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Background The definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs. Aim To evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries. Methods A database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared. Main Outcome Measure The primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups. Results A total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P Clinical Implications IPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer. Strengths & Limitations The strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding. Conclusion ASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk.

Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction. There may be insufficient BMG for applications requiring large grafts, such as urethral stricture after gender-affirming phalloplasty. Rectal mucosa in lieu of BMG avoids oral impairment, while potentially affording less postoperative pain and larger graft dimensions. Transanal minimally invasive surgery (TAMIS) using laparoscopic instruments has been described. Due to technical challenges of harvesting a sizable graft within the rectal lumen, we adopted a new robotic approach. We demonstrate the feasibility and safety of a novel technique of Robotic TAMIS (R-TAMIS) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty. Six patients (ages 28–60) presenting with urethral stricture and one vaginal stricture underwent robotic rectal mucosal harvest. The procedure, which was first studied on an inanimate bovine colon model, was performed under general anesthesia in lithotomy position using the GelPOINTTM Path Transanal Access. Mucosa was harvested robotically after submucosal hydrodissection. Graft size harvested correlated with surface area needed for urethral or vaginal reconstruction. Following specimen retrieval, flexible sigmoidoscopy confirmed hemostasis. The graft was placed as an onlay for urethroplasty. There were no intraoperative or postoperative complications. Mean graft size was 11.4 × 3.0 cm. All reconstructions had excellent graft take. All patients recovered without morbidity or mortality. They reported minimal postoperative pain and all regained bowel function on postoperative day one. Patients with prior BMG harvests subjectively self-reported less postoperative pain and greater quality of life. There have been no long-term complications at a median follow-up of 17 months. To our knowledge, this is the first use of R-TAMIS for rectal mucosa harvest. Our preliminary series indicates this approach is feasible and safe, constituting a promising minimally invasive technique for urethral reconstruction. Prospective studies evaluating graft outcomes and donor site morbidity with more long-term follow-up are needed.

Many transgender men will pursue gender affirmation surgery with metoidioplasty or phalloplasty. This chapter provides an overview of the urethral complications associated with transmasculine genital reconstructive surgery. Reported complications include urethrocutaneous fistulas, persistent vaginal cavities, and urethral strictures. Reconstructive surgery presents a challenge due to decreased blood flow at anastomotic sites and other unique anatomical differences associated with a neophallus. Fortunately, there are several techniques that aid in the management of these complications. However, even after successful reconstruction, urinary incontinence is common. Urologic follow-up is important in managing both expectations and subsequent urologic problems that may require intervention.

Background Minimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation. Objective To evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers. Design, setting, and participants This retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016. Surgical procedure RBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side. Outcome measurements and statistical analysis Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. Results and limitations The onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0cm (range 2.0–8.0), operative time was 200min (range 136–397), estimated blood loss was 95ml (range 25–420), and length of stay was 2 d (range 1–15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%. Conclusions RBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures. Patient summary We studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction.

Phalloplasty may be performed in patients with acquired or congenital penile insufficiency or transgender individuals who desire phallic construction. Demand for neophallus creation and prosthesis placement has increased in recent years with growing coverage for gender affirming surgery among transgender patients. This report describes consideration of prosthetic implantation in neophallic reconstruction. Prosthesis implantation in a neophallus requires special consideration regarding avoidance of critical structures, proximal prosthesis anchoring, and distal cushioning in patients without native corpora cavernosa. Neophallus prostheses are associated with increased risk of infection, extrusion, erosion, and device migration relative to standard prostheses, with a high revision rate. Implanters should have a thorough understanding of neophallic reconstructive technique prior to proceeding with device placement. Current literature on this subject consists predominantly of retrospective reviews and case reports with variable outcome measures. The creation of validated assessment tools will provide more meaningful data to inform provider counseling and patient expectations.

We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery.The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications.A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p0.001), 2.4 (p0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively.Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.

Objective To demonstrate the technique and the outcomes of robot assisted Y-V plasty bladder neck reconstruction (RYVBNR). Methods We present our technique for treatment of recalcitrant bladder neck contracture (BNC) in 7 patients who underwent RYVBNR at our institution between March 2016 and September 2017. Indication for the procedure was incomplete emptying, recurrent urinary tract infections, and dysuria. On follow-up, patients were assessed for clinical success by absence of infections, symptoms, and cystoscopic evaluation. Robotic assisted dissection is performed to open the space of Retzius and mobilize the bladder. The cystoscope is passed to the level of the BNC, and Firefly technology is used to localize the BNC. The BNC is incised anteriorly, and a V-shaped bladder flap is advanced into the BNC in a Y-V plasty fashion. We place a perioperative closed suction drain, which is removed before discharge, and a 22 Fr catheter, which that will be removed in the office at approximately 2 weeks. Results Six men developed recalcitrant BNCs and 1 developed a recalcitrant vesicourethral anastomotic stenosis. All patients had previously undergone an endoscopic procedure. Median time for last attempt at endoscopic management to robot-assisted bladder neck repair was 4.7 months. The average number of prior attempts at endoscopic management was 2. All patients underwent RYVBNR without conversion to open surgery. The median operative time was 240 minutes, estimated blood loss was 67 mL, and length of stay was 1 day. There were no intraoperative complications. Catheters were removed in the office at a median time of 15 days. At a median follow-up of 8 months, all cases were successful with no evidence of recurrence. Only 2 patients had persistent urinary incontinence at 1 pad per day. Conclusion RYVBNR with a Y-V plasty is a feasible and effective technique for managing a difficult reconstructive problem.

