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Background: Problem-based learning (PBL) is a pedagogy involving self-directed learning in small groups around case problems. Group function is important to PBL outcomes, but there is currently poor scaffolding around key self-reflective practices that necessarily precedes students' and tutors' attempts to improve group function. This study aims to create a structured, literature-based and stakeholder-informed tool to help anchor reflective practices on group function. This article reports on the development process and perceived utility of this tool. Methods: Tool development unfolded in four steps: 1) a literature review was conducted to identify existent evaluation tools for group function in PBL, 2) literature findings informed the development of this new tool, 3) a group of PBL experts were consulted for engagement with and feedback of the tool, 4) four focus groups of stakeholders (medical students and tutors with lived PBL experiences) commented on the tool's constructs, language, and perceived utility. The tool underwent two rounds of revisions, informed by the feedback from experts and stakeholders. Results: Nineteen scales relating to group function assessment were identified in the literature, lending 18 constructs that mapped into four dimensions: Learning Climate, Facilitation and Process, Engagement and Interactivity, and Evaluation and Group Improvement. Feedback from experts informed the addition of missing items. Focus group discussions allowed further fine-tuning of the organization and language of the tool. The final tool contains 17 descriptive items under the four dimensions. Users are asked to rate each dimension holistically on a 7-point Likert scale and provide open comments. Researchers, faculty, and students highlighted three functions the tool could perform: (1) create space, structure, and language for feedback processes, (2) act as a reference, resource, or memory aid, and (3) serve as a written record for longitudinal benchmarking. They commented that the tool may be particularly helpful for inexperienced and poor-functioning groups, and indicated some practical implementation considerations. Conclusion: A four-dimension tool to assist group function reflection in PBL was produced. Its constructs were well supported by literature and experts. Faculty and student stakeholders acknowledged the utility of this tool in addressing an acknowledged gap in group function reflection in PBL. [ABSTRACT FROM AUTHOR]

Purpose: To provide our single-center experience with an approach to refractory stress urinary incontinence (SUI) with permanent urethral ligation (PUL) and suprapubic tube (SPT) placement, in hopes of contributing to the limited body of research surrounding this surgical treatment option for patients with end-stage urethra (ESU). Methods: All patients undergoing PUL with SPT placement from 01/01/2018 to 04/30/2022 were identified from an institutional database. Institutional Review Board exempt status was granted for the conduct of this study. Patients were seen postoperatively at 1 month and 1 year. If there were any concerns of incontinence, an antegrade urethrogram via the SPT was performed. Descriptive statistics were used to evaluate patients. Results: Seven patients underwent PUL with SPT in our timeframe and were included in the study. All patients previously had an AUS placed, and two patients had a urethral sling previously placed. The median follow-up time was 21 months, ranging between 2 and 48 months. Complications included bladder spasms (43%) and continued leakage per urethra (14%). Of the 7 patients, 6 have reported continence through their urethra at their most recent follow-up. Conclusion: This initial data suggest that PUL with SPT placement may be a viable surgical approach to treating refractory SUI, especially for patients with ESU who wish to avoid the morbidity associated with more formal supravesical diversion. Further study of this technique and longer follow-up is required to determine its long-term efficacy and tolerability for patients. [ABSTRACT FROM AUTHOR]

Purpose of Review: This review explores the current literature surrounding non-surgical and surgical management strategies for urinary tract infections (UTIs) in adult patients with neurogenic lower urinary tract dysfunction. UTIs in patients with neurogenic bladders (NB) are recurrent and lifelong contributors to morbidity and mortality. Diagnosis and treatment of UTIs in this patient population are significantly more challenging and require thoughtful clinical decision-making. Topics such as risk factors, diagnosis, nonoperative treatment strategies, and surgical management will be discussed. Recent Findings: Current recommendations indicate that only symptomatic UTIs require treatment. Nonoperative treatments such as antibiotic therapies, bladder instillations, and coated catheters are typically exercised before proceeding with more invasive surgical management. There are no clear guidelines to recommend when patients should or are required to have surgical intervention. Summary: Non-surgical management strategies continue to evolve through recent clinical trials. Major surgical intervention is typically considered only after non-surgical options have been exhausted or based on patient and caregiver preference. [ABSTRACT FROM AUTHOR]

