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Objective To describe a novel method of robotic assisted laparoscopic parastomal hernia repair (RAL-PHR), including the evolving use of the Da Vinci Single Port (SP) robotic system. Methods Demographic, intraoperative, and postoperative variables were collected for patients who underwent RAL-PHR. The technique for RAL-PHR utilizes a 3 cm incision in the contralateral upper quadrant for the robotic trocar and a 12 mm assistant port. The hernia sac is freed from the fascial defect. Dual Surface Mesh is approximated to the fascial edges with a portion excised to tailor the conduit. Results Four patients underwent RAL-PHR and three utilized the SP robot. Median age was 74.4 (range: 69.0-76.9) and median BMI 28.6 (26.5-43.2). All patients underwent cystectomy for bladder cancer and median time from index operation to parastomal hernia repair was 47.3 (40.4-11.48) months. Concurrent operations to hernia repair included ureteroenteric stricture repair, panniculectomy, abdominal wall reconstruction, stoma revision, and incisional hernia repair. Median operative time was 3.9 (2.6-8.7) hours including concurrent operations, median EBL was 50 (10-100) cc, mesh used in 3 cases, with no intraoperative complications reported. Median length of stay was 1 day and 1 post-operative complication greater than Clavien 2 reported. At median follow up of 18.3 (3.63-38.3) months, no recurrences were reported and 1 patient had undergone stoma dilation in the OR. Conclusion RAL-PHR using the SP system maximizes advantages of laparoscopic repair while allowing for flexibility to perform concurrent procedures and safer takedown of adhesions through just two incisions. RAL-PHR is a safe and effective alternative to open and laparoscopic parastomal hernia repair with several additional benefits.

BACKGROUND: Among men with bulbar strictures, we aimed to analyze stricture characteristics, repair type, and treatment success in younger versus older patient cohorts. METHODS: We retrospectively reviewed our single surgeon database with patients undergoing bulbar urethroplasty from 2007 to 2017. This population was then age-stratified into ≤40 and >40-year-old cohorts. Exclusion criteria included patients with penile strictures and those with history of hypospadias. Patient characteristics, surgical approach, and outcome were compiled by medical record and database review. Criterion for success included functional emptying and lack of repeat surgical intervention. Parameters associated with failure were included in multivariate logistic regression models. RESULTS: Eight hundred and fifty-three patients with bulbar strictures were identified, 231 patients (27.1%) ≤40 years old and 622 patients (72.9%) >40 years old. Mean stricture length was significantly longer in older men (2.3 vs. 2.7 cm, P=0.005). Excision and primary anastomosis (EPA) were more commonly utilized when managing younger compared to older patient groups (87% in ≤40 group, 77% in >40, P=0.0009). Younger men underwent significantly fewer endoscopic stricture treatments than older men (2.1 vs. 4.9, P=0.001). Traumatic etiology was more commonly attributable in the younger group (48% vs.17%, P40 cohort (87.3%, P40 years old. Bulbar strictures are more amenable to EPA in the younger population, likely due to fewer endoscopic treatments and favorable tissue characteristics.

BACKGROUND: We sought to compare outcomes between inpatient and outpatient buccal mucosal graft (BMG) urethroplasty among a large tertiary referral center series. METHODS: A retrospective review of consecutive patients who underwent BMG urethroplasty between 2007 and 2018 was performed, including only first stage and one stage graft procedures. Patients were divided into inpatient and outpatient groups. Demographic and outcome data were collected and analyzed, with success defined as no need for further endoscopic or open reoperative management. RESULTS: Of 143 patients undergoing BMG urethroplasty during the study period, 87 cases (60.8%) were performed on an inpatient basis, and 56 (39.2%) on an outpatient basis. Patient characteristics such as age, BMI, prior endoscopic procedures and co-morbid factors were similar between inpatient and outpatient groups. Perioperative characteristics such as estimated blood loss were also similar between groups, but the inpatient cohort had a longer operative time (157.6 vs. 123.1 min, P

INTRODUCTION AND OBJECTIVE:Silber and Kelly first described the successful autotransplantation of an intra-abdominal testis in 1976. Over subsequent decades, other authors have adopted the use of l...