Introduction Erectile dysfunction is a common problem that may be definitively treated with the implantation of an inflatable penile prosthesis (IPP). The preponderance of available data on IPP surgery derives from institutional studies, most notably from academic centers or large single-surgeon series, where the majority of procedures are performed in a hospital setting. Because insurance companies and health systems look to reduce health care costs, IPP surgery in outpatient freestanding ambulatory surgery centers (ASC) is becoming more prevalent. Aim To review the utility of surgery in an ASC setting and to explore its role in the modern practice of urology, focusing on IPP implantation. Methods A critical review was performed of the literature on ambulatory surgery, with specific focus on IPP surgery, using the PubMed database. Key search terms and phrases included erectile dysfunction, penile prosthesis, ambulatory surgery, ambulatory surgery center, outpatient surgery. Main Outcome Measure The main outcome measure was the use of IPP implantation in an ASC. Results In contemporary surgical practice, the implementation of ambulatory surgery in free-standing centers is increasing. The principal benefits include reducing cost and improving efficiency. Studies on the modern use of IPPs support the prospect of implantation in an ambulatory setting, which can achieve similar outcomes to surgeries classically performed in the inpatient hospital setting. Novel approaches to anesthesia, surgical, and nursing care have revolutionized IPP surgery so that it can now be safely and effectively performed in the ambulatory setting. Conclusion The role of ambulatory IPP implantation has increased, with the majority of cases being performed outside the hospital. Although there will always be a need for hospital-based surgery, such as significant medical comorbidities, more studies demonstrating the safety and feasibility of ambulatory surgery are needed. For those men who would otherwise be candidates for ambulatory surgery but whose insurance mandates hospital-based treatment, such studies proving utility, safety, and reduced cost could inspire policy change and broaden the ambulatory practice of IPP surgery. Segal RL, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis Implantation in the Ambulatory Setting: A Systematic Review. Sex Med Rev 2020;8:338–347.

Loss of penile length is a common complaint of men with Peyronie’s disease (PD), both before and after corrective intervention, which has a significant negative effect on patient quality of life. We sought to identify and describe the methods by which penile length can be preserved or increased. We conducted an extensive, systematic literature review, based on a search of the PUBMED database for articles published between 1990 and 2015. Articles with the key words “Peyronie’s disease”, “penile length” and/or “penile lengthening” were reviewed if they contained subjective or objective penile length outcomes. Only English-language articles that were related to PD and penile size were included. We found no evidence in the literature that medical therapy alone increases penile length. Classic inflatable penile prosthesis (IPP) placement, plication procedures, and the Nesbit procedure appear likely to maintain or decrease penile length. Plaque incision (PI) and grafting appears likely to maintain or increase penile length, but is complicated by risk of post-operative erectile dysfunction (ED). There are several surgical procedures performed concomitantly with IPP placement that may be suitable treatment options for men with comorbid ED, and consistently increase penile length with otherwise good outcomes concerning sexual function. These include the subcoronal penile prosthesis (scIPP), Egydio circumferential technique, the sliding technique, the modified sliding technique (MoST), and the multiple slice technique (MuST). In addition, adjuvant therapies such as penile traction therapy (PTT), post-operative inflation protocols, suspensory ligament relaxation, lipectomy, and adjuvant medical therapy for glans engorgement appear to increase subjective and/or objective penile length for men at high risk of decreased penile length after PD surgery. Considering the psychological burden of length loss in men with PD, providers with adequate volume and expertise should attempt, if possible, to maintain or increase penile length for men undergoing surgical intervention. There are several evidence-based, safe, and effective ways to increase penile length for these men and multiple emerging adjuvant therapies that may help ensure adequate length.

Introduction The robotic platform in surgery has been widely adopted as it facilitates complex surgical reconstructions such as renorrhaphy during partial nephrectomy. Although the robotic approach to radical nephrectomy has higher costs and a lack of perioperative and oncologic evidence, the use of robotic platforms for radical nephrectomy is increasing. We evaluated a national database to explain the increased use of robotic radical nephrectomy despite a lack of perioperative and oncologic evidence. Methods The current retrospective cohort study used NIS (Nationwide Inpatient Sample) to identify patients who underwent radical nephrectomy from the last quarter of 2008 through 2010. We investigated hospital and patient specific factors associated with the robotic approach to radical nephrectomy, including hospital volume of robotic partial nephrectomy and robot-assisted radical prostatectomy. Results Of the 124,462 radical nephrectomies 4.7% were performed robotically. The median cost of robotic radical nephrectomy was $1,324 to $2,759 higher than that of open and laparoscopic radical nephrectomy. No differences in complications, length of stay, blood transfusion rates or mortality were found between laparoscopic and robotic radical nephrectomy. However the rate of open and laparoscopic radical nephrectomy decreased during the study period while the use of robotic radical nephrectomy increased almost fourfold. At hospitals in the middle or highest tertile of robotic partial nephrectomy the procedure was more likely to be performed. Patients younger than 60 years were less likely to undergo the surgery than those older than 80 years (p Conclusions Although increased median costs and equivalent outcomes (perioperative and oncologic) question the benefit of robotic radical nephrectomy, its use is increasing. Robotic radical nephrectomy is more likely to be done at medium-high volume robotic centers for partial nephrectomy. This nationwide overtreatment and inefficiency may reflect the use of robotic radical nephrectomy as a training tool to facilitate the robotic learning curve and the proliferation of robotic partial nephrectomy.

