Shubham Gupta

The Artificial Urinary Sphincter is Superior to a Secondary Transobturator Male Sling in Cases of a Primary Sling Failure

PURPOSEnWe compared continence outcomes in patients with post-prostatectomy stress urinary incontinence treated with a salvage artificial urinary sphincter vs a secondary transobturator sling.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of patients undergoing salvage procedures after sling failure from 2006 to 2012. Postoperative success was defined as the use of 0 or 1 pad, a negative stress test and pad weight less than 8 gm per day. We performed the Wilcoxon test and used a Cox regression model and Kaplan-Meier survival analysis.nnnRESULTSnA total of 61 men presenting with sling failure were included in study, of whom 32 went directly to an artificial urinary sphincter and 29 received a secondary sling. Of the artificial urinary sphincter cohort 47% underwent prior external beam radiation therapy vs 17% of the secondary sling cohort (p = 0.01). Average preoperative 24 hour pad weight and pad number were higher in the artificial urinary sphincter cohort. Median followup in artificial urinary sphincter and secondary sling cases was 4.5 (IQR 4-12) and 4 months (IQR 1-5), respectively. Overall treatment failure was seen in 55% of patients (16 of 29) with a secondary sling vs 6% (2 of 32) with an artificial urinary sphincter (unadjusted HR 7, 95% CI 2-32 and adjusted HR 6, 95% CI 1-31).nnnCONCLUSIONnIn this cohort of patients with post-prostatectomy stress urinary incontinence and a failed primary sling those who underwent a secondary sling procedure were up to 6 times more likely to have persistent incontinence vs those who underwent artificial urinary sphincter placement. These data are useful for counseling patients and planning surgery. We currently recommend placement of an artificial urinary sphincter for patients in whom an initial sling has failed.

Pubic Symphysis Osteomyelitis in the Prostate Cancer Survivor: Clinical Presentation, Evaluation, and Management

OBJECTIVEnTo describe pelvic bone osteomyelitis in the prostate cancer survivor, to report on clinical presentation and treatment, and to suggest an algorithmic approach to managing this syndrome complex.nnnMATERIALS AND METHODSnA retrospective chart review from January 2011 to June 2014 was performed to identify prostate cancer patients with pubic symphysis osteomyelitis at a tertiary-care academic medical center with emphasis on genitourinary cancer survivorship. Data on clinical presentation and outcomes were reviewed.nnnRESULTSnTen patients were diagnosed with having osteomyelitis of the pubic symphysis with or without extension into the pubic rami. Three patients had associated rectal fistulas. Four patients had radical prostatectomy, 5 patients received radiotherapy, and 1 patient received high-intensity focused ultrasound as the primary treatment for prostate cancer. The most common presenting symptoms were pelvic and suprapubic pain, difficulty in walking, and recurrent urinary infections at a median of 7 years after prostate cancer treatment (range, 1.5-16 years). Eight of the 10 patients underwent pubic bone debridement with urinary and fecal diversion when needed. Two patients continue to be managed conservatively with suppressive antibiotics owing to low disease burden. Complete resolution of symptoms was noted in patients undergoing operative intervention, without any pelvic ring instability due to pubic bone resection.nnnCONCLUSIONnThe combination of pelvic pain, difficulty with ambulation, and recurrent infections in a prostate cancer survivor should prompt investigation for pubic bone osteomyelitis-a poorly recognized syndrome complex that is best managed in a multidisciplinary setting.

Stress urinary incontinence in the prostate cancer survivor.

PURPOSE OF REVIEWnUrinary incontinence after treatment for prostate cancer is common, and the burden of disease is substantial with an increasing number of prostate cancer survivors. We aim to review recent advances in this field with a focus on therapeutic surgical interventions and their outcomes.nnnRECENT FINDINGSnRecent studies have proven the efficacy of the male transobturator sling while elucidating the prognostic factors associated with its failure. Heavy incontinence and radiation history are strongly associated with poor outcomes after a sling. The artificial urinary sphincter continues to provide excellent outcomes even in patients with prior sling failure. A new quadratic sling has been introduced to the market, but clinical outcomes data are sparse. The use of urethral bulking and oral medicines for stress incontinence remains low because of inconsistent results.nnnSUMMARYnStress urinary incontinence after prostate cancer treatment is common. Fortunately, there are excellent options for managing stress urinary incontinence in men, and recent data have allowed us to approach this problem in a systematic, algorithmic fashion.