AIMS To examine the rate of lower urinary tract complications (LUTC) and urinary diversion (UD) after artificial urinary sphincter (AUS) explantation with the acute reconstruction of AUS cuff erosion defects. METHODS We performed a retrospective study of patients who underwent in-situ urethroplasty (ISU) for AUS cuff erosion from June 2007 to December 2020. Outcomes included LUTC (urethral stricture, diverticulum, fistula), AUS reimplantation, and UD. Defect size was prospectively estimated acutely and a subanalysis was performed to determine the impact of erosion severity (small erosions [

Objectives To present a multi-institutional experience with functional and patient-reported outcomes among men undergoing excision and primary anastomosis (EPA) urethroplasty for pendulous urethral strictures. Methods We describe the technique and present our experience with EPA for focal penile strictures. Patients undergoing urethroplasty (2004-2017) at 2 tertiary referral centers were reviewed, of whom 14 (0.7%) underwent EPA of radiographically confirmed pendulous urethral strictures. Validated questionnaires were utilized to evaluate overall improvement (Patient Global Impression of Improvement), urinary bother (International Prostate Symptom Score), and sexual function (International Index of Erectile Function-5). Treatment success was defined as urethral patency without need for subsequent reconstruction. Results Among 14 men undergoing penile EPA, 13/14 (93%) had durable treatment success over a median follow-up of 43 months. No patient reported penile curvature postoperatively. Stricture etiology in most cases was posttraumatic (12/14), of which 4 had a history of urethral disruption secondary to penile fracture and 8 iatrogenic trauma. Median age was 51 years (IQR 30-60) and stricture length 1.0 cm (IQR 1.0-1.4). Erectile function was normal in 8/14 patients preoperatively, and postoperative median International Index of Erectile Function was 21. Most men reported significant global improvement in condition (median Patient Global Impression of Improvement 2, IQR 1-3) and most had only mild urinary bother (median International Prostate Symptom Score 4, quality of life 1). The single treatment failure had a history of hypospadias with multiple prior urethral procedures. Conclusion For men with short strictures of the pendulous urethra, EPA has a high success rate, without adverse sequelae such as erectile function or penile curvature.

Objective To evaluate procedural trends and outcomes for reconstruction of complex strictures at our tertiary center over the last decade. Methods We retrospectively reviewed complex urethral reconstruction comparing 3 techniques: (1) buccal mucosal graft (BMG), (2) penile skin flap, or (3) perineal urethrostomy (PU) at our center (2007-2017) with ≥6 months follow-up. Strictures amenable to anastomotic repair were excluded. Success was defined as no need for further operative management. Results Among 1129 strictures cases, 403 complex strictures were identified for analysis (median length 4.5 cm). Median age was 53.2 years (standard deviation ± 14.9). Reconstruction was most commonly performed using BMG (61.3%), followed by penile skin flap (21.6%) and PU (19.1%). PU use has increased steadily over the past decade, rising from 4.3% of case volume in 2008 to 38.7% in 2017 (P = .01). Over time, the proportion of reconstruction using BMG has remained stable, while penile skin flaps are now less commonly utilized. Over a median follow-up of 50.7 months, 16.9% (68/403) patients failed at a median of 13.9 months. Success rates were higher following PU (94.8%) compared to BMG and skin flaps (78.5% and 78.2%, respectively) (P = .003) despite PU patients being older (median age 62.6 years), having longer strictures (median 5.0 cm) and more commonly having lichen sclerosus (LS) (22.1%). Conclusion Over a decade of a urethral reconstructive practice, PU has increasingly become preferred for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for these complex strictures are markedly higher than those of grafts and flaps.

Erectile ability is a common goal for transgender men seeking phalloplasty, which necessitates prosthesis placement in most phalloplasty techniques. In the absence of preexisting corpora, implant placement is associated with increased risk of poor proximal fixation, device migration, distal erosion, and neurovascular compromise, infection, and malfunction. Modifications to conventional surgical technique, such as avoidance of critical structures, proximal prosthesis anchoring, and distal cushioning with vascular or synthetic grafts, are common techniques to address anatomic challenges.

OBJECTIVE To describe a technique for perineal urethrostomy (PU) revision using a posterior thigh propeller flap for a complex repair at high risk for stenosis. METHODS Our technique utilizes the consistent posterior thigh perforators for a local flap with ideal length and thickness for repair. The stenotic PU is incised. Potential flaps are marked around a perforator blood supply closest to the defect. The flap is then elevated and rotated on its pedicle with its apex placed directly in the defect. Absorbable sutures partially tubularize the flap apex at the level of the urethrotomy which is calibrated to 30 Fr. We subsequently monitored the patient's clinical progress. RESULTS With 17 months of follow-up the patient is voiding well without complaint, reports improved quality of life with a patent PU. Post void residuals have been less than 100cc. The patient, who has had a long history of urinary tract infections requiring hospitalization, has only reported one infection during follow up which was treated as an out-patient. CONCLUSION For challenging PU revisions a distant local propeller flap of healthy tissue outside the zone of injury is the ideal choice for length, thickness, and minimal morbidity resulting in excellent clinical results for our patient.