Introduction The surgical treatment of disorders of male sexual function requires specific exposure to correct the underlying problem safely and efficiently. Currently, sub-coronal exposure is used for treatment of phimosis, Peyronie's disease plaque (PDP), and semirigid penile prosthesis insertion. Infra-pubic and scrotal incisions are used for inflatable penile prosthesis (IPP) placement. However, men who present with several disorders might require multiple procedures and surgical incisions. Aim To report a prospective review of our surgical experience and outcomes with a single sub-coronal incision for IPP placement with a modified no-touch technique. This approach allows for access to the entire corporal body for multiple reconstructive procedures. Methods Two hundred men had IPPs placed through a sub-coronal incision using our modified no-touch technique. The penis was degloved to the level of the penoscrotal junction and the dartos muscle was everted and secured to the drapes. This allowed exclusion of the scrotal and penile skin from the operative field. After artificial erection, the patient's corpora were inspected for PDP and other abnormalities. Penoscrotal IPP models were placed in all cases with insertion proximal to the penoscrotal junction. After placement of the IPP, the abnormalities were repaired. Main Outcome Measures Feasibility of the procedure, operative times, complication rate, utilization of accessory, reconstructive procedures, and post-operative penile length. Results Of the 200 men who had IPP placement, 92 had PDP that was treated, 106 (53%) consented to circumcision, 24 (12%) had their reservoir placed ectopically, and 31 (16%) had a prosthesis exchanged through the sub-coronal technique. Mean operative time was 73 minutes (39–161 minutes). Conclusion Specialists in the surgical treatment of disorders of male sexual function can perform multiple procedures safely and easily through a modified no-touch single sub-coronal incision. This approach allows access to the entire corporal body, providing excellent visibility and allowing the surgeon to perform multiple penile reconstructive surgeries through a single incision.

Objective To review a robotic approach to recalcitrant bladder neck obstruction and to assess success and incontinence rates. Materials and Methods Patients with a recalcitrant bladder neck contracture or vesicourethral anastomotic stenosis who underwent robotic bladder neck reconstruction (RBNR) were identified. We reviewed patient demographics, medical history, etiology, previous endoscopic management, cystoscopic and symptomatic outcomes, urinary continence, and complications. Stricture success was anatomic and functional based upon atraumatic passage of a 17 Fr flexible cystoscope or uroflowmetry rate >15 ml/s. Incontinence was defined as the use of >1 pad per day or procedures for incontinence. Results Between 2015 and 2017, 12 patients were identified who met study criteria and underwent RBNR. Etiology of obstruction was endoscopic prostate procedure in 7 and radical prostatectomy in 5. The mean operative time was 216 minutes (range 120-390 minutes), with a mean estimated blood loss of 85 cc (range 5-200 cc). Median length of stay was 1 day (range 1-5 days). Three of 12 patients had recurrence of obstruction for a 75% success rate. Additionally, 82% of patients without preoperative incontinence were continent with a median follow-up of 13.5 months (range 5-30 months). There was 1 Clavien IIIb complication of osteitis pubis and pubovesical fistula that required vesicopubic fistula repair with pubic bone debridement. Conclusion RBNR is a viable surgical option with high patency rates and favorable continence outcomes. This is in contrast to perineal reconstruction, which has high incontinence rates. If future incontinence procedures are needed, outcomes may be improved given lack of previous perineal dissection.

We analyze the relationship among various patient, operative and tumor characteristics to determine which factors correlate with renal parenchymal volume loss after nephron sparing surgery using a novel 3-dimensional volume assessment.We conducted a retrospective review of an institutional database of patients who underwent nephron sparing surgery from 1992 to 2014 for a localized renal mass. Tumors were classified according to the R.E.N.A.L. nephrometry system. Using 3-dimensional reconstruction imaging software, preoperative and postoperative renal parenchymal volume was calculated for the ipsilateral and contralateral kidney.A total of 158 patients were analyzed. Mean patient age was 58.7 years and mean followup was 40.1 months. Mean preoperative tumor volume was 34.0 cc and mean tumor dimension was 3.4 cm. Mean R.E.N.A.L. nephrometry score was 6.2, with 60.1%, 34.2% and 5.7% of tumors classified as low, medium and high complexity, respectively. Mean change in renal parenchymal volume after nephron sparing surgery was -15.3% for the ipsilateral kidney and -6.8% for total kidney volume. On univariate analysis ischemia time, tumor size, R.E.N.A.L. nephrometry score, complexity grouping and the individual nephrometry components of tumor size, percent exophytic, anterior/posterior, depth and tumor proximity to the renal artery or vein were associated with greater renal parenchymal volume loss. On multivariate analysis only ischemia time, tumor size, posterior location and percent exophytic were independently associated with more renal parenchymal volume loss.Using precise 3-dimensional volumetric analysis we found that ischemia time, tumor size and endophytic/exophytic properties of a localized renal mass are the most important determinants of renal parenchymal volume loss.

