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Background: Robotic pelvic surgery is being increasingly utilized for reconstruction proximal to the genitourinary diaphragm. We describe a combined robotic, transabdominal, and open transperineal approach for complex anastomotic posterior urethroplasty. Materials and Methods: We performed a multi-institutional retrospective study of patients who underwent anastomotic posterior urethroplasty by a combined robotic, transabdominal, and open transperineal approach between January 2012 and December 2018. Patient demographics; preoperative, intraoperative, and postoperative clinical data; and complications were reviewed. Urethroplasty success, de novo stress urinary incontinence (SUI), and de novo erectile dysfunction (ED) were evaluated. Results: Twelve patients were identified with a mean follow-up of 596 (range 73–1618) days. Mean patient age was 65.9 (range 53.4–76.8). Reconstruction required corporal splitting, prostatectomy, and gracilis muscle flap use in one (8.3%), eight (66.7%), and four (33.3%) patients, respectively. Postoperative urinary leak, thromboembolic event, and wound abscess occurred in one (8.3%), one (8.3%), and two (16.7%) patients, respectively. Stenosis recurrence occurred in two patients (16.7%) at a mean 187.5 (20–355) postoperative days. De novo ED and de novo SUI were reported in two (16.7%) and four (33.3%) patients, respectively. Nine patients (75.0%) underwent placement of an artificial urinary sphincter at a mean interval of 359.2 (111–1456) days after the index procedure, with no subsequent erosion. Conclusions: Complex posterior urethroplasty by a combined robotic, transabdominal and open transperineal approach is associated with success and complications rates that are comparable to open techniques and may allow for adjunctive procedures such as prostatectomy. This technique allows for the reconstruction of posterior urethral stenoses that would otherwise have been managed conservatively or with urinary diversion. [ABSTRACT FROM AUTHOR]

Background and Purpose: With the extensive documentation afforded by our electronic medical record (EMR), we observed an unusually high number of patient-initiated encounters following ureteroscopy (URS). We sought to quantify and categorize patient encounters following URS to determine if we could identify avoidable common problems. Materials and Methods: Following IRB approval, we reviewed the records of 298 consecutive patients with stones who underwent 314 URS procedures between July 2013 and November 2014. Patient demographics, stone characteristics and operative details, as well as telephone encounters, secure online patient-initiated (MyChart) messages, and emergency department (ED) visits following URS were extracted from our EMR (Epic, Verona, WI). We performed univariate (UVA) and multivariate (MVA) analysis to identify factors predictive of postoperative patient encounters and compared URS patients to a group of 56 patients undergoing transurethral resection of bladder tumor (TURBT) for number and type of encounters. Results: We identified 443 encounters generated by 201 URS patients, including 334 telephone calls, 71 MyChart messages, and 38 ED visits. Among these encounters, 352 (79%) were medically related (pain comprised 45%) and the remainder involved scheduling issues. By UVA age, bilateral versus unilateral URS, stone location (both kidney and ureter), ureteral access sheath size, and total number of stones predicted a postoperative encounter. By MVA, only younger age and larger UAS size were independent predictors. When compared with TURBT patients, URS patients had a 2.5-fold higher risk of having a pain-related postoperative encounter (OR 2.54, 95% CI 1.08-7.04, P = 0.03). Conclusions: Among patients undergoing URS for stones, two-thirds made unprompted contact with a healthcare provider and 80% of contacts involved postoperative pain, a finding that is distinct from another endoscopic procedure that does not involve upper tract manipulation. Patients do not perceive URS as the benign procedure doctors do. [ABSTRACT FROM AUTHOR]