Background: The optimal management strategy for recurrent urethral stricture disease (USD) following urethroplasty remains undefined. We aim to evaluate the role and efficacy of endoscopic urethral balloon dilation in temporizing recurrent USD after failed urethroplasty. Methods: Between 2007–2018 at our institution, 80 patients underwent balloon dilation procedures for bulbomembranous urethral strictures. Balloon dilation was performed with an 8-cm, 24-French UroMax Ultra™ balloon dilator, under direct vision, guided by a 16-French flexible cystoscope. Patients who underwent concomitant open or endoscopic urethral procedures were excluded. Treatment failure was defined as the need for subsequent surgical intervention for stricture recurrence. Stricture characteristics including etiology, length, location, severity stage, and prior surgical procedures were compared between patients with and without treatment failure. Results: Failure cases were more likely to have strictures following urethroplasty (21/27, 78%) [vs. the no-failure group (27/53, 51%)]. Among the 27/80 (33.8%) failures with a median follow-up of 8.4 months (IQR, 3.9–22.5 months), median time to recurrence was 4 months (IQR, 2–12 months). These patients had a greater incidence of prior stricture intervention in general (P=0.01) and prior urethroplasty specifically (P=0.03). On multivariable analysis, the number of prior treatments specifically independently remained associated with treatment failure. Complications of balloon dilation were uncommon (6/80, 7.5%) and minor in nature. Conclusions: Endoscopic balloon dilation performs poorly as a salvage strategy after failed open urethral reconstruction in addition to prior urethral dilations.

Silber and Kelly first described the successful autotransplantation of an intra-abdominal testis in 1976. Subsequent authors incorporated laparoscopy and demonstrated the viability of transplanted testes based on serial postoperative exams. We sought to extend this experience with use of the da Vinci surgical robot, thereby demonstrating a novel robotic technique for the management of cryptorchidism. The procedure was performed for an 18-year-old male with a solitary left intra-abdominal testis. Following establishment of pneumoperitoneum, the robot is docked with four trocars oriented towards the left lower quadrant. Testicular dissection is carried out as shown. The gonadal and inferior epigastric vessels are isolated and mobilized; once adequate length is achieved, the former is clipped and transected, and the testicle and inferior epigastric vessels are delivered out of the body. The robot is then undocked and exchanged for the operating microscope. Arterial and venous anastomoses are completed with interrupted and running 9-0 Nylon, respectively, and satisfactory re-anastomosis is confirmed visually and with Doppler. The transplanted testicle is then fixed inferiorly and laterally within the left hemiscrotum, and all incisions are closed. We note that intraoperative testicular biopsy was not performed, for three reasons: (1) to avoid further risk to an already tenuous, solitary organ, (2) because our primary aim was to preserve testicular endocrine function, and (3) because the presence of ITGCN would neither prompt orchiectomy nor obviate the need for ongoing surveillance via periodic self-examination and ultrasonography. The patient is maintained on bed rest for two days and discharged on postoperative day seven in good condition. Over one year since autotransplantation, his now intra-scrotal testicle remains palpable and stable in size. Serum testosterone is unchanged from preoperative measurements. Robotic-assisted testicular autotransplantation is a feasible and efficacious management option for the solitary intra-abdominal testis.

Objective To compare long-term outcomes and erosion rates of 3.5-cm artificial urinary sphincter (AUS) cuffs vs larger cuffs amongst men with stress urinary incontinence (SUI), with and without a history of pelvic radiotherapy (RT). Patients and methods We reviewed the records of all men who underwent AUS placement by a single surgeon between September 2009 and June 2017 at our tertiary urban medical centre. A uniform perineal approach was used to ensure cuff placement around the most proximal corpus spongiosum after precise spongiosal measurement. Patients were stratified by cuff size and RT status, and patient demographics and surgical outcomes were analysed. Cases of AUS revision in which a new cuff was not placed were excluded. Success was defined as patient-reported pad use of ≤1 pad/day. Results Amongst 410 cases included in the analysis, the 3.5-cm cuff was used in 166 (40.5%), whilst 244 (59.5%) received larger cuffs (≥4.0 cm). Over a median follow-up of 50 months, there was AUS cuff erosion in 44 patients at a rate nearly identical in the 3.5-cm cuff (10.8%, 18/166) and the ≥4-cm cuff groups (10.7%, 26/244, P = 0.7). On multivariate logistic regression, clinical factors associated with AUS cuff erosion included a history of pelvic RT, prior AUS cuff erosion, prior urethroplasty, and a history of inflatable penile prosthesis (IPP) placement. Patient demographics were similar between the cuff-size groups; including age, body mass index, comorbidities, smoking history, RT history, prior AUS, and prior IPP placement. Continence rates were high amongst all AUS patients, with similar success in both groups (82% for 3.5-cm cuff, 90% for ≥4-cm cuff, P = 0.1). Conclusions After 8 years of experience and extended follow-up, the outcomes of the 3.5-cm AUS cuff appear to be similar to ≥4-cm cuffs for effectiveness and rates of urethral erosion. RT patients have a higher risk of cuff erosion regardless of cuff size.

