with congenital genitourinary conditions are living into adulthood. These patients can continue to face lifelong issues related to their conditions, including urinary incontinence, recurrent urinary tract infections, chronic kidney disease, and difficulties with sexual health and function.Recent FindingsThe practice of transitional urology continues to grow nationwide and abroad, and it will be important to develop evidence-based practices for coordinated transition of these patients into the adult health care setting.SummaryThis review describes the broader attention to transitions of care in medicine and specifically evaluates spina bifida as a model disease system for implementation of transitional practices in urology.

Transitional Urology Care for Patients with Spina Bifida

Purpose of ReviewPatients with spina bifida require urologic care and follow-up throughout all phases of life. The transition from adolescence to adult care represents a high-risk time for these individuals and their families and can be challenging for providers. In this review, we seek to analyze the literature on spina bifida patients regarding issues pertinent to transition of their urologic care to adult clinics, providers, and hospitals, and to summarize the experience in the field to date.Recent FindingsExperience in transitioning spina bifida patients to adult care is increasing. Efforts to better define the factors that determine successful transition and affect long-term care outcomes are ongoing.SummaryA growing body of literature exists regarding spina bifida patients transitioning to adult care, but further experience and research will be required to define optimal ways to manage and provide care for these individuals in the future.

Morbidity Associated with Urinary Diversion in the United States: A Contemporary Evaluation Using the NSQIP Database

Introduction: We identified preoperative differences between patients undergoing incontinent vs continent diversion, and compared 30‐day complication outcomes between the 2 procedures. Methods: Using the NSQIP® (National Surgical Quality Improvement Program) database we identified patients undergoing urinary diversion incorporating bowel, with or without cystectomy, between 2010 and 2012. We compared preoperative characteristics, surgical parameters and 30‐day postoperative outcomes. We stratified patients based on the continence status of the diversion as incontinent vs continent. Results: We identified 1,959 urinary diversions in the NSQIP database, including 1,568 incontinent diversions (80.0%) and 391 continent diversions (20.0%). Significantly higher rates of chronic obstructive pulmonary disease (9.1% vs 4.3%), previous cardiac surgery (4.3% vs 1.8%), hypertension (63.3% vs 47.1%) and disseminated disease (4.7% vs 2.1%) were noted in patients undergoing incontinent diversion. Patients undergoing continent diversion were significantly more likely to have received preoperative chemotherapy (10.5% vs 5.2%). Operative time was longer for continent diversion (388 vs 336 minutes). Postoperative urinary tract infection (13.8% vs 7.9%) and sepsis rates (11.5% vs 7.9%) were significantly higher with continent diversion, whereas transfusion rates were higher with incontinent diversion (45.2% vs 37.1%). Thirty‐day readmission rates (18.2% vs 15.6%), length of stay (10.2 vs 10.7 days), presence of at least 1 NSQIP captured complication (61.4% vs 64.0%) and mortality (1.5% vs 2.1%) were not statistically different between continent diversion and incontinent diversion. Conclusions: Urinary diversion incorporating bowel continues to carry a significant risk of postoperative morbidity. While continent diversion offers potential long‐term advantages, these must be balanced against longer operative times and higher rates of postoperative infectious complications.

MP43-03 ENDOTHELIAL DYSFUNCTION DETECTED BY PERIPHERAL ARTERIAL TONOMETRY IS MORE PREVALENT IN MEN WITH ERECTILE DYSFUNCTION

INTRODUCTION AND OBJECTIVES: The relationship between erectile dysfunction (ED) and cardiovascular disease (CVD) has been described. Peripheral arterial tonometry (PAT) is a novel, noninvasive method of detecting endothelial dysfunction and shown to be predictive of cardiac events. We hypothesized that the prevalence of endothelial dysfunction defined by PAT testing would be greater among men with ED than those without ED. We also sought to characterize whether common co-morbidities such as obesity, tobacco use, dyslipidemia, hypertension, and diabetes affected the relationship of ED and PAT scores. METHODS: 205 men underwent PAT testing and a screening questionnaire. Briefly, the PAT system monitors peripheral vasodilation response at the fingertips with pulse amplitude tonometry. A generated endoscore of < 1.67 is indicative of endothelial dysfunction. Ten men were tested at an ED specific urology clinic, and the remaining 195 men were tested at a primary care well visit exam. Student t-tests were performed to compare age, BMI and endoscores between patients with and without reported ED. The same tests were performed stratifying men according to the presence/absence of endothelial dysfunction. Furthermore, contingency tables were used to compare the prevalence of endothelial dysfunction between men with ED vs those without ED and compare the co-morbidity profile between groups accounting for smoking, hyperlipidemia/hypercholesterolemia, hypertension, and diabetes mellitus. RESULTS: 47 of 205 men reported having ED. The mean endoscore for ED patients was significantly lower than non-ED patients (1.63 vs 1.87 respectively, p < 0.05). Significantly more men with reported ED than without ED had endoscores < 1.67, indicative of endothelial dysfunction (55% vs 36% respectively, p < 0.05). There was no significant difference in endoscores of men attending an ED specific urology clinic versus men with ED in a screening population (p 1⁄4 0.37). Age, BMI, tobacco use, hyperlipidemia/hypercholesterolemia, hypertension and diabetes mellitus prevalence were not associated with endothelial dysfunction. CONCLUSIONS: To the best of our knowledge, this is the first study examining the association between PAT testing and ED. Our study confirms that men with ED have lower mean endoscores suggestive of a higher prevalence of endothelial dysfunction in this population. Non-invasive PAT testing for endothelial dysfunction has been shown to be useful in screening patients at risk for cardiac events, and may be particularly useful for patients with ED.