Objective:To compare the utilization, perioperative complications and predictors of LCA versus RPN in the treatment of localized renal tumors.Methods:From the Nationwide Inpatient Sample we identified patients undergoing RPN or LCA for the treatment of localized renal tumors from October 2008 through 2010. Patient and hospital-specific factors which predict postoperative complications and use of LCA were investigated.Results:14,275 patients with localized renal tumors were identified: 70.3% had RPN and 29.7% had LCA. LCA was more common in older patient and at hospitals without robotic consoles. No difference was identified in perioperative complications (0.2% vs. 0.2%), transfusion (5.1% vs. 6.2%), length of stay (2.9 vs. 3.0 days) or median cost ($41,753 vs. $44,618) between the groups, LCA vs. RPN. On multivariate analysis sicker patients were more likely to have LCA (OR 1.34, p=0.048) and sicker patients had greater postoperative complications (OR 3.30, pConclusions:More patients had RPN vs. LCA; surgical technique was not predictive of postoperative complications. As technology develops to treat localized renal tumors, it will be important to continue to track outcomes and costs for procedures including RPN and LCA.

To examine the practice patterns and predictors of VTE prophylaxis following radical prostatectomy (RP).This was a population-based observational study of 94,709 men with a diagnosis of prostate cancer (ICD-9 code 185) who underwent RP were identified from a hospital-based database from 2000 to 2010, including 68,244 (72.1 %) open RP (ORP) and 26,465 (27.9 %) robotic-assisted laparoscopic RP (RALP). VTE prophylaxis was classified as none, mechanical, pharmacologic, or combination.Following RP, 35,591 (52.2 %) received mechanical, 4,945 (7.2 %) pharmacologic, 7,720 (10.6 %) combination, and 20,438 (30.0 %) no VTE prophylaxis. A total of 245 VTE events (145 DVT, 114 PE) were identified, representing 0.25 % of all procedures. Men with2 comorbidities (OR = 2.44; 95 % CI 1.78-3.35) and those who were black (OR = 1.44; 95 % CI 1.06-1.97) were more likely to have a VTE. Men who had RALP (OR = 0.61; 95 % CI 0.45-0.99), surgery at high-volume hospitals (OR = 0.45; 95 % CI 0.28-0.73), or received prophylaxis (OR = 0.67; 95 % CI 0.50-0.88) were less likely to develop a VTE.Despite the observation that VTE prophylaxis reduces the risk of VTE by 40 %, VTE prophylaxis was not used in almost one-third of men who underwent radical prostatectomy.

Purpose To validate the Spanish translation of the Overactive Bladder Symptom Score (OABSS) questionnaire. Materials and Methods The OABSS was translated into Spanish (OABSS-S) and back translated. The OABSS-S was self-administered to subjects, following internal IRB and ISPOR Good Practices guidelines. Spanish speaking patients >18 years of age were recruited from primary care clinics. Content validity was achieved by having the first 25 subjects complete the questionnaire in privacy; afterwards they were interviewed and the clarity of each question was discussed with the patient. All subjects recruited, including the first 25, were divided into two groups by the presence of OAB as determined by a previously validated intake question. Subjects completed the OABSS-S in privacy on two occasions within 10 days. Patients were excluded if their symptoms changed between the first and second administration of the questionnaire. Internal consistency was determined with Cronbach's alpha. Test–retest was determined by Spearman's rho. Discriminant validity was assessed between each group using one-way ANOVA and the Tukey post hoc test. Results One hundred and seventeen of 128 enrolled subjects completed this study (mean age 55; SD 18). Of 117, 74 (63%) were women 29 with OAB and 45 without OAB. There were 43 men (37%), 18 with OAB and 25 without OAB. A high level of consistency was observed among the seven items answered at visit 1 and 2, with a Cronbach's raw alpha statistic of 0.92. No differences in OABSS-S with age or gender were noted. However, subgroup analysis showed patients in the OAB group were significantly older and post-test analysis showed they had higher scores both for each individual question as well as overall symptom severity scores. Spearman's rank order correlation coefficients showed that there was significant difference between the seven items of the OABSS-S; a strong association (Spearman's rho) was also observed between the total seven-item score at visits 1 and 2 for the total score of all subjects r = 0.84, with OAB: r = 0.81, and without OAB: r = 0.83. Comparison of average total scores obtained for all patients at visits 1 and 2 was not significant (10.47 ± 6.53 vs. 11.02 ± 0.66). Discriminant validity testing revealed that there were significant differences in the responses between all diagnostic groups at visits 1 and 2: with OAB versus without OAB; total versus with OAB; total versus without OAB. Conclusion The Spanish version of the OABSS is valid and reliable and will allow health care providers to easily and quickly assess a Spanish-speaking patient's symptoms. Neurourol. Urodynam. 31:664–668, 2012. © 2012 Wiley Periodicals, Inc.