Reconstruction of the posterior urethra and bladder outlet is challenging due to poor surgical exposure. Robotic assistance allows for enhanced visualization and improved dexterity in the deep pelvis, offering an addition or alternative to traditional perineal and transabdominal approaches. Moreover, the perineal approach to posterior urethral reconstruction may require extensive urethral mobilization and bulbar artery transection. The robotic approach may allow for preservation of periurethral tissue planes and vasculature, and thus contribute towards improved outcomes if future artificial urinary sphincter placement is necessary.

Objective To report our experience with permanent urethral ligation for severe incontinence among men with end-stage urethra. Materials and Methods From our institutional artificial urinary sphincter database of 512 patients from 2010 to 2016, 10 men underwent permanent urethral ligation with concurrent suprapubic tube diversion following recurrent artificial urinary sphincter cuff erosion. Clinical characteristics and outcomes were evaluated. Quality of life was assessed using the Michigan Incontinence Symptom Index and the Patient Global Index of Improvement. Results Urethral ligation resulted in resolution of incontinence in 8 men (80%), including 7 (70%) after 1 surgery and in 1 (10%) after a single revision. The average American Society of Anesthesiologists physical status rating was 2.7 (range 2-3). Seven patients (70%) experienced postoperative complications (4 Clavien-Dindo grade II complications [1 Clostridium difficile infection, 3 refractory bladder spasms) and 5 grade III complications (2 abscesses, 2 urethrocutaneous fistula, and 1 bladder stone formation]). Overall, satisfactory Michigan Incontinence Symptom Index urinary scores were reported in 8 (80%) men. On the Patient Global Index of Improvement, 6 (60%) men reported improvement in overall condition following surgery. All men (10/10) stated that they would recommend this procedure to others. Conclusion For debilitated men with end-stage urethra and severe refractory stress urinary incontinence, permanent urethral ligation with chronic suprapubic tube drainage can restore continence and improve quality of life without the need for more invasive formal urinary diversion, though with a high risk of complication.

Current imaging and biopsy practices offer limited insight into preoperative detection of seminal vesicle invasion despite the implications for treatment decisions and patient prognoses. We identified magnetic resonance imaging features to assess the risk of seminal vesicle invasion and inform the inclusion of seminal vesicle sampling during biopsy.Patients underwent multiparametric magnetic resonance imaging and fusion targeted biopsy with or without seminal vesicle biopsy. Magnetic resonance imaging suspicion of seminal vesicle invasion, multiparametric magnetic resonance imaging of prostate base lesions of moderate or greater suspicion, extraprostatic extension, anatomical zone and biopsy data were used to generate multivariable logistic regression models. One model without and 1 with biopsy data were externally validated in a multi-institutional cohort. Decision curve analyses were done to determine net benefit of the 2 models.The training and validation cohorts comprised 564 and 250 patients, respectively. In the training cohort 55 patients (9.8%) had pathologically confirmed seminal vesicle invasion. In the prebiopsy model magnetic resonance imaging suspicion of seminal vesicle invasion (OR 9.5, 95% CI 4.0-22.4, p0.001), multiparametric magnetic resonance imaging base lesions of moderate or greater suspicion with extraprostatic extension (OR 13.6, 95% CI 4.0-46.5, p0.001) and a transition and/or central zone location (OR 11.6, 95% CI 3.5-38.3, p0.001) showed strong correlations. In the post-biopsy model the risk of pathologically confirmed seminal vesicle invasion increased with the base Gleason Group (Gleason Group 5 OR 85.3, 95% CI 11.8-619.1, p0.001). In the validation cohort the AUC of the prebiopsy and post-biopsy models was 0.84 and 0.93, respectively (p = 0.030).Magnetic resonance imaging evidence of seminal vesicle invasion or extraprostatic extension at the prostate base transition and/or central zone and high grade prostate cancer from the prostate base are significant features associated with an increased risk of pathologically confirmed seminal vesicle invasion. Our models successfully incorporated these features to predict seminal vesicle invasion and inform when to biopsy the seminal vesicles.

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.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.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 (p0.05). 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 (p0.05). 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).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.

