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Objectives To evaluate the effect of ureteral rest on outcomes of robotic ureteral reconstruction. Methods We retrospectively reviewed all patients who underwent robotic ureteral reconstruction of proximal and/or middle ureteral strictures in our multi-institutional database between 2/2012—03/2019 with ≥12 months follow-up. All patients were recommended to undergo ureteral rest, which we defined as the absence of hardware (ie. double-J stent or percutaneous nephroureteral tube) across a ureteral stricture ≥4 weeks prior to reconstruction. However, patients who refused percutaneous nephrostomy tube placement did not undergo ureteral rest. Perioperative outcomes were compared after grouping patients according to whether or not they underwent ureteral rest. Continuous and categorical variables were compared using Mann-Whitney U and 2-tailed chi-squared tests, respectively; P Results Of 234 total patients, 194 (82.9%) underwent ureteral rest and 40 (17.1%) did not undergo ureteral rest prior to ureteral reconstruction. Patients undergoing ureteral rest were associated with a higher success rate compared to those not undergoing ureteral rest (90.7% versus 77.5%, respectively; P = .027). Also, patients undergoing ureteral rest were associated with lower estimated blood loss (50 versus 75 milliliters, respectively; p Conclusions Implementing ureteral rest prior to ureteral reconstruction may allow for stricture maturation and is associated higher surgical success rates, lower estimated blood loss, and decreased utilization of buccal mucosa graft ureteroplasty.

Objective To evaluate the health status of men who have undergone vasectomy versus nonsterilized fertile men. Methods Using the National Survey for Family Growth from 2002 to 2017, univariate and multivariate analyses were performed on demographic and health data, including health status and health care utilization. Results Men who have undergone vasectomy are more likely to be older, healthier, have more children, identify as non-Hispanic white, be married, have a higher level of education, earn a higher mean household income, and were more likely to be privately insured than non-sterilized fertile men. On multivariate analysis, men who underwent vasectomy had a better health status despite being older. Conclusion There are significant socioeconomic and health differences between men who elect vasectomy and non-sterilized fertile men. These differences should be considered when considering using sterilized men as a proxy for proven fertile men in epidemiological studies.

Introduction: To evaluate overall survival (OS) of T1a kidney cancers stratified by histologic subtype and curative treatment including partial nephrectomy (PN), percutaneous ablation (PA), and radical nephrectomy (RN). Materials and Methods: We queried the National Cancer Data Base (2004–2015) for patients with T1a kidney cancers who were treated surgically. OS was estimated by Kaplan-Meier curves based on histologic subtype and management. Cox proportional regression models were used to determine whether histologic subtypes and management procedure predicted OS. Results: 46,014 T1a kidney cancers met inclusion criteria. Kaplan Meier curves demonstrated differences in OS by treatment for clear cell, papillary, chromophobe, and cystic histologic subtypes (all p

Preoperative urodynamic studies (UDS) are frequently performed before pelvic organ prolapse (POP) surgery to assess urethral and bladder function. The primary goal of this study is to examine how preoperative UDS are utilized and what value these studies have in patient treatment and/or counseling. We retrospectively reviewed patients who underwent prolapse surgery and had preoperative UDS between June 2010 and February 2015. Indications for UDS were classified into four categories: (1) occult stress urinary incontinence only, (2) overactive bladder symptoms, (3) mixed or insensible urinary incontinence, and (4) voiding symptoms and/or elevated post-void residual. We identified changes in management or counseling that were directly attributable to UDS results prior to surgery. Three hundred ninety-two patients underwent urodynamic testing for indications 2–4 above, and 316 met the inclusion criteria. Fifty-seven percent (180/316) had OAB symptoms (34.4% wet, 65.6% dry), 40.2% (127/316) had mixed incontinence, and 17.1% (54/316) had voiding symptoms and/or elevated PVR. A total of 3.5% (11/316) patients had alteration in their management or counseling based on the results of the UDS; 29.4% (50/170) of the women evaluated for occult SUI alone or with other symptoms demonstrated it and 41 underwent sling placement. UDS did not have a significant impact on preoperative management or counseling in POP surgery if demonstration of occult SUI was not the indication for preoperative study in women committed to POP surgery. Major alterations in treatment were rare and occurred mostly in women with stress incontinence that also had concomitant voiding symptoms and/or elevated PVR.

Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) are highly prevalent in the general population and are a crucial component in the evaluation of male patients in the primary care setting. The etiology and pathophysiology can be quite complex. Initial treatment of BPH/LUTS has shifted from primary surgical therapy to medical treatment with the advent of many novel therapeutics. With the proper background knowledge, primary care providers can be actively involved in the management of patients with BPH/LUTS. After consideration of the differential diagnosis, primary care providers can initiate treatment for patients and continue to monitor patients for improvement. There are useful tools that providers can use to objectively measure the degree of symptoms and whether patients are responding to treatment. When medical management fails, urologists can provide advanced management and surgical intervention. Through the use of many new and innovative technologies, urologists are able provide treatment for patients in a minimally invasive fashion.

INTRODUCTION AND OBJECTIVE:Retained surgical items (RSIs) remain the most frequently encountered sentinel event despite increased vigilance and improved patient safety measures. Recently, a greater...

INTRODUCTION AND OBJECTIVE:Robotic-assisted posterior urethral reconstruction has shown great promise in early series with excellent patency rates. While Y-V or T plasty remains useful for short su...

Activities of daily living provide information about the functional status of an individual and can predict postoperative complications after general and oncological surgery. However, they have rarely been applied to urology. We evaluated whether deficits in activities of daily living could predict complications after percutaneous nephrolithotomy and how this compares with the Charlson comorbidity index and the ASA(®) (American Society of Anesthesiologists(®)) classification.We retrospectively reviewed the records of all patients who underwent percutaneous nephrolithotomy between March 2013 and March 2014. Those with complete assessment of activities of daily living were included in analysis. Perioperative outcomes, complications and hospital length of stay were examined according to the degree of deficits in daily living activities.Overall 176 patients underwent a total of 192 percutaneous nephrolithotomies. Deficits in activities of daily living were seen in 16% of patients, including minor in 9% and major in 7%. Complications developed more frequently in those with vs without deficits in daily living activities (53% vs 31%, p = 0.029) and length of stay was longer (2.0 vs 4.5 days, p = 0.005). On multivariate logistic regression activities of daily living were an independent predictor of complications (OR 1.11, p = 0.01) but ASA classification and Charlson comorbidity index were not.Activities of daily living are easily evaluated prior to surgery. They independently predict complications following percutaneous nephrolithotomy better than the Charlson comorbidity index or the ASA classification. Preoperative assessment of daily living activities can help risk stratify patients and may inform treatment decisions.

Percutaneous nephrolithotomy is commonly performed with the patient prone. There is concern that the prone position, especially in obese patients, negatively affects ventilation due to the restriction of chest compliance and respiratory mechanics. We analyzed the change in airway resistance between supine and prone positioning of patients undergoing percutaneous nephrolithotomy.We retrospectively reviewed the intraoperative respiratory parameters of 101 patients who underwent prone percutaneous nephrolithotomy. Peak inspiratory pressure was assessed with the patient supine, at several time points after being turned prone and at the end of the case. The change in peak inspiratory pressure with time was calculated. Results were stratified based on body mass index and data were compared using the paired t-test and Spearman ρ.Of 101 patients 50 (50%) were obese (body mass index 30 kg/m(2) or greater). Median body mass index was 25.6 kg/m(2) in the nonobese cohort and 38.3 kg/m(2) in the obese cohort. Average peak inspiratory pressure while supine and prone was 18.0 and 18.5 cm H2O in the nonobese cohort, and 25.5 and 26.6 cm H2O, respectively, in the obese cohort. Obese patients had significantly higher peak inspiratory pressure in the supine and the prone positions relative to nonobese patients (p0.0001). However, there was no change in peak inspiratory pressure from the supine to the prone position in either cohort.Obese patients have higher baseline peak inspiratory pressure regardless of position. However, prone positioning does not impact peak inspiratory pressure in either cohort. It remains a safe and viable option.

Extrinsic malignant compression of the ureter is not uncommon, often refractory to decompression with conventional polymeric ureteral stents, and frequently associated with limited survival. Alternative options for decompression include tandem ureteral stents, metallic stents and metal-mesh stents, though the preferred method remains controversial. We reviewed and updated our outcomes with tandem ureteral stents for malignant ureteral obstruction, and carried out a PubMed search using the terms "malignant ureteral obstruction," "tandem ureteral stents," "ipsilateral ureteral stents," "metal ureteral stent," "resonance stent," "silhouette stent" and "metal mesh stent." A comprehensive review of the literature and summary of outcomes is provided. The majority of studies encountered were retrospective with small sample sizes. The evidence is most robust for metal stents, whereas only limited data exists for tandem or metal-mesh stents. Metal and metal-mesh stents are considerably more expensive than tandem stenting, but the potential for less frequent stent exchanges makes them possibly cost-effective over time. Urinary tract infections have been associated with all stent types. A wide range of failure rates has been published for all types of stents, limiting direct comparison. Metal and metal-mesh stents show a high incidence of stent colic, migration and encrustation, whereas tandem stents appear to produce symptoms equivalent to single stents. Comparison is difficult given the limited evidence and heterogeneity of patients with malignant ureteral obstruction. It is clear that prospective, randomized studies are necessary to effectively scrutinize conventional, tandem, metallic ureteral and metal-mesh stents for their use in malignant ureteral obstruction.