The objective of this study was to anatomically describe the relationship of penile intracavernosal pillars to penile surgery, specifically corporal dilation during penile prosthesis placement. Corpora cavernosa from four embalmed male cadavers were dissected and subjected to probe dilation. Corpora were cross-sectioned and examined for the gross presence and location of pillars and dilated spaces. Infrapubic penile prosthesis insertion was performed on one fresh-frozen cadaveric male pelvis, followed by cross-sectioning. A single patient had intracavernosal pillars examined intraoperatively during Peyronie's plaque excision and penile prosthesis insertion. Intracavernosal pillars were identified in all cadavers and one surgical patient, passing obliquely from the dorsolateral tunica albuginea across the sinusoidal space to the ventral intercorporal septum. This delineated each corpus into two potential compartments for dilation: dorsomedial and ventrolateral. Dorsal dilation seated instruments and prosthetics satisfactorily in the dorsal mid glans and provided additional tissue coverage over weak ventral areas of the tunica albuginea, while ventrolateral dilation appeared to result in ventral seating and susceptibility to perforation. Intracavernosal pillars are an important anatomic consideration during penile prosthesis placement. Dorsal dilation appears to result in improved distal seating of cylinder tips, which may be protective against tip malposition, perforation or subsequent erosion.

Radical prostatectomy (RP) is associated with a high risk of intraoperative blood loss and subsequent blood transfusions. The shift in surgical technique from open radical prostatectomy (ORP) to robot-assisted radical prostatectomy (RARP) has resulted in lower operative blood loss, and reduced the need for transfusions. We analyzed the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database to compare real-world, contemporary trends in utilization and timing of blood transfusion following ORP and RARP.We identified men undergoing both RARP and ORP and then queried for patients who received a blood transfusion in the perioperative period. The outcomes of interest were need and timing of perioperative blood transfusion (PBT), which was categorized into early (postoperative day [POD] ≤1) or late (POD ≥2). Logistic regression analysis was used to identify variables associated with the need and timing for PBT.A total of 16,144 men who underwent RP were identified from 2007 to 2012. The overall PBT rate was 3.1%. Highest rate of transfusions occurred on day of surgery for patients undergoing ORP, and first POD for patients undergoing RARP. On multivariate analysis significant predictors of blood transfusion included history of bleeding disorder (OR: 2.8, p=0.002), preoperative dyspnea (odds ratio [OR]: 1.7, p=0.03), starting hematocrit42% (OR: 1.9, p0.001), open approach (OR: 0.09, p0.001), year of surgery (OR: 0.5, p0.001), resident involvement (OR: 1.6, p=0.003), and operative time (OR: 4.4, p0.001). The only predictor of receiving a blood transfusion on POD 2 or later was having the procedure performed through a robot-assisted approach (OR: 3.7, p0.001).In this study we found that the rate of perioperative transfusions is lower than previously published. A clear separation in timing of transfusion exists based on the utilized surgical approach. It is prudent that surgeons performing RARP be aware of the low, but present risk of a delayed blood transfusion.

Objective To determine whether socioeconomic status (SES) predicts the size and local extent of tumors at presentation, and if this association leads to differences in survival. Materials and Methods The National Cancer Institute's Survival, Epidemiology, and End Results registry was queried for patients diagnosed with renal cancers between 2004 and 2010. Demographic, tumor, survival, and socioeconomic data were obtained. Cancers with T0 classification, nonrenal cell histology, or missing clinical or pathologic data were excluded. An SES measure was created from available metrics. Outcomes analyzed were tumor size, TNM classifications at diagnosis, tumor grade and histology subtype, and survival duration. Results A total of 40,212 cases were identified. On regression modeling, lower SES was an independent risk factor for tumor size ≥4 cm ( P = .003) and for T classification ≥T2 ( P = .040) at presentation, but did not predict histology subtype, positive lymph nodes, or metastasis. Lower SES predicted high-grade disease on univariate analysis ( P = .012) but lost significance in the multivariate model. Lower SES was also independently predictive of shortened cancer-specific survival on multivariate analysis after adjusting for available cofactors (lowest vs highest SES quartile; P = .001). Conclusion This study suggests that low SES is correlated with poorer survival outcomes in renal cancer, and this may be related to a tendency toward larger and more locally advanced tumors at diagnosis. Additional investigation is needed to ascertain whether these effects could be mediated by relatively lower rates of incidental detection via abdominal imaging in disadvantaged populations.