To develop a decision aid in predicting sling success, incorporating the Male Stress Incontinence Grading Scale (MSIGS) into existing treatment algorithms.We reviewed men undergoing first-time transobturator sling for stress urinary incontinence (SUI) from 2007 to 2016 at our institution. Patient demographics, reported pads per day (PPD), and Standing Cough Test (SCT) results graded 0-4, according to MSIGS, were assessed. Treatment failure was defined as subsequent need for1 PPD or further procedures. Parameters associated with failure were included in multivariable logistic models, compared by area under the receiver-operating characteristic curves. A nomogram was generated from the model with greatest AUC and internally validated.Overall 203 men (median age 67 years, IQR 63-72) were evaluated with median follow-up of 45 months (IQR 11-75 months). A total of 185 men (91%) were status-post radical prostatectomy and 29 (14%) had pelvic radiation history. Median PPD and SCT grade were both two. Eighty men (39%) failed treatment (use of ≥1 PPD or subsequent anti-incontinence procedures) at a median of 9 months. History of radiation (P = 0.03), increasing MSIGS (P 0.0001) and increasing preoperative PPD (P 0.0001) were associated with failure on univariate analysis. In a multivariable model with AUC 0.81, MSIGS, and PPD remained associated (P = 0.002 and0.0001 respectively, and radiation history P = 0.06), and was superior to models incorporating PPD and radiation alone (AUC 0.77, P = 0.02), PPD alone (AUC 0.76, P = 0.02), and a cutpoint of2 PPD alone (AUC 0.71, P = 0.0001).MSIGS adds prognostic value to PPD in assessing success of transobturator sling for treatment of SUI.

Background For prolonged ischemic priapism, outcomes after distal shunt are poor, with only 30% success for priapic episodes lasting longer than 48 hours. Aim To present a novel, glans-sparing approach of corporal decompression through a penoscrotal approach for cases of refractory ischemic priapism (RIP) after failed distal shunt procedures. Methods We describe the technique and present our initial experience with penoscrotal decompression (PSD) for treatment of RIP after failed distal shunt. We compared outcomes of patients with RIP undergoing surgical management using PSD or malleable penile prosthesis (MPP) placement after failed distal penile shunt procedures (2008–2017). Outcomes Our initial experience showed favorable outcomes with PSD compared with early MPP placement in patients with RIP whose distal shunt failed. Results Of 14 patients with RIP undergoing surgical management after failed distal penile shunt procedures, all patients presented after a prolonged duration of priapism (median = 61 hours) after which the priapism was refractory to multiple prior treatments (median = 3, range = 1–75) including at least 1 distal shunt. MPP was inserted in 8 patients (57.1%), whereas the most recent 6 patients (42.9%) underwent PSD. All patients with PSD (6 of 6, 100%) were successfully treated with corporal decompression without additional intervention and noted immediate relief of pain postoperatively. In contrast, 37.5% of patients (3 of 8) undergoing MPP after failed distal shunt procedures required a total of 8 revision surgeries during a median follow-up of 41.5 months. The most common indications for revision surgery after MPP placement included distal (4 of 8, 50%) and impending lateral (2 of 8, 25%) extrusion. Clinical Implications PSD is a simple, effective technique in the management of RIP after failed distal shunt procedures with fewer complications than MPP placement. Strengths and Limitations Although PSD is effective in the management of RIP after failed distal shunt procedures, long-term assessment of erectile function and ease of future penile prosthetic implantation is needed. Conclusion Corporal decompression resolves RIP through a glans-sparing approach and avoids the high complication rate of prosthetic insertion after failed distal shunt procedures.

To characterize the presence of bland (nontumor) thrombus in advanced renal cell carcinoma and assess the impact of this finding on cancer-specific survival.A multi-institutional database of patients treated with nephrectomy with caval thrombectomy for locally-advanced renal tumors was assembled from 5 tertiary care medical centers. Using clinicopathologic variables including patient age, body mass index, Eastern Cooperative Oncology Group performance status, tumor stage, grade, nodal status and histology, and nearest-neighbor and multiple-matching propensity score matched cohorts of bland thrombus vs nonbland thrombus patients were assessed. Multivariable analysis for predictors of cancer-specific survival was performed.From an initial cohort of 579 patients, 446 met inclusion criteria (174 with bland thrombus, 272 without). At baseline, patients with bland thrombus had significantly worse performance status, higher tumor stage, higher prevalence of regional nodal metastases and higher nuclear grade (P .01 for all). In both nearest-neighbor and multiple-matching propensity score matched cohorts, the presence of bland thrombus presence was associated with inferior median cancer-specific survival (28.1 months vs 156.8 months, and 28.1 months vs 76.7 months, P .001 for both). The presence of bland thrombus remained independently associated with an increased risk of cancer-specific mortality on multivariable analysis (hazard ratio 4.33, 95% confidence interval 2.79-6.73, P .001).Presence of bland thrombus is associated with adverse survival outcomes in patients treated surgically for renal tumors with venous tumor thrombus. These findings may have important implications in patient counseling, selection for surgery and inclusion in clinical trials.