Gross testicular heterogeneity on ultrasound has been associated with testis loss following testicular torsion in children. We aimed to quantify the extent of temporal heterogeneity associated with testis loss in testicular torsion cases using a noninvasive technique to determine a HI (heterogeneity index) on ultrasound images.We retrospectively studied the records of patients who presented with acute scrotal pain to the Pediatric Emergency Department over a 6-year period. Ultrasound images of the affected testis and the unaffected contralateral testis were examined using a proprietary program to determine the extent of heterogeneity of each image. The difference between the HI of the torsed testis and that of the contralateral normal testis was termed ΔHI. Receiver operating characteristics curve analysis was performed to determine the ΔHI threshold for nonviability.Among 529 patients who presented with acute scrotal pain 147 had testicular torsion based on surgical findings. Of these 147 patients 110 (74.8%) were found to have a viable testis while 37 (25.2%) had a nonviable testis. Using the ΔHI cutoff of 0.394 or greater for nonviability, sensitivity and specificity were 100% and 94.5%, respectively. Positive and negative predictive values were 86% and 100%, respectively.Our results demonstrate that a quantifiable temporal gradation of heterogeneity exists and the heterogeneity index can be used as an objective parameter to determine the viability of a torsed testicle. By developing the technology to measure the heterogeneity index in real time, we could potentially identify which patients with testicular torsion have a nonviable testicle and, thus, would not require immediate surgical exploration.

Circumcision is the most common surgical procedure performed worldwide. However, there is a dearth of literature regarding medical indications for adult circumcisions. Here, we describe our experience with adult circumcision and contemporary demographics, indications and complications.We reviewed all circumcisions performed in our institution between July 2008 and January 2015. Patient demographics, procedure indications and postoperative complications were recorded, and patients were grouped by age as either less than 50 years old or 50 years and older.A total of 202 charts were reviewed. The most common indications for circumcision were phimosis (46.5%), dyspareunia (17.8%), balanitis (14.4%), and concurrent phimosis and balanitis (8.9%). Older patients were more likely to undergo circumcision for concurrent phimosis and balanitis or cancer, whereas younger patients sought circumcision for dyspareunia. The complication rate was 3.5% and there was no significant difference in complication rates between the two age groups.Circumcision is performed in the adult population for a variety of reasons. Circumcision remains a safe surgical option for patient management with a low complication rate.

A clinical dilemma surrounds the use of aspirin therapy during laparoscopic partial nephrectomy. Despite reduced cardiac morbidity with perioperative aspirin use, fear of bleeding related complications often prompts discontinuation of therapy before surgery. We evaluate perioperative outcomes among patients continuing aspirin and those in whom treatment is stopped preoperatively.A total of 430 consecutive cases of laparoscopic partial nephrectomy performed between January 2012 and October 2014 were reviewed. Patients on chronic aspirin therapy were stratified into on aspirin and off aspirin groups based on perioperative status of aspirin use. Primary end points evaluated included estimated intraoperative blood loss and incidence of bleeding related complications, major postoperative complications, and thromboembolic events. Secondary outcomes included operative time, transfusion rate, length of hospital stay, rehospitalization rate and surgical margin status.Among 101 (23.4%) patients on chronic aspirin therapy, antiplatelet treatment was continued in 17 (16.8%). Bleeding developed in 1 patient in the on aspirin group postoperatively and required angioembolization. Conversely 1 myocardial infarction was observed in the off aspirin cohort. There was no significant difference in the incidence of major postoperative complications, intraoperative blood loss, transfusion rate, length of hospital stay and rehospitalization rate. Operative time was increased with continued aspirin use (181 vs 136 minutes, p=0.01).Laparoscopic partial nephrectomy is safe and effective in patients on chronic antiplatelet therapy who require perioperative aspirin for cardioprotection. Larger, prospective studies are necessary to discern the true cardiovascular benefit derived from continued aspirin therapy as well as better characterize associated bleeding risk.