To analyze the influence of preoperative renal function on postoperative renal outcomes after radical nephrectomy (RN) and nephron-sparing surgery (NSS) for malignancy in patients stratified according to preoperative chronic kidney disease (CKD) stage and surgical extent (NSS vs RN).Retrospective review of patients undergoing renal surgery for localized renal masses stratified by surgical extent and preoperative CKD stage based on glomerular filtration rate (GFR) level: stage I (90 mL/min/1.73 m(2)), stage II (60-89 mL/min/1.73 m(2)), and stage III (30-59 mL/min/1.73 m(2)). Survival analysis for significant renal impairment was based on freedom from the development of new-onset GFR30 or45 mL/min/1.73 m(2).A total of 1306 patients were included in the analysis with preoperative CKD stage I (27.9%), II (52.1%), and III (20.1%); 41.3% and 58.7% underwent NSS and RN, respectively. NSS was associated with a lower annual rate of GFR decline in preoperative CKD stage-I (P = .028) and stage-II patients (P = .018), but not in CKD stage-III patients (P = .753). Overall, 5.0% and 15.0% developed new-onset GFR30 mL/min/1.73 m(2) and45 mL/min/1.73 m(2), respectively. There was no difference in the probability of developing significant renal impairment between NSS and RN in CKD stage-I or -III patients, whereas only in CKD stage-II patients was the surgical extent independently associated with development of significant renal impairment (RN: odds ratio, 9.0; P = .042 for GFR30 mL/min/1.73 m(2) and odds ratio, 2.3; P = .003 for GFR45 mL/min/1.73 m(2)).Compared with RN, NSS is associated with a lower rate of GFR decline for preoperative CKD stage-I and -II patients, but only CKD stage-II patients demonstrated a decreased risk of developing significant renal impairment.

Objective To investigate the incidence and timing of venous thromboembolism (VTE) and identify risk factors for venous thromboembolism among patients undergoing major surgery for urologic malignancies. VTE events are stratified by occurrence in the inpatient vs outpatient settings. Materials and Methods The National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Statistical Classification of Diseases, Ninth Revision codes to identify patients undergoing major surgery for urologic malignancies between 2005 and 2012. The incidence of overall 30-day VTE, postdischarge VTE, and post-VTE death was calculated for each surgical procedure. Logistic regression analysis was used to identify risk factors for VTE, adjusting for covariates including age, race, gender, smoking status, medical comorbidities, performance of pelvic lymph node dissection, and operative time. Results The study identified 27,455 patients who underwent an operation for malignancy—radical nephrectomy, partial nephrectomy, nephroureterectomy, radical prostatectomy, or radical cystectomy. The incidence and timing of VTE varied substantially across the procedures of interest. Overall, VTE occurred after radical cystectomy in 113 of 2065 of patients (5.5%), whereas only 19 of 2624 (0.7%) and 12 of 1690, respectively, of patients undergoing minimally invasive radical or partial nephrectomy procedures suffered a VTE event within 30-days of surgery. Among patients suffering a VTE after radical prostatectomy, 147 of 178 of venous thromboembolic events (82.6%) occurred after hospital discharge. Conclusion This study demonstrates the significant burden of VTE beyond the time of hospital discharge. Identification of high-risk patients should prompt consideration of extended-duration VTE prophylaxis in the outpatient setting.

End-stage renal disease (ESRD) and acquired renal cystic disease associated with dialysis are known risk factors of papillary renal cell carcinoma (pRCC); however, it is not known whether renal insufficiency alone is a risk factor for pRCC. Our aim was to test whether renal insufficiency is associated with an increased preponderance of pRCC. Retrospective review of institutional database to identify all patients who underwent extirpative renal surgery for renal cell carcinoma (RCC) with complete records from 1992 to 2012. We excluded those patients with preoperative ESRD as defined by GFR

While robot-assisted radical prostatectomy (RARP) is associated with shortened convalescence and decreased blood loss over open prostatectomy, little objective data is available regarding postoperative pain/discomfort and use of analgesic medications after RARP. We sought to examine these parameters in a contemporary cohort.From 2011 to 2013, patients undergoing RARP were prospectively enrolled in a study to examine various pain parameters and carefully monitor opiate and other analgesic medication use while the patient recovered in the hospital. After discharge, the patients were asked to fill out a daily questionnaire regarding their pain parameters and self-report opiate usage. All questionnaires were based on the Wong-Baker FACES pain rating scale (0-10). Opiate dosages were converted to the approximate oral morphine sulfate equivalent dose (MSE).A total of 60 patients, mean age 61 years, were enrolled in the study, underwent RARP, and completed follow-up questionnaires. None had a history of chronic narcotic use. Intraoperative opiate use was 94.1 mg MSE. There were 73.3% who received immediate postoperative ketorolac. After RARP, the main source of pain/discomfort was abdominal/incisional, followed by urethral catheter-related, penile, and bladder spasm-related discomfort. Abdominal pain was generally moderate for most patients and decreased significantly after about 4 days. Penile and urethral catheter-related discomfort was mild throughout the study period. Opiate analgesic medication use quickly decreased as the subjective pain scores improved.After RARP, most patients experience mild/moderate abdominal discomfort, which improves steadily over several days. There is also a quick decline in the average opiate pain medication use that corresponds to the subjective improvement in pain symptoms. This information is useful for clinicians counseling patients on the pain associated with RARP and can serve as a reference to compare the convalescence associated with the other options for treatment of patients with localized prostate cancer.