Objective: Robot-assisted laparoscopic prostatectomy (RALP) with suprapubic tube (SPT), compared to urethral catheter (UC) drainage, has been proposed to improve patient comfort and recovery. We sought to compare short-term outcomes for pain and morbidity after RALP with SPT vs UC drainage. Methods: Between August 2012 and 2014, 159 men underwent a RALP and prospectively completed a questionnaire addressing postoperative pain and satisfaction. Group 1 ( n = 94) underwent a RALP by one surgeon who placed a UC and removed it between postoperative day (POD) 7 and 10. Group 2 ( n = 65) underwent a RALP by a different surgeon who placed an SPT and UC. On POD 1, the UC was removed. On POD 9, the SPT was capped and removed on POD 11 if the patient was voiding adequately. Preoperative and intraoperative data, complications, questionnaires, and patient-reported morbidity, including unplanned telephone calls and emergency department (ED) visits, were compared between groups. Results: Patient characteristics were similar between groups. One week after surgery, the penile pain score was statistically significantly lower in Group 2 compared to Group 1 (56.9% and 79.8%, respectively, reported minimal-to-moderate pain, p = 0.003). Bladder spasms and overall pain were not significantly higher for Group 1 compared to Group 2 ( p > 0.05). When asked 'How big a problem has your urine storage device been?,' 20.2% of patients in Group 1 reported it as a 'moderate-to-big' problem compared to 10.8% in Group 2 ( p > 0.05). The number of catheter-related unplanned telephone encounters did not differ between the two groups ( p = 0.7), however, although not statistically significant, 4.6% of patients in Group 2 presented to the ED with catheter-related issues ( p = 0.07). Conclusion: SPT after RALP was associated with less penile pain compared to UC drainage, and modestly better patient satisfaction. There were no significant differences in bladder spasms, overall pain, and patient-reported morbidity between groups. [ABSTRACT FROM AUTHOR]

Objective: To correlate the highest percentage core involvement (HPCI) and corresponding tumor length (CTL) on systematic 12-core biopsy (SBx) and targeted magnetic resonance imaging/transrectal ultrasonography (MRI/TRUS) fusion biopsy (TBx), with total MRI prostate cancer (PCa) tumor volume (TV). Patients and Methods: Fifty patients meeting criteria for active surveillance (AS) based on outside SBx, who underwent 3.0T multiparametric prostate MRI (MP-MRI), followed by SBx and TBx during the same session at our institution were examined. PCa TVs were calculated using MP-MRI and then correlated using bivariate analysis with the HPCI and CTL for SBx and TBx. Results: For TBx, HPCI and CTL showed a positive correlation (R2=0.31, P<0.0001 and R2=0.37, P<0.0001, respectively) with total MRI PCa TV, whereas for SBx, these parameters showed a poor correlation (R2=0.00006, P=0.96 and R2=0.0004, P=0.89, respectively). For detection of patients with clinically significant MRI derived tumor burden greater than 500 mm3, SBx was 25% sensitive, 90.9% specific (falsely elevated because of missed tumors and extremely low sensitivity), and 54% accurate in comparison with TBx, which was 53.6% sensitive, 86.4% specific, and 68% accurate. Conclusions: HPCI and CTL on TBx positively correlates with total MRI PCa TV, whereas there was no correlation seen with SBx. TBx is superior to SBx for detecting tumor burden greater than 500 mm3. When using biopsy positive MRI derived TVs, TBx better reflects overall disease burden, improving risk stratification among candidates for active surveillance. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the correlation between multiparametric prostate MRI (MP-MRI) suspicion for seminal vesicle invasion (SVI) by prostate cancer (PCa) and pathology on MRI/ultrasound (US) fusion-guided biopsy. Patients and Methods: From March 2007 to June 2013, 822 patients underwent MP-MRI at 3 Tesla and MRI/US fusion-guided biopsy. Of these, 25 patients underwent targeted biopsy of the seminal vesicles (SVs). In six patients, bilateral SVI was suspected, resulting in 31 samples. MP-MRI findings that triggered these SV biopsies were scored as low, moderate, or high suspicion for SVI based on the degree of involvement on MRI. Correlative prostate biopsy and radical prostatectomy (RP) pathology were reviewed by a single genitourinary pathologist. Results: At the time of MP-MRI, the median age was 64 years with a median prostate-specific antigen of 10.74 ng/mL. Of the 31 SV lesions identified, MP-MRI suspicion scores of low, moderate, and high were assigned to 3, 19, and 9 lesions, respectively. MRI/US fusion-guided biopsy detected SVI in 20/31 (65%) of cases. For the four patients who underwent RP after a preoperative assessment of SVI, biopsy pathology and RP pathology were concordant in all cases. Conclusions: As this technology becomes more available, MP-MRI and MRI/US fusion-guided biopsy may play a role in the preoperative staging for PCa. Future work will determine if improved preoperative staging leads to better surgical outcomes. [ABSTRACT FROM AUTHOR]