Objective: To compare peri-operative factors and renal function following open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN) for intermediate and high complexity tumors when controlling for tumor and patient complexity. Methods: A retrospective review of 222 patients undergoing partial nephrectomy was performed. Patients with intermediate (nephrometry score NS 7–9) or high (NS 10–12) complexity tumors were matched 2:1 for RPN:OPN using NS, Charlson Comorbidity Index (CCI), and BMI. Patient demographics, peri-operative values, renal function, and complication rates were analyzed and compared. Results: Seventy-four OPN patients were matched to 148 RPN patients with no difference in patient demographics. Estimated blood loss in OPN patients was significantly higher (368.5 vs 210.5 mL, p < 0.001) as was transfusion rate (17% vs 1.6%, p < 0.001). Warm ischemia time was longer in OPN (25.5 vs 19.7 min, p = 0.001) while operative time was reduced (200.5 vs 226.5 min, p = 0.010). RPN patients had significantly shorter hospitalizations (5.3 vs 3.0 days, p < 0.001). GFR decrease after one month was not statistically significant (12.9 vs 6.6 ml/min, p = 0.130). Clavien III–V complications incidence was higher for OPN compared to RPN although not significantly (20.3% vs 10.8%, p = 0.055). Conclusion: When matching for tumor and patient complexity, RPN patients had fewer high grade post-operative complications, decreased blood loss, and shorter hospitalizations. RPN is a safe option for patients with intermediate and high complexity tumors. [ABSTRACT FROM AUTHOR]

Background: The impact of obesity on AdVance male urethral sling outcomes has been poorly evaluated. Anecdotally, male urethral sling placement can be more challenging due to body habitus in obese patients. The objective of this study was to evaluate the impact of obesity on surgical complexity using operative time as a surrogate and secondarily to evaluate the impact on postoperative pad use. Methods: A retrospective cohort analysis was performed using all men who underwent AdVance male urethral sling placement at a single institution between 2013 and 2019. Descriptive statistics comparing obese and non-obese patients were performed. Results: A total of 62 patients were identified with median (IQR) follow up of 14 (4-33) months. Of these, 40 were non-obese and 22 (35.5%) were obese. When excluding patients who underwent concurrent surgery, the mean operative times for the non-obese versus obese cohorts were 61.8 min versus 73.7 min (p = 0.020). No Clavien 3-5 grade complications were noted. At follow up, 47.5% of the non-obese cohort and 63.6% of the obese cohort reported using one or more pads daily (p = 0.290). Four of the five patients with a history of radiation were among the patients wearing pads following male urethral sling placement. Conclusion: Obese men undergoing AdVance male urethral sling placement required increased operative time, potentially related to operative complexity, and a higher proportion of obese compared with non-obese patients required postoperative pads for continued urinary incontinence. Further research is required to better delineate the full impact of obesity on male urethral sling outcomes. [ABSTRACT FROM AUTHOR]

Purpose of Review: Autonomic dysreflexia (AD) is an acute, imbalanced autonomic response to noxious or visceral stimuli in patients with a spinal cord injury (SCI) above T6. In this review, we provide the clinician with an overview of the prevention, diagnosis, and management of AD.Recent Findings: Practice patterns of physicians that manage AD are shifting. Many practitioners are moving away from use of nifedipine and towards alternate pharmacologic therapies, namely nitrates and analgesics. Additionally, through better awareness of common triggers of AD, anesthetics have helped to prevent many cases of AD that may have previously occurred.Summary: Many pharmacologic interventions are available to the practicing physician; however, more important is a knowledge and understanding of common triggers to avoid as prevention is key. [ABSTRACT FROM AUTHOR]