Purpose: Following Robotic-Assisted Radical Prostatectomy (RARP) patients routinely have penile pain and urethral discomfort secondary to an indwelling urethral catheter. Our objective was to assess the effect of dorsal penile nerve block with bupivacaine on urethral catheter-related pain after RARP. Methods: From 2012–2013, 140 patients with organ-confined prostate cancer were enrolled in an IRB approved double-blinded, randomized control trial comparing a dorsal penile nerve block of bupivacaine versus placebo after RARP performed by a single-surgeon. Patients were asked to complete questionnaires using the Wong-Bakers FACES Pain Rating scale while hospitalized and for 9 days post-operatively, until the catheter was removed. The primary end-points were: catheter-related discomfort, abdominal (incisional) pain, and bladder spasm-related discomfort. Secondary end-points included narcotic and other analgesic usage. Results: 120 patients were randomized to placebo vs. bupivacaine dorsal penile nerve bock. The two arms (n = 56 bupivacaine and n = 60 placebo) did not differ in preoperative, perioperative, or pathological results. There was no difference in narcotic utilization between the two cohorts. Abdominal pain was slightly lower in the bupivacaine arm at 6 hours compared to the placebo arm, but there was no difference in abdominal pain at other time points, and there were no differences in reported catheter-related discomfort or bladder spasm-associated discomfort at any of the measured time points. Conclusions: The data does not support the routine use of a dorsal penile nerve block with bupivacaine following RARP.

To validate the Spanish translation of the Overactive Bladder Symptom Score (OABSS) questionnaire.The OABSS was translated into Spanish (OABSS-S) and back translated. The OABSS-S was self-administered to subjects, following internal IRB and ISPOR Good Practices guidelines. Spanish speaking patients18 years of age were recruited from primary care clinics. Content validity was achieved by having the first 25 subjects complete the questionnaire in privacy; afterwards they were interviewed and the clarity of each question was discussed with the patient. All subjects recruited, including the first 25, were divided into two groups by the presence of OAB as determined by a previously validated intake question. Subjects completed the OABSS-S in privacy on two occasions within 10 days. Patients were excluded if their symptoms changed between the first and second administration of the questionnaire. Internal consistency was determined with Cronbach's alpha. Test-retest was determined by Spearman's rho. Discriminant validity was assessed between each group using one-way ANOVA and the Tukey post hoc test.One hundred and seventeen of 128 enrolled subjects completed this study (mean age 55; SD 18). Of 117, 74 (63%) were women 29 with OAB and 45 without OAB. There were 43 men (37%), 18 with OAB and 25 without OAB. A high level of consistency was observed among the seven items answered at visit 1 and 2, with a Cronbach's raw alpha statistic of 0.92. No differences in OABSS-S with age or gender were noted. However, subgroup analysis showed patients in the OAB group were significantly older and post-test analysis showed they had higher scores both for each individual question as well as overall symptom severity scores. Spearman's rank order correlation coefficients showed that there was significant difference between the seven items of the OABSS-S; a strong association (Spearman's rho) was also observed between the total seven-item score at visits 1 and 2 for the total score of all subjects r = 0.84, with OAB: r = 0.81, and without OAB: r = 0.83. Comparison of average total scores obtained for all patients at visits 1 and 2 was not significant (10.47 ± 6.53 vs. 11.02 ± 0.66). Discriminant validity testing revealed that there were significant differences in the responses between all diagnostic groups at visits 1 and 2: with OAB versus without OAB; total versus with OAB; total versus without OAB.The Spanish version of the OABSS is valid and reliable and will allow health care providers to easily and quickly assess a Spanish-speaking patient's symptoms.

Purpose Significant research has been dedicated to the management of vesicoureteral reflux (VUR). However, few studies have been published to evaluate the impact of this disease on quality of life. The aim of this study was a prospective examination of the health-related quality of life (HRQoL) in children with VUR who have either been treated medically (antibiotics or surveillance) or by ureteral reimplant (UR) using a validated patient satisfaction survey. Materials and methods A prospective, longitudinal study was conducted using a validated HRQoL questionnaire, the Pediatric Quality of Life Inventory (PedsQL™ 4.0 Generic Core). 353 children or parents of children with VUR, age 2–18 years, completed the survey. Statistical analysis was performed with significance set at p-value ≤ 0.05. Results Children and parents of children with VUR did not score lower on total or subscale domains of HRQoL when compared to a historical healthy control. On univariate analysis, patients who underwent UR scored lower on total as well as physical, social, and school subscale HRQoL domains, compared to patients managed medically. When controlling for gender, ethnicity, age, reflux grade, and antibiotic use, there was no difference in total HRQoL between patients who underwent UR compared to those managed medically. Conclusions In terms of HRQoL, VUR is a benign clinical entity and neither antibiotic use nor UR is associated with lower HRQoL. Disease-specific quality of life surveys are needed to accurately evaluate patient and parent satisfaction in the management of VUR.