The Ohmmeter Identifies the Site of Fluid Leakage during Artificial Urinary Sphincter Revision Surgery

PURPOSEnWhile the AMS 800 artificial urinary sphincter improves continence in up to 90% of patients, revision surgery may be needed in up to 50%. We determined whether an ohmmeter could accurately assess the site of fluid leak from individual components of the artificial urinary sphincter at the time of revision surgery.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of patients who underwent artificial urinary sphincter revision surgery between 1996 and 2013. Patients in whom fluid loss was identified preoperatively by plain film radiography and who subsequently underwent revision surgery using the ohmmeter were assessed for outcomes.nnnRESULTSnThe ohmmeter was used intraoperatively in a total of 20 surgeries in 19 patients and it correctly identified the location of fluid loss in 18 of 20 (90%). Fluid leakage was found from the pressure regulating balloon in 13 cases, from the cuff in 4 and from the tubing to the pressure regulating balloon in 1. None had fluid loss from the pump. In the 17 cases in which only the malfunctioning component was replaced a satisfactory postoperative outcome with a fully functional device was documented in all. Repeat surgery was performed in 5 of 17 cases (29.4%) at a median of 17 months (range 2 to 39). No patient underwent repeat surgery due to failure to accurately diagnose a component leak.nnnCONCLUSIONSnIn cases of suspected fluid loss as a cause of artificial urinary sphincter malfunction an ohmmeter can identify the site of fluid loss during component revision surgery.

Risk Factors for Removal or Revision of Penile Prostheses in the Veteran Population

OBJECTIVEnTo identify comorbid conditions that may increase the likelihood of revision surgery after primary penile prosthesis implantation. To evaluate trends in utilization of prostheses and selection of device within the Veterans Affairs (VA) system.nnnMETHODSnA retrospective review of the VA Informatics and Computing Infrastructure database was performed using Current Procedural Technology codes to identify any Veteran who underwent penile prosthesis surgery between January 2000 and December 2013. Age, race, procedure type, and relevant comorbidities were identified and compared between groups.nnnRESULTSnA total of 6586 patients underwent primary penile prosthesis placement with at least 1 year of follow-up. Peripheral vascular disease (Pu2009<.001), smoking (Pu2009<.001), hypertension (Pu2009=u2009.012), and history of prostate cancer (Pu2009=u2009.043) were each associated with a significant increased risk of revision or removal surgery. There was an increase in overall number of implants placed during the study and increased durability with malleable penile prosthesis (MPP), but there was a downward trend in the number of MPP placed relative to inflatable penile prosthesis (Pu2009<.001). MPP were more likely to be placed with increasing age (Pu2009<.05) and there was a trend toward increased MPP placement in African Americans compared with Caucasians (Pu2009=u2009.06).nnnCONCLUSIONnPeripheral vascular disease, hypertension, smoking, and history of prostate cancer are associated with increased risk for secondary surgery. This raises a provocative question of how vascular insufficiency may play a role in the likelihood of secondary surgery after penile prosthesis placement. Utilization of penile prosthesis placement in the VA system is steadily increasing, most notably with increased numbers of inflatable penile prosthesis placement.

Short-term Complication Rates Following Anterior Urethroplasty: An Analysis of National Surgical Quality Improvement Program Data

Objective: To determine the characteristics and predictors of perioperative complications after male anterior urethroplasty. Materials and Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) is a validated outcomes-based program comprising academic and community hospitals in the United States and Canada. Data from 2007-2015 were queried for single-stage anterior urethroplasty using Current Procedure Terminology (CPT) codes. The primary outcome was frequency of complications within the 30-day postoperative period. Preoperative and intraoperative parameters were correlated with morbidity measures and univariate and multivariate regression analyses were used. Results: 556 patients underwent anterior urethroplasty, of whom 180 (32.4%) had graft/flap placement. 127 patients (22.9%) went home the same day after surgery, 255 patients (45.9 %) stayed 1 night, and 173 (31.2%) stayed for 2 or more nights. No deaths, cardiovascular complications, or sepsis were noted. 47 (8.5%) patients had complications in the 30-day period. The most common complications were infection (57.4%), readmission (42.9%) and return to the operating room (17%). On univariate analysis, patients who had substitution urethroplasty (p=0.04) and longer operative times (p=0.002) were more likely to have complications, but only longer operative time showed significance on multivariate analysis (p=0.006). Age, American Society of Anesthesiologists (ASA) score and length of stay were not predictive of complication frequency. Conclusions: Anterior urethroplasty has low postoperative morbidity. Longer operative times were associated with increased rate of complications. Longer hospital stay after surgery is not protective against perioperative complications.OBJECTIVEnTo determine the characteristics and predictors of perioperative complications after male anterior urethroplasty.nnnMATERIALS AND METHODSnThe American College of Surgeons-National Surgical Quality Improvement Program is a validated outcomes-based program comprising academic and community hospitals in the United States and Canada. Data from 2007 to 2015 were queried for single-stage anterior urethroplasty using Current Procedure Terminology codes. The primary outcome was frequency of complications within the 30-day postoperative period. Preoperative and intraoperative parameters were correlated with morbidity measures, and univariate and multivariate regression analyses were used.nnnRESULTSnA total of 555 patients underwent anterior urethroplasty, of whom 180 (32.4%) had graft or flap placement. Of the patients, 127 (22.9%) went home the same day after surgery, 255 (45.9%) stayed for 1 night, and 173 (31.2%) stayed for 2 or more nights. No deaths, cardiovascular complications, or sepsis were noted. Forty-seven patients (8.5%) had complications in the 30-day period. The most common complications were infection (57.4%), readmission (42.9%), and return to the operating room (17%). On univariate analysis, patients who had substitution urethroplasty (Pu2009=u2009.04) and longer operative times (Pu2009=u2009.002) were more likely to have complications, but only longer operative time showed significance on multivariate analysis (Pu2009=u2009.006). Age, American Society of Anesthesiologists score, and length of stay were not predictive of complication frequency.nnnCONCLUSIONnAnterior urethroplasty has low postoperative morbidity. Longer operative times were associated with increased rate of complications. Longer hospital stay after surgery is not protective against perioperative complications.

