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Objective To evaluate the success of urethroplasty for urethral strictures arising after erosion of an artificial urinary sphincter (AUS) and rates of subsequent AUS replacement. Patients and Methods From 2009-2016, we identified patients from the Trauma and Urologic Reconstruction Network of Surgeons and several other centers. We included patients with urethral strictures arising from AUS erosion undergoing urethroplasty with or without subsequent AUS replacement. We retrospectively reviewed patient demographics, history, stricture characteristics, and outcomes. Variables in patients with and without complications after AUS replacement were compared using chi-square test, independent samples t test, and Mann-Whitney U test when appropriate. Results Thirty-one men were identified with the inclusion criteria. Radical prostatectomy was the etiology of incontinence in 87% of the patients, and 29% had radiation therapy. Anastomotic (28) and buccal graft substitution (3) urethroplasty were performed. Follow-up cystoscopy was done in 28 patients (median 4.5 months, interquartile range [IQR]: 3-8) showing no urethral stricture recurrences. Median overall follow-up was 22.0 months (IQR: 15-38). In 27 men (87%), AUS was replaced at median of 6.0 months (IQR: 4-7) after urethroplasty. In 25 patients with >3 months of follow-up after AUS replacement, urethral complications requiring AUS revision or removal occurred in 9 patients (36%) and included subcuff atrophy (3) and erosion (6). Mean length of stricture was higher in patients who developed a complication after urethroplasty and AUS replacement (2.2 vs. 1.5 cm, P = .04). Conclusion In patients with urethral stricture after AUS erosion, urethroplasty is successful. However, AUS replacement after urethroplasty has a high erosion rate even in the short-term.

Patient-reported outcomes and quality of life assessments are essential to studying conditions such as neurogenic bladder in which multiple management strategies are approximately equally efficacious. Innovations for the treatment of neurogenic bladder need to be guided by both clinical and patient-reported outcomes that are rigorously tested via high-quality prospective cohort or randomized studies. Collaborative research groups in reconstructive urology are critical to the study of uncommon disease processes because they allow studies to be powered adequately, foster innovative treatment strategies through collaboration, and help moderate the risk of investigator and or institutional biases.

Introduction Erectile dysfunction (ED) is a common complication in patients with diabetes mellitus (DM). However, the utility of serum biomarkers as clinical surrogates for the development and/or progression of ED is unknown. Aim To summarize the current literature for serum biomarkers for ED in DM and emphasize areas for future research. Main Outcome Measures Human subject data demonstrating the utility of serum markers for the development and progression of ED in patients with DM. Methods We performed a systematic PubMed-Medline search in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using Medical Subject Headings (MeSH) for articles published from January 1, 2000 through December 31, 2016 of serum biomarkers for development or progression of ED in patients with DM using erectile dysfunction [MeSH] AND ( biomarkers [MeSH] or inflammation mediators [MeSH] or intercellular signaling peptides and proteins [MeSH] or cell adhesion molecules [MeSH]). A thorough review of these studies was completed. Results Of the 327 abstracts screened, 12 full-text studies were assessed and 1 study was excluded. Eleven studies assessing serum biomarkers for ED in patients with DM were included in this review. The most studied serum biomarkers for ED in men with DM included endothelial dysfunction markers such as serum E-selectin, endothelial progenitor cells, and endothelial microparticles and specific markers of inflammation such as interleukin-10, ratio of tumor necrosis factor-α to interleukin-10, and reactive oxygen species such as nitric oxide and malondialdehyde. Reliable serum biomarkers will enable earlier diagnosis and objective monitoring of disease progression and responses to treatment in patients with ED. Conclusion Serum biomarkers for ED in men with DM are very limited. Future longitudinal studies with uniform patient characteristics are needed to evaluate the potential clinical use of serum biomarkers in men with DM for the development and progression of ED. Patel DP, Craig JR, Myers JB, et al. Serum Biomarkers of Erectile Dysfunction in Diabetes Mellitus: A Systematic Review of Current Literature. Sex Med Rev 2017:5:339–348.

We evaluated the short and long-term surgical outcomes of urinary diversion done for urinary adverse events arising from prostate radiation therapy. We hypothesized that patient characteristics are associated with complications after urinary diversion.We performed a retrospective cohort study of 100 men who underwent urinary diversion (urinary conduit or continent catheterizable pouch) due to urinary adverse events after prostate radiotherapy from 2007 to 2016 from 9 academic centers in the United States. Outcome measurements included predictors of short and long-term complications, and readmission after urinary diversion of patients who had prostate cancer treated with radiotherapy. The data were summarized using descriptive statistics and univariate associations with complications were identified with logistic regression controlling for center.Mean patient age was 71 years and median time from radiotherapy to urinary diversion was 8 years. Overall 81 (81%) patients had combined modality therapy (radical prostatectomy plus radiotherapy or various combinations of radiotherapy). Grade 3a or greater Clavien-Dindo complications occurred in 31 (35%) men, including 4 deaths (4.5%). Normal weight men had more short-term complications compared to overweight (OR 4.9, 95% CI 1.3-23.1, p=0.02) and obese men (OR 6.3, 95% CI 1.6-31.1, p=0.009). Hospital readmission within 6 weeks of surgery occurred for 35 (38%) men. Surgery was needed to treat long-term complications after urinary diversion in 19 (22%) patients with a median followup of 16.3 months.Urinary diversion after prostate radiotherapy has a considerable short and long-term surgical complication rate. Urinary diversion most often cannot be avoided in these patients but appreciation of the risks allows for informed shared decision making between surgeons and patients.

INTRODUCTION AND OBJECTIVE:Measurement of objective measures following urethroplasty (e.g., urethral patency, uroflowmetry) is vital, but patient-reported input via condition-specific outcome measu...

INTRODUCTION AND OBJECTIVE:The purpose of the study was to develop and then validate a retrograde urethrogram (RUG), patient history, and physical exam-based classification system for urethral stri...

INTRODUCTION AND OBJECTIