William R. Boysen

Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique Modifications Contribute to Optimized Outcomes

BACKGROUND Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is being adopted at large pediatric urology centers in the United States, but currently there is not consensus on surgical technique to facilitate the best possible outcomes. OBJECTIVE To describe technique modifications that may lead to improved radiographic vesicoureteral reflux (VUR) resolution. DESIGN, SETTING, AND PARTICIPANTS Between December 2008 and February 2015, a single surgeon performed RALUR-EV at an academic medical center. Only children with persistent grade 3-5 VUR at age 5 yr on voiding cystourethrogram (VCUG), those who had breakthrough urinary tract infections, or those with renal scarring were selected to undergo surgical correction of VUR with RALUR-EV. Children undergoing RALUR-EV for obstructive megaureter or ureterovesical junction obstruction were excluded. Fifty-eight patients (83 ureters) fit the inclusion criteria. SURGICAL PROCEDURE We highlighted adjustments to our technique, called LUAA to represent length of detrusor tunnel (L), use of a U stitch (U), placement of permanent ureteral alignment suture (A), and inclusion of ureteral adventitia (A) in detrusorraphy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary end point was resolution of VUR on postoperative VCUG. RESULTS AND LIMITATIONS Because technique modifications were made at two distinct time points, we generated three patient groups for comparison. We observed complete resolution of VUR in 82% of ureters, including 8 of 12 ureters (67%), 8 of 11 ureters (73%), and 52 of 60 ureters (87%) for technique modification cohorts 1, 2, and 3, respectively. There were no ureteral complications at median follow-up of 30 mo. Retrospective design and possible confounding from the learning curve limit this study. CONCLUSIONS Using the standardized LUAA technique, we demonstrated an improvement in outcomes. Given the wide range of published resolution rates following RALUR-EV, there is a need for standardization of technique to facilitate best possible outcomes. We propose the LUAA technique as a new standard for RALUR-EV to achieve this goal. PATIENT SUMMARY We examined the safety and efficacy of a minimally invasive surgery in children. We identified several critical adjustments to surgical technique that improve rates of successful outcome.

Multi-Institutional Review of Outcomes and Complications of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Primary Vesicoureteral Reflux in Children

Purpose: Robot‐assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally invasive alternative to open ureteral reimplantation for correcting primary vesicoureteral reflux in children. However, in the current literature there are conflicting data regarding the safety and efficacy of this approach. Amid ongoing debate we analyzed outcomes and complications from this procedure in a large multi‐institutional cohort. Materials and Methods: We reviewed the records of children who underwent robot‐assisted laparoscopic extravesical ureteral reimplantation at 9 academic centers from 2005 to 2014. Radiographic failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram. Complications were graded using the Clavien‐Dindo scale. Results: A total of 260 patients (363 ureters) underwent robot‐assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux during the study period. The cohort included 90 patients with either duplex ureter (42), failed endoscopic treatment (40) or concomitant diverticulectomy (8). Of the 280 ureters with postoperative voiding cystourethrogram or radionuclide cystogram available radiographic resolution was seen in 246 (87.9%). There were 25 complications overall (9.6%), with 7 grade 3 complications (2.7%) and no grade 4 or 5 complications. Four patients (3.9%) had transient urinary retention following bilateral reimplantation. Conclusions: Robot‐assisted laparoscopic extravesical ureteral reimplantation has a low complication rate consistent with published series of open ureteral reimplantation. Radiographic success rates are approaching those of the open procedure but continue to fall short of the gold standard approach. These findings necessitate critical thinking regarding potential technique improvements and further prospective investigation into the efficacy of this procedure.

Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications

BACKGROUND Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve. OBJECTIVE To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons. DESIGN AND METHODS We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure. RESULTS In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure. DISCUSSION We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients. CONCLUSIONS Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children.

Thirty-day Morbidity of Abdominal Sacrocolpopexy Is Influenced by Additional Surgical Treatment for Stress Urinary Incontinence

OBJECTIVE To assess the impact of concurrent anti-incontinence procedure (AIP) at time of abdominal sacrocolpopexy (ASC) on 30-day complications, readmission, and reoperation. METHODS The American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2013 was queried to identify patients who underwent ASC with or without AIP. We assessed baseline characteristics and 30-day perioperative outcomes including complications, readmission, and reoperation. RESULTS There were 4793 patients who underwent ASC, of whom 1705 underwent concurrent AIP (35.6%). The majority of patients (4414, 92.1%) were treated by a gynecologist, but those treated by a urologist were older, had higher American Society of Anesthesiologists (ASA) class, and had increased frailty. Rates of 30-day postoperative urinary tract infection (UTI) and overall complication were higher among women who underwent concurrent AIP (4.75% vs 2.33%, P <.001; 7.74% vs 6.02%, P = .02). On multivariate analysis controlling for age, body mass index, approach, ASA physical status, modified frailty index, resident involvement, and surgeon specialty, AIP was associated with increased odds of UTI (odds ratio 2.20, 95% confidence interval 1.14-4.13, P = .02) and increased odds of overall complication (odds ratio 1.80, 95%confidence interval 1.10-2.93, P = .02). Thirty-day readmission and reoperation rates did not differ between the groups. CONCLUSION AIP performed at the time of ASC are associated with higher rates of 30-day postoperative UTI but do not impact 30-day readmission or reoperation. The decision to perform AIP at the time of ASC should be made following a thorough discussion of the risks and benefits, including the potential for increased UTI with concurrent AIP.

Erratum to: Robot-assisted laparoscopic pyeloplasty in the pediatric population: a review of technique, outcomes, complications, and special considerations in infants

Ureteropelvic junction obstruction is a common condition encountered by the pediatric urologist, and treated with pyeloplasty when indicated. Recent technological advancements and a shift across all surgical fields to embrace minimally invasive surgery have led to increased utilization of minimally invasive pyeloplasty. Conventional laparoscopy is a reasonable choice, but its use is limited by the technical challenges of precise suturing in a confined space and the associated considerable learning curve. Robotic technology has simplified the minimally invasive approach to pyeloplasty, offering enhanced visualization and improved dexterity with a fairly short learning curve. As utilization of robotic pyeloplasty continues to increase, we sought to critically assess the literature on this approach. We begin with a review of the technical aspects of robot-assisted laparoscopic pyeloplasty including tips for surgical proficiency and patient safety. Outcomes and complications from the contemporary literature are reviewed, as well as special considerations in the pediatric population including infant pyeloplasty, cost concerns, training, and postoperative diversion/drainage.

Evaluating the Role of Postoperative Oral Antibiotic Administration in Artificial Urinary Sphincter and Inflatable Penile Prosthesis Explantation: A Nationwide Analysis

OBJECTIVE To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown. MATERIALS AND METHODS We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates. RESULTS We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation. CONCLUSION Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.

PD39-04 COMBINED PLACEMENT OF ARTIFICIAL URINARY SPHINCTER AND INFLATABLE PENILE PROSTHESIS DOES NOT INCREASE RISK OF PERIOPERATIVE COMPLICATIONS OR IMPACT LONG-TERM DEVICE SURVIVAL

OBJECTIVE To determine the impact of concurrent inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) implantation on perioperative complications and long-term device survival, among men with postprostatectomy erectile dysfunction and urinary incontinence. METHODS We identified men older than 65 treated with radical prostatectomy in the Surveillance, Epidemiology, and End Results Medicare database between 2002 and 2016. IPP or AUS placement was determined by current procedural terminology (CPT) code, with dual implantation (DI) defined as IPP and AUS placement on the same date. Device survival was assessed using CPT codes for device removal, replacement, and/or repair. Complications were assessed within 90 days using ICD-9 codes. Statistical analysis was performed using SAS v9.3 (Cary, NC). RESULTS A total of 37,599 men underwent radical prostatectomy, with AUS placed in 793 (2.1%), IPP placed in 644 (1.7%), and DI in 62 (0.2%). Relative to AUS placement alone, men undergoing DI were younger (68.8 vs 70.2 years, P = 0.03), but had equivalent Charlson comorbidity index, tumor grades, and rates of prior radiotherapy. Relative to IPP placement alone, men were more likely to undergo DI if treated with adjuvant or salvage radiotherapy. The incidence of complications within 30 and 90 days of prosthetic implantation did not differ between groups. Long-term device survival on Kaplan-Meier analysis was not impacted by DI relative to single device implantation with median follow-up of 61 months. CONCLUSION Combined AUS and IPP placement does not adversely affect perioperative complications or device survival relative to placement of either device alone.

The Role of Chemical Sphincterotomy with Urethral Botulinum Toxin Injection in Patients with Neurogenic and Non-neurogenic Failure to Empty

Purpose of ReviewThis review focuses on the evidence for injection of botulinum A toxin (BTX) to the external urinary sphincter for management of impaired bladder emptying secondary to neurogenic conditions such as detrusor sphincter dyssynergia (DSD) and non-neurogenic conditions such as dysfunctional voiding (DV). The application of urethral BTX for patients with impaired emptying secondary to detrusor underactivity will also be discussed. The goal of the review is to comprehensively analyze the evidence surrounding urethral BTX in this context and help guide decision-making.Recent FindingsA robust body of literature including case series, a randomized control trial (RCT), and a meta-analysis support the use of urethral BTX for the treatment of DSD in spinal cord injury (SCI) patients, with documented improvement in urethral pressure and post-void residual urine volume (PVR). A second RCT among patients with DSD and MS demonstrated no improvement in urethral pressure, PVR, or maximum urine flow rate following urethral BTX relative to control. For non-neurogenic conditions like DV and pelvic floor spasticity, there are mixed data regarding the efficacy of urethral BTX. Small series have reported improvement in PVR and urethral pressure, but a RCT in this patient population demonstrated no benefit of urethral BTX relative to control.SummaryUrethral BTX effectively lowers urethral pressure and PVR in SCI patients with DSD, though the long-term impact on renal function requires further study. For patients with MS and those with non-neurogenic conditions like DV, pelvic floor spasticity, and detrusor under activity, the role of urethral BTX is not well defined. Further study in these patient populations should be undertaken prior to widespread utilization.

MP46-13 EVALUATING THE ROLE OF PERIOPERATIVE ANTIBIOTICS IN PREVENTING ARTIFICIAL URINARY SPHINCTER EXPLANTATION: ANALYSIS OF A LARGE NATIONAL PROSPECTIVE DATABASE

p1⁄40.543 (UTI)], patient satisfaction [p1⁄40.913, 0.863, 0.913, 0.552], pain rates [p1⁄40.389, 0.389, 0.637, 0.160], and IQOL scores [p1⁄40.522]. Regarding the surgical procedure, duration of perioperative antibiotics prophylaxis significantly effected long-term pain rates (p1⁄40.036), patient satisfaction rates (p1⁄40.007), and correlated significantly with reduced IQOL scores (R1⁄4-0.531, p<0.001). Surgical approach, catheter size and indwelling time, and intraoperative complications had no significant effect on the analyzed endpoints. CONCLUSIONS: This is the first study to analyze long-term effects of perioperative complications on favorable outcomes after AUS implantation. We show that perioperative morbidity does not lead to less favorable long-term results and therefore reassure both implanting surgeon and patient. Since duration of antibiotic prophylaxis had a negative effect on AUS outcomes, our results advocate a more restrictive use of perioperative antibiotics.

MP25-15 FACTORS ASSOCIATED WITH INFLATABLE PENILE PROSTHESIS (IPP) EXPLANTATION: EVALUATING THE ROLE FOR POSTOPERATIVE ORAL ANTIBIOTICS ADMINISTRATION

initial implanter (26% vs 11%, p1⁄40.004), and when reoperation was performed by a high volume implanter (p<0.001). On multivariate analysis, salvage was less common when the operation for infection was not performed by the original implanter (OR 0.42, p1⁄40.04) or was performed by a low volume implanter ( 2/year vs >20/year, OR 0.21, p1⁄40.01). CONCLUSIONS: Men treated for infected IPPs with salvage procedures are far more likely to end up with a prosthesis than those treated with explant. Despite these favorable functional outcomes, salvage of infected IPPs is an underutilized strategy. We identified surgeon factors that may partially explain this suboptimal practice pattern. Proactive referral of patients with IPP infections to their original surgeons or to experienced implanters could improve functional outcomes for affected patients.