Prior to urethral reconstruction many patients with stricture undergo a variable period during which endoscopic treatments are performed for recurrent obstructive symptoms. We evaluated the association among urethroplasty delay, endoscopic treatments and subsequent reconstructive outcomes.We reviewed the records of men who underwent primary bulbar urethroplasty from 2007 to 2014. Those with prior urethroplasty, penile and/or membranous strictures and incomplete data were excluded from analysis. Men were stratified by a urethroplasty delay of less than 5, 5 to 10 or greater than 10 years from diagnosis.A total of 278 primary bulbar urethroplasty cases with complete data were evaluated. Median time between stricture diagnosis and reconstruction was 5 years (IQR 2-10). Patients underwent an average ± SD of 0.9 ± 2.4 endoscopic procedures per year of delay. Relative to less than 5 and 5 to 10 years a delay of greater than 10 years was associated with more endoscopic treatments (median 1 vs 2 vs 5), repeat self-dilations (13% vs 14% vs 34%), strictures longer than 2 cm (40% vs 39% vs 56%) and complex reconstructive techniques (17% vs 17% vs 34%). An increasing number of endoscopic treatments was independently associated with strictures longer than 2 cm (OR 1.06, p = 0.003), which had worse 24-month stricture-free survival than shorter strictures (83% vs 96%, p = 0.0003). Each consecutive direct vision internal urethrotomy was independently associated with the risk of urethroplasty failure (HR 1.19, p = 0.02).Urethroplasty delay is common and often associated with symptomatic events managed by repeat urethral manipulations. Endoscopic treatments appear to lengthen strictures and increase the complexity of repair.

Introduction A preoperative negative urine culture is generally advised before implantation of urologic prosthetics to prevent device infection. However, a review of the medical literature indicates sparse evidence to support this practice. Aim To describe outcomes for patients undergoing prosthetic implantation without preoperative urine cultures. Methods The cases of men undergoing artificial urinary sphincter (AUS) and/or inflatable penile prosthesis (IPP) placement at a tertiary care center from 2007 through 2015 were reviewed. Of 713 devices implanted in 681 patients (337 AUSs in 314 patients, 376 IPPs in 367), 259 cases without preoperative urine cultures were analyzed (41%). Patients received standard perioperative antibiotics. Main Outcome Measures Device infection was diagnosed clinically. Average follow-up was 15 months. Results Device infection occurred in 4 of 259 patients (1.5%) with no difference noted in infection rate between device groups (AUS = 3 of 174 [2%]; IPP = 1 of 85 [1%]; P = .99); this rate appears to be consistent with the infection rate of numerous other published prosthetic series. Common skin organisms were implicated as the infectious agents in half the infected devices. Only one patient (0.4%) developed an Escherichia coli infection. Conclusion This study suggests that prosthetic urologic surgery can be safely performed without preoperative urine cultures. Kavoussi NL, Viers BR, Pagilara TL, et al. Are Urine Cultures Necessary Prior to Urologic Prosthetic Surgery? Sex Med Rev 2017;X:XXX–XXX.

To compare the outcomes of robotic-assisted laparoscopic prostatectomy (RALP) using a dual versus single-console system in a resident training program using intraoperative, perioperative and postoperative measures. Patients with PCa who underwent RALP prior to and after implementing a dual-console system at an academic institution were reviewed from 2006–2012. All surgeries were performed by a single-faculty surgeon well after the learning curve was established. In all cases, chief residents participated in the surgery and performed progressively more portions. Demographic, intraoperative and pathologic parameters were obtained. Continence and erectile function were assessed at 6 and 12 months. Postoperative complications were graded using the Clavien–Dindo classification. Predictors of outcomes on univariate analysis were included in multivariate logistic or linear models. Of 381 patients, 185 and 196 underwent single- or dual-console RALP, respectively. There was a significant decrease in mean operative time using the dual-console system (222 vs. 171 min, p

OBJECTIVES:To evaluate the utility of preoperative multiparametric magnetic resonance imaging (MP-MRI) in predicting biochemical recurrence (BCR) following radical prostatectomy (RP). MATERIALS/METHODS:From March 2007 to January 2015, 421 consecutive patients with prostate cancer (PCa) underwent preoperative MP-MRI and RP. BCR-free survival rates were estimated using the Kaplan-Meier method. Cox proportional hazards models were used to identify clinical and imaging variables predictive of BCR. Logistic regression was performed to generate a nomogram to predict three-year BCR probability. RESULTS:Of the total cohort, 370 patients met inclusion criteria with 39 (10.5%) patients experiencing BCR. On multivariate analysis, preoperative prostate-specific antigen (PSA) (p = 0.01), biopsy Gleason score (p = 0.0008), MP-MRI suspicion score (p = 0.03), and extracapsular extension on MP-MRI (p = 0.03) were significantly associated with time to BCR. A nomogram integrating these factors to predict BCR at three years after RP demonstrated a c-index of 0.84, outperforming the predictive value of Gleason score and PSA alone (c-index 0.74, p = 0.02). CONCLUSION:The addition of MP-MRI to standard clinical factors significantly improves prediction of BCR in a post-prostatectomy PCa cohort. This could serve as a valuable tool to support clinical decision-making in patients with moderate and high-risk cancers.