Open Vesicocalicostomy for the Management of Transplant Ureteral Stricture

Abstarct A 59-year-old male developed a proximal stricture of his transplant ureter ten years after a living donor renal transplant. Endoscopic management was unsuccessful, and the patient was temporized with percutaneous nephrostomy tubes for months. Eventually, it became clear he would require surgical revision. Intraoperatively, complete fibrosis of the renal hilum, and intrarenal location of the pelvis precluded the planned pyelovesicostomy. A successful open vesicocalicostomy was performed, anastomosing a bladder flap to a lower pole calix. The patient remains recurrence free after 6 months of follow-up.

Urethroplasty Practice Patterns of Genitourinary Reconstructive Surgeons

Introduction: To our knowledge there are no studies evaluating urethroplasty practice patterns among genitourinary reconstructive surgeons. Methods: An electronic survey was sent to members of the Society of Genitourinary Reconstructive Surgeons. Respondents were queried regarding approach to bulbar urethral reconstruction in 6 index cases. Results: A total of 91 society members who regularly treated men with urethral strictures responded to the survey. For a 1.5 cm stricture excision and primary anastomosis was the preferred treatment, although less unanimously than expected (only 83% in older men and 67% in younger men). For 2.5 cm strictures urethroplasty with buccal mucosal graft was the preferred treatment for a 35‐year‐old man, and excision and primary anastomosis for a 65‐year‐old man. Excision and primary anastomosis was preferred less frequently in younger patients and in patients with longer strictures (Cochran Q test, p <0.001). No other variables were independently associated with use of excision and primary anastomosis, but there were trends toward increased use of excision and primary anastomosis in higher volume surgeons and surgeons who trained fellows. Of the respondents 90% harvest their own buccal grafts, with 46% leaving harvest sites open and 36% closing them. Of the respondents 48% use stricture location to determine graft placement, while 33% use dorsal onlay and 19% use ventral onlay when substitution urethroplasty is chosen. Conclusions: Urethroplasty consisting of excision and primary anastomosis is performed less commonly than expected among genitourinary reconstructive surgeons. Considerable variation exists regarding operative technique, management of buccal mucosal graft harvest site and substitution onlay site.

Utilization of surgical procedures and racial disparity in the treatment of urinary incontinence after prostatectomy

To analyze the rates of incontinence procedures after radical prostatectomy, and define the variables associated with them.

Management of End-Stage Radiation Cystitis in the Cancer Survivor

Millions of cancer survivors have received pelvic radiation, and a significant minority of them will have long-term lower urinary tract sequelae manifesting as hematuria, storage and emptying dysfunction, and fistulas. Hemorrhagic radiation cystitis is managed with intravesical agents in the acute setting, and systemic oral and hyperbaric oxygen therapy for long-term control. In certain cases, however, urinary diversion will be required. Similarly, most cases of lower urinary tract symptoms relating to poor storage and emptying can be managed conservatively. However, some will warrant urinary diversion. Radiation-related urinary fistulas have notoriously poor outcomes after attempts at repair, and early consideration to urinary diversion should be given in these cases. Continent as well as incontinent urinary diversion can be safely performed in patients with prior pelvic radiation, and limited contemporary data confirm significant quality-of-life improvements after urinary diversion in patients with end-stage radiation cystitis.