Introduction: We aim to present a modified technique and outcomes of a novel method allowing for direct visualization of the reservoir placement during a penoscrotal inflatable penile prosthesis (IPP). Methods: Out of165 patients who underwent IPP placement from August 2012 to March 2015, 157 underwent a modified technique and comprised the cohort of this study. A Deaver's retractor was placed lateral to the penis and over the pubic bone to allow for direct visualization of the tissues overlying the lower abdomen. After dissecting through the superficial layers, the Deaver's was slowly advanced, allowing for visualization of the fascia, which was incised. Using blunt dissection, a space for the reservoir was created between the bladder and the pubic bone. The reservoir was then placed safely into this space and the Deaver's retractor was removed. Results: The causes of ED in the study cohort included postprostatectomy ED (n = 107), organic impotence (n = 40), Peyronie's disease (n = 3), ED following cystoprostatectomy (n = 2), ED due to spinal cord injury (n = 2), ED resulting from priapism (n = 2), and ED after pelvic injury (n = 1); all of which were refractory to medical management. The median age of study population was 66 years and the mean (standard deviation) operative time was 72.8 (14.7) min. Eighty percent of the procedures were performed on outpatient basis. Complication rates were low (<5%), with four infections, one proximal pump migration, one scrotal hematoma, and one urinary tract infection. Conclusion: The modified technique for placement of the IPP's spherical reservoir under direct visualization through a penoscrotal incision is quick, safe, and effective. [ABSTRACT FROM AUTHOR]

Purpose: Radiation-induced ureteral stricture disease poses significant surgical challenges. Ureteral substitution with ileum has long been a versatile option for reconstruction. We evaluated outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction due to radiation-induced ureteral stricture versus other causes.Methods: Between July 1989 and June 2013, 155 patients underwent consecutive ileal ureter creation. The study cohort included 104 patients with complete data sets and at least 7 months of follow up. Records were retrospectively reviewed with regard to demographics, indications, complications, and renal deterioration.Results: Surgical indications included radiation-induced stricture in 23 (22%) and non-radiation-induced stricture in 81 (78%). Comparing ileal ureter substitution due to radiation versus other stricture etiologies, no statistical significance was observed in regard to age (45.6 vs. 51.2, p = 0.141), hospital length of stay in days (8.8 vs. 7.7, p = 0.216), percent GFR loss (MDRD-4 vs. -5%, p = 0.670 and CKD-EPI-7 vs. -6%, p = 0.914), 30-day surgical complications (26.1 vs. 30.1%, p = 0.658), metabolic acidosis (8.7 vs. 1.2%, p = 0.059), and renal failure requiring dialysis (4.3 vs. 1.2%, p = 0.337). Fistula formation (13.0 vs. 3.7%, p = 0.095), partial small bowel obstructions (21.7 vs. 7.4%, p = 0.063), and small bowel obstructions requiring reoperation (13.0 vs. 1.2%, p = 0.033) approached or reached statistical significance. Using Kaplan-Meier methodology, there was no difference in time to worsening renal outcome between the radiation and non-radiation groups (p > 0.05).Conclusion: Ureteral substitution with ileum is an effective reconstructive option for radiation-induced ureteral strictures in carefully selected patients. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the impact of obesity on patients developing wound complications within 30 days of open and robotic radical prostatectomy using the National Surgical Quality Improvement Program (NSQIP). Methods: Patients undergoing radical prostatectomy in 2011 to 2012 were identified from NSQIP, which is a multi-institutional database of comprehensive 30-day postoperative outcomes. Wound complication included superficial surgical site infections (SSIs), deep SSI, organ space infections, and dehiscence. Descriptive statistics and multiple logistic regression examined the relationship between obesity and wound complications in open and robotic radical prostatectomy. Results: Of the 12,454 radical prostatectomy cases reported in the study period, 9248 were robotic (74%), 2244 (18%) patients were normal weight (body mass index [BMI] <25), 5836 (47%) were overweight (BMI 25-30), and 4374 (35%) were obese (BMI >30). Wound complications occurred in 134 (4%) of open and 114 (1%) of robotic radical prostatectomies. After adjusting for age, history of smoking, history of diabetes, history of chronic steroid use, and operative time, it was determined that obese patients were at 71% increased odds of developing a wound complication after open prostatectomy (p = 0.034), while there was no difference in the odds of a wound complication after robotic radical prostatectomy (odds ratio 1.14, p = 0.665). Conclusions: Obese patients are at increased risk of developing wound complications when undergoing open vs robotic radical prostatectomy. Obese patients likely benefit from robotic radical prostatectomy whenever feasible. [ABSTRACT FROM AUTHOR]