PSA of 0.3 ng/mL. Pre-operatively, 32% of men underwent a bone scan; this decreased slightly to 22% post-treatment. CT use was more common than bone scan both before and after treatment, while MRI was the least common. The majority (63%) of bone scans was obtained in men who did not receive adjuvant or salvage ADT at a median PSA 0.13 ng/mL (Figure). Median PSA at time of post prostatectomy bone scan was 0.24 ng/mL. On multivariable modeling, increased bone scan use was associated with D’Amico risk category (OR 1.3, 95% CI [1.2-1.4]) and receipt of adjuvant or salvage treatment (OR 3.1, 95% CI [2.9-3.3]), but not with pre-treatment PSA (OR 1.0, 95% CI [1.0-1.0]) or comorbidity (OR 1.1, 95% CI [0.9-1.2]). CONCLUSIONS: We found a substantial rate of bone scan utilization after radical prostatectomy, comparable to the pre-operative setting. The majority was performed for PSA

PURPOSE: Magnetic resonance imaging detects extracapsular extension by prostate cancer with excellent specificity but low sensitivity. This limits surgical planning, which could be modified to account for focal extracapsular extension with image directed guidance for wider excision. In this study we evaluate the performance of multiparametric magnetic resonance imaging in extracapsular extension detection and determine which preoperative variables predict extracapsular extension on final pathology when multiparametric magnetic resonance imaging predicts organ confined disease. MATERIALS AND METHODS: From May 2007 to March 2014, 169 patients underwent pre-biopsy multiparametric magnetic resonance imaging, magnetic resonance imaging/transrectal ultrasound fusion guided biopsy, extended sextant 12-core biopsy and radical prostatectomy at our institution. A subset of 116 men had multiparametric magnetic resonance imaging negative for extracapsular extension and were included in the final analysis. RESULTS: The 116 men with multiparametric magnetic resonance imaging negative for extracapsular extension had a median age of 61 years (IQR 57–66) and a median prostate specific antigen of 5.51 ng/ml (IQR 3.91–9.07). The prevalence of extracapsular extension was 23.1% in the overall population. Sensitivity, specificity, and positive and negative predictive values of multiparametric magnetic resonance imaging for extracapsular extension were 48.7%, 73.9%, 35.9% and 82.8%, respectively. On multivariate regression analysis only patient age (p=0.002) and magnetic resonance imaging/transrectal ultrasound fusion guided biopsy Gleason score (p=0.032) were independent predictors of extracapsular extension on final radical prostatectomy pathology. CONCLUSIONS: Because of the low sensitivity of multiparametric magnetic resonance imaging for extracapsular extension, further tools are necessary to stratify men at risk for occult extracapsular extension that would otherwise only become apparent on final pathology. Magnetic resonance imaging/transrectal ultrasound fusion guided biopsy Gleason score can help identify which men with prostate cancer have extracapsular extension that may not be detectable by imaging.

Equivocal ureteropelvic junction obstruction refers to clinical symptoms and/or other radiological suggestions of possible ureteropelvic junction obstruction but with inconclusive results of obstruction on diuretic renogram. We evaluated long-term outcomes in patients with equivocal ureteropelvic junction obstruction treated with minimally invasive pyeloplasty.We retrospectively analyzed the records of 125 consecutive patients who underwent minimally invasive pyeloplasty as performed by a single surgeon from May 2004 to July 2013. Of 98 patients with followup those with more than 6-month followup were included in analysis. Equivocal ureteropelvic junction obstruction, defined as half-life less than 20 minutes on diuretic renogram, was identified in 23 patients. All patients underwent transperitoneal minimally invasive pyeloplasty. We evaluated patient demographics, preoperative and postoperative symptoms and renal function.The 16 female and 7 male patients with equivocal ureteropelvic junction obstruction had flank pain and associated hydronephrosis on imaging. At a median followup of 20.2 months (range 7 to 75) 95.7% of patients with equivocal obstruction achieved complete symptom resolution. Mean ± SD preoperative and postoperative half-life was 14.1 ± 3.7 and 7.4 ± 4.2 minutes, respectively, for an improvement of 6.7 minutes (p0.001). In 1 patient (4.3%) with equivocal obstruction of a complicated iatrogenic etiology treatment ultimately failed postoperatively and endopyelotomy was required. There was no statistically significant difference in clinical or radiological success between the equivocal obstruction group and the 75 patients treated with minimally invasive pyeloplasty for definitive ureteropelvic junction obstruction (p = 0.44 and 0.07, respectively).In patients with radiographic equivocal ureteropelvic junction obstruction and flank pain minimally invasive pyeloplasty efficaciously provides symptomatic relief and functional preservation. Results are comparable to those in patients with high grade obstruction.