• o determine differences in surgical outcomes by surgical approach during a period of rapid adoption of minimally invasive surgical approaches in radical prostatectomy.• We identified 19 542 men undergoing minimally invasive (MIRP), perineal (PRP), and retropubic (RRP) radical prostatectomy from 2003 to 2006 from the MarketScan® Medstat database, a national employer-based administrative database. • We assessed for temporal trends in perioperative complications, use of postoperative cystography and anastomotic strictures by surgical approach.• Between 2003 and 2006, MIRP use increased 33.6% vs 31.8% and 1.7% decreases in RRP and PRP, respectively. During the 4-year study, median length of stay for MIRP decreased from 2.0 to 1.0 day (P = 0.004) and overall perioperative complications decreased from 13.8 to 10.7%, (P = 0.023). • These findings were driven by reductions in genitourinary complications (3.3 to 2.5%, P = 0.049), miscellaneous surgical complications (3.6 to 2.3%, P = 0.006) and intestinal injury (1.5 to 0.1%, P= 0.009). • Median length of stay for RRP decreased from 3.2 to 2.9 days, (P0.001), overall perioperative complications decreased from 18.1 to 14.6%, (P = 0.007), because of reductions in both wound/bleeding complications (2.0 to 1.1%, P = 0.002) and heterologous blood transfusions. • Men undergoing MIRP vs RRP were less likely to have perioperative complications (12.5 vs 17.1%, P0.001), blood transfusions (1.5 vs 8.9%, P0.001) and anastomotic strictures (6.3 vs 12.8%, P0.001), and they had shorter mean lengths of stay (1.8 vs 3.1 days, P0.001) during the study period.• The increased use of MIRP corresponds with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. Further study is needed to assess the impact of tumour characteristics and surgeon volume on these perioperative outcomes as well as effects on long-term cancer control.

Prognosis (cohort).2b. What's known on the subject? and What does the study add? Prior population and single-centre studies have assessed incidence of positive surgical margins. The current study derived population-based positive surgical margin cut-offs in order to help identify underperforming surgeons who may benefit from further courses and/or self study to improve outcomes.To characterize factors associated with positive surgical margins (PSMs) and derive population-based PSM cutoffs to evaluate surgeon performance in radical prostatectomy (RP). SEER-Medicare data were used to identify 4247 men diagnosed with prostate cancer during 2004-2005 who underwent RP up to 2006. We performed logistic regression to assess the impact of tumour characteristics, surgeon volume and surgical approach on the likelihood of PSMs for pT2 and PT3a disease. Moreover, we derived 25th and 10th percentile cutoffs from binomial distribution equations. Overall, 19.4% of men experienced PSMs with a pT2 vs pT3a PSM rate of 14.9% vs 42% (P0.001). Extrapolating from our population-based results, a surgeon incurring more than three PSMs in 10 cases of pT2 disease performed below the 25th percentile. There was a trend for fewer PSMs with minimally invasive vs open RP (17.4% vs 20.1%, P=0.086), and the PSM rate also decreased over the study period from 21.3% in 2004 to 16.6% in 2006 (P=0.028) with significant geographic variation (P0.001). In adjusted analyses, temporal and geographic variation in PSM persisted, and men with high (odds ratio 3.68, 95% CI 2.82-4.81) and intermediate (odds ratio 2.52, 95% CI 2.03-3.13) vs low-risk disease were at greater odds to experience PSMs. Notably, neither surgical approach nor surgeon volume was significantly associated with PSMs.Our population-based PSM benchmarks allow identification of under-performing outliers who may seek courses or video self-study to improve outcomes. There was significant temporal and geographic variation in PSMs but neither surgeon volume nor surgical approach was associated with PSMs.

Background There are numerous studies in the adult literature correlating comorbidities and pre- and intraoperative parameters with postoperative outcomes. However, there is a paucity of similar data in the pediatric population. Our goal was to elucidate which pre- and intraoperative patient characteristics in children undergoing surgery are associated with an increased risk of major complication within 30 days. Study Design We identified 108 children who underwent surgery at our institution between June 2005 and May 2007 and had major complication or death within 30 days of surgery. Forty-two preoperative patient characteristics and 22 intraoperative variables were evaluated. The severity of the complications was graded based on the Clavien classification system, with major complications grade III or greater. We randomly selected 723 controls who had undergone surgery within a 3-month date range of the original cohort, but did not develop complications. Statistical significance was assessed by univariate and multivariate analyses. Results Most complications were cardiovascular, occurred 1 to 3 days after surgery, and were classified as grade IIIB. We identified 5 independent risk factors on multivariate analysis: ≤36 weeks of gestation, American Society of Anesthesiologists score >3, undergoing a cardiovascular or neurosurgical procedure, and receiving an intraoperative albumin transfusion. Three scoring systems (overall, preoperative, and intraoperative complication score) were developed to provide objective risk stratification. Conclusions We found 5 patient-specific parameters that were independent risk factors for major complications or death after pediatric surgery. Future prospective studies will help to fully stratify risk and guide interventions to improve postoperative outcomes.