Background and Purpose: To assess the safety of omitting cortical renorrhaphy during robot-assisted partial nephrectomy and measure preliminary functional outcomes. Patients and Methods: Fifteen robot-assisted partial nephrectomies were performed with a running, base-layer suture for the collecting system and vessel hemostasis but without cortical renorrhaphy. The nonrenorrhaphy group was matched 1:2 by R.E.N.A.L. nephrometry score to a running, sliding-clip cortical renorrhaphy group retrospectively. Intraoperative blood loss, urine leaks, postoperative bleeds, and functional outcomes were evaluated. Predictors of %volume loss were evaluated using multivariable regression. Results: No differences were seen between renorrhaphy and nonrenorrhaphy in sex ( P=0.53), age ( P=0.14), body mass index ( P=0.08), Charlson score ( P=0.44), tumor diameter ( P=0.55), nephrometry score ( P=0.77), preoperative glomerular filtration rate (GFR, P=0.63), or the amount of resected healthy kidney margin ( P=0.21). Warm ischemia time was less for the nonrenorrhaphy group ( P<0.002). One pseudoaneurysm necessitating embolization (1/30=3%) was seen in the renorrhaphy group compared with none in the nonrenorrhaphy group. No urine leaks occurred in either group. The median %GFR loss was 8.8% for renorrhaphy and 4.4% for nonrenorrhaphy ( P=0.14) at a median follow-up of 4.1 months. The median %volume loss was 17 cm3 for renorrhaphy and 9 cm3 for nonrenorrhaphy ( P=0.003). In a multivariable model, both cortical renorrhaphy ( P=0.004) and tumor diameter ( P=0.004) were predictors of %volume loss. Conclusion: Omission of cortical renorrhaphy appears feasible with no urine leaks or bleeding complications observed. The percent renal volume loss was improved by omission of cortical renorrhaphy. Reconstruction technique is important to control for when studying renal function after partial nephrectomy. [ABSTRACT FROM AUTHOR]

Objective To explain differences over time between operative approach and surgeon type for adrenal surgery in the USA. Patients and methods A retrospective cohort analysis was performed on all patients undergoing adrenalectomy between 2002 and 2011 using the Nationwide Inpatient Sample. Patients undergoing concurrent nephrectomy were excluded. Surgeon specialty was only available for 2003-2009. Descriptive analyses and multivariable logistic regression models were used to assess variables associated with minimally invasive surgery ( MIS) and urologist-performed procedures. Results In all, 58 948 adrenalectomies were identified. A MIS approach was used in 20% of these operations. There was a 4% increase in MIS throughout the study period ( P < 0.001). Cases performed at teaching hospitals were more likely to be MIS (odds ratio [ OR] 1.47, P < 0.001). We were able to identify surgical specialty in 23 746 cases, of which 60% were performed by urologists. Cases performed in the Midwest compared with Northeast were at increased adjusted odds of being performed by urologists ( OR 1.38, P = 0.11). Despite most cases being performed by urologists, adrenalectomy by urologists showed a 15% annual decrease over the analysed period ( P < 0.001). Conclusions The use of a MIS technique to perform adrenalectomy is increasing at a slower rate compared with most other surgical extirpative procedures. Further investigation to explain the decreased performance of adrenalectomy by urologists is warranted. [ABSTRACT FROM AUTHOR]

Spinal cord injury (SCI) patients pose complex urologic management challenges. Not only is neurogenic bowel/bladder oversight required of urologists, but also sexual dysfunction as well. These patients with SCI are frequently encountered in clinical practice, but a significant number of physicians are not knowledgeable about the set of guidelines available for clinical management. In this review, we discuss the pathophysiology behind sexual dysfunction and fertility in SCI patients, the thorough clinical evaluation required, and the many treatment options available to this specific patient population. [ABSTRACT FROM AUTHOR]