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.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.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.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.

INTRODUCTION AND OBJECTIVES: In patients with prostate cancer (CaP), preoperative identification of extracapsular extension (ECE) can provide vital information for the surgical planning of robotassisted radical prostatectomy (RARP). Historically, MRI has had limited sensitivity for ECE. We aim to evaluate which parameters on multiparametric MRI (MP-MRI) and MRI/ultrasound (MRI/US) fusionguided biopsy aid in the pre-operative assessment of ECE. METHODS: Between May 2007 and August 2013, 299 patients at our institution underwent 3T MP-MRI, MRI/US fusion-guided biopsy with standard 12-core biopsy, and RARP. Visualized lesions were identified as low, moderate, or high suspicion for CaP according to the previously validated NIH scoring system. Findings were characterized as “presence of ECE,” “extracapsular bulge,” or neither. MP-MRI findings were correlated with biopsy results, final RARP pathology and margin status. Univariate analysis was performed to evaluate preoperative predictors of ECE on final pathology. RESULTS: MRI was positive for ECE in 27 patients and negative in 272, with a sensitivity of 17.2% and a specificity of 93.2% when compared to final pathology. In all patients, the rate of positive surgical margins was 15.1%. This rate increased to 22.2% in the subset of patients with MRIs that were positive for ECE, but increased to 31.1% in those patients whose MRIs were false negatives. In the group of patients with negative MRIs, PSA, MRI suspicion score, presence of bulge, and highest Gleason score on MRI/US fusion-guided biopsy were all associated with ECE on final pathology (p

161 Background: Multiparametric magnetic resonance imaging (mpMRI) used in conjunction with MR/TRUS fusion-guided biopsy has improved detection and localization of clinically significant prostate cancer. We aim to evaluate the utility of preoperative MRI characteristics to predict biochemical recurrence (BCR) following radical prostatectomy. Methods: Patients who underwent robotic assisted radical prostatectomy (RARP) between 2007-2014 at the National Institutes of Health were reviewed. We identified patients with BCR defined following the guidelines of the AUA Localized Prostate Cancer Update Panel report (serum PSA ≥0.2 ng/ml with a subsequent confirmatory value). Bivariate analysis and logistic regression were used to determine the association of mpMRI and preoperative patient characteristics with BCR. Results: Of 365 patients who had RARP, 21 met criteria for BCR with a median follow up of 19 months (IQR: 10-34). Mean preoperative PSA (ng/mL) [p

84 Background: Historically, pathologic findings from standard 12-core prostate biopsies are upgraded in 25 to 33% of patients after radical prostatectomy (RP). MRI/US fusion prostate biopsy has been shown to upgrade prostate cancer compared to standard 12-core biopsy in 32% of patients. MRI/US fusion biopsy may offer a more accurate representation of whole gland pathology. We evaluate the rate of pathologic upgrade in standard 12-core biopsy and MRI/US fusion biopsy when compared with whole gland pathology from RP. Methods: Patients who underwent random prostate biopsy, fusion biopsy and subsequently RP for prostate cancer from 2012 to 2013 were included. Pathology was reviewed by a single pathologist. The cohort was divided into clinically significant high-grade (Gleason score 4+3 or higher) and clinically insignificant low-grade (Gleason score 3+4 or lower) sub cohorts. Pathological upgrade was defined as any increase in Gleason sum or primary Gleason score. McNemar’s test was used to compare the proportion of patients who were upgraded from random biopsy to RP versus the proportion that were upgraded from fusion biopsy to RP. Results: Sixty eight patients underwent 12-core and fusion prostate biopsy then subsequently RP. Mean prostate-specific antigen was 9.2ng/ml. There are total of 43 patients with clinically insignificant low-grade and 25 patients with clinically significant high-grade. Fusion biopsy upgraded 19 patients (28%) compared to 12-core biopsy, eight of these patients had negative 12-core biopsy. Pathology on the RP specimen upgraded 18 of the 12-core results (26%) compare to only eight fusion biopsy results (11%). (p =0.0095) 14 patients (20%) who had clinically insignificant low-grade disease on 12-core biopsy were upgraded to clinically significant high-grade on RP. Only two patients (3%) with clinically insignificant low-grade from fusion biopsy were upgraded on RP. (p< 0.0005) Conclusions: Prostate cancer detected on MRI/US fusion prostate biopsy has significantly lower rates of pathologic upgrade than standard 12-core biopsy when both were compared to prostatectomy specimens. MRI/US fusion biopsy may represent whole gland pathology more accurately compared to 12-core biopsy.