INTRODUCTION AND OBJECTIVES: Adult patients with myelomeningocele (MMC) and the associated neurogenic bladder require consistent, lifelong vigilance. Preventing these complications may be possible if adequate surveillance can be implemented for these patients. Our objectives are to evaluate the adequacy of urologic surveillance in this population and to outline the prevalence and risk factors for medical complications. METHODS: We performed a retrospective cohort study using a 5% sample of Medicare administrative data from 2007 2010. We used the Paralyzed Veterans of America screening guideline to define the minimum adequacy of surveillance: serum creatinine, upper urinary tract imaging and a urologist visit within a 2 year period. Neurogenic bladder associated complications and diagnosis of MMC were collected using ICD 9 codes. Complications were graded based on their clinical implications. We completed a multivariate analysis to identify predictors of complications based on severity. We included the following variables: age, gender, race, travel distance to referral center, and geographic location of residence. RESULTS: 825 MMC patients were included in our study and were a predominantly Caucasian (85.1%) female population (61.3%) with a mean age of 51.2 þ/ 17.2 years. Most patients (61.3%) received some form of neurogenic bladder surveillance, although only 33% of the patients met the minimum acceptable criteria for adequacy. A urologist visit within two years took place for 44% of the patient population. Most complications observed in the patient sample were mild complications, which occurred in 27.6% of patients. Moderate and severe complications were observed in 17.0% and 6.6% of patients, respectively. The most common complications were acute or recurrent cystitis (16.4%), pressure ulcers (7.1%), chronic kidney disease (4.4%), and kidney infection (3.7%). Multivariate analysis showed that the risk factors for increased complications included younger patient age, male gender and better adequacy of neurogenic bladder surveillance. CONCLUSIONS: This retrospective sample of patients highlights the opportunity for improvement in surveillance in this susceptible population. The select minority of patients who received adequate observation was diagnosed with a larger number of complications. Disease ascertainment may be better in the adequately screened MMC population. This emphasizes a need for a close watch on this high risk patient population.

Extrinsic malignant compression of the ureter is not uncommon, often refractory to decompression with conventional polymeric ureteral stents, and frequently associated with limited survival. Alternative options for decompression include tandem ureteral stents, metallic stents and metal-mesh stents, though the preferred method remains controversial. We reviewed and updated our outcomes with tandem ureteral stents for malignant ureteral obstruction, and carried out a PubMed search using the terms "malignant ureteral obstruction," "tandem ureteral stents," "ipsilateral ureteral stents," "metal ureteral stent," "resonance stent," "silhouette stent" and "metal mesh stent." A comprehensive review of the literature and summary of outcomes is provided. The majority of studies encountered were retrospective with small sample sizes. The evidence is most robust for metal stents, whereas only limited data exists for tandem or metal-mesh stents. Metal and metal-mesh stents are considerably more expensive than tandem stenting, but the potential for less frequent stent exchanges makes them possibly cost-effective over time. Urinary tract infections have been associated with all stent types. A wide range of failure rates has been published for all types of stents, limiting direct comparison. Metal and metal-mesh stents show a high incidence of stent colic, migration and encrustation, whereas tandem stents appear to produce symptoms equivalent to single stents. Comparison is difficult given the limited evidence and heterogeneity of patients with malignant ureteral obstruction. It is clear that prospective, randomized studies are necessary to effectively scrutinize conventional, tandem, metallic ureteral and metal-mesh stents for their use in malignant ureteral obstruction.

Serology data are limited for patients with sputum smear-negative HIV-associated active tuberculosis (TB). We evaluated the serum antibody responses against the mycobacterial proteins MPT51, MS, and echA1 and the 38-kDa protein via enzyme-linked immunosorbent assay (ELISA) in South African (S.A.) HIV-positive (HIV + ) smear-negative TB patients ( n = 56), U.S. HIV + controls with a positive tuberculin skin test (TST + ; n = 21), and S.A. HIV-negative (HIV − ) ( n = 18) and HIV + ( n = 24) controls. TB patients had positive antibody reactivity against MPT51 (73%), echA1 (59%), MS (36%), and the 38-kDa protein (11%). Little reactivity against MPT51 and echA1 was observed in control groups at low risk for TB, i.e., S.A. HIV − (0% and 6%, respectively), and at moderate risk for TB development, i.e., U.S. HIV + TST + controls (14% and 10%, respectively). By contrast, more reactivity was detected in the S.A. HIV + control group at higher risk for TB (25% and 45%, respectively). Our data hold promise that antibody detection against MPT51 and echA1 might have adjunctive value in the detection of HIV + smear-negative TB and might reflect increasing Mycobacterium tuberculosis infection activity in asymptomatic HIV + individuals.

The ability to utilize serum or plasma samples interchangeably is useful for tuberculosis (TB) serology. We demonstrate a strong correlation between antibody titers to several mycobacterial antigens in serum versus plasma from HIV-infected and non-HIV-infected TB and non-TB patients ( r = 0.99 to 0.89; P < 0.0001). Plasma and serum can be used interchangeably in the same antibody detection assays.