Objective To report our experience, and to evaluate the long-term outcomes and complication profiles of ventral onlay buccal mucosal graft urethroplasty ( BMU) after prior urological intervention. Methods We retrospectively reviewed 114 consecutive patients between February 2001 and April 2009 who underwent buccal mucosal graft urethroplasty for recurrent anterior urethral stricture disease. Seven patients were excluded for incomplete data. The remaining 107 patients comprised the study cohort. The mean follow-up time was 39.3 months (range 6.6-127.3 months). All patients had prior urological attempts at operative management. Results The mean stricture length was 3.14 cm (range 1.0-8.0 cm). Indications for buccal mucosal graft urethroplasty included: lichen sclerosis (2.8%), iatrogenic (24.3%), infection (4.7%) and perineal trauma/straddle injury (20.6%). Of these patients, 78 had bulbo-membranous stricture disease, 20 had penile involvement and nine were multifocal strictures. The average number of prior urological procedures was 2.83 (range 1-9). The overall graft failure rate was 6.5%. Importantly, the re-operation rate was 20.6%, primarily for stricture recurrence (18), meatal stenosis (3) and urethral diverticulum. The mean time to complication was 10.8 months. Conclusions Ventral onlay buccal mucosal graft urethroplasty offers satisfactory results in the setting of recurrent and complicated urethral stricture disease. Graft failures and complications generally occur within the first year after surgery. Bulbar strictures enjoy greater graft patency and lower complication rates than other stricture locations. In particular, guarded expectations should be given for stricture length >4 cm and multifocal disease. [ABSTRACT FROM AUTHOR]

Autonomic dysreflexia (AD) is a medical emergency characterized by an acute, imbalanced autonomic response to specific stimuli in patients with a spinal cord injury (SCI) above T5 to T6. AD requires an early recognition and prompt treatment to prevent any devastating complications or even death. Patients with SCI are frequently encountered in clinical practice, but a significant number of physicians are not knowledgeable about AD or the relatively basic set of guidelines recommended for its management. In this review, we discuss the pathophysiology as well as the diagnosis and management of AD. [ABSTRACT FROM AUTHOR]

Purpose: Open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN) are widely utilized techniques for small renal masses. The lack of tactile feedback and limitations of laparoscopy may result in differences in the surgical specimen that may impact oncologic outcome. We present postoperative pathological outcomes data in a cohort of patients matched for nephrometry score, tumor size, gender and age. Materials and methods: We reviewed 81 patients who underwent partial nephrectomy between January 2003 and March 2010. Twenty-seven underwent RPN and 54 received OPN. Two OPN cases were matched for nephrometry score, tumor size, gender and age for each RPN. Postoperative pathological specimens were reviewed by a urologic pathologist regarding margin status, pathologic stage, histology, renal capsule violation, among other variables. Results: Sixty-two (76.5 %) patients were found to have renal cell carcinoma on final pathology. Frozen sectioning with tumor bed sampling was intra-operatively employed in 70 cases (86.4 %). The overall positive margin occurrence was 1 of 81 patients, which occurred during an RPN for a hilar tumor and converted to radical nephrectomy to achieve negative clinical margins. Additionally, 14.8 % of OPN patients had renal capsule violation as compared to 3.7 % of RPN cases ( p = 0.34). Importantly, the mean distance to the proximal margin edge for RPN specimens (2.77 mm) was equivalent to OPN (3.01 mm), p = 0.46. Conclusion: When matched for nephrometry score, tumor size, gender and age, RPN produces similar pathological outcomes to OPN. [ABSTRACT FROM AUTHOR]

Since its first description in 1992, laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal conditions. The benefits of a minimally invasive approach to adrenal resection such as decreased hospital stay, shorter recovery time and improved patient satisfaction are widely accepted. However, as this procedure becomes more widespread, critical steps of the operation must be maintained to ensure expected outcomes and success. This article reviews the surgical techniques for the laparoscopic adrenalectomy. [ABSTRACT FROM AUTHOR]

The author reflects on the morphological effects of mitomycin C (MMC) injections for urethral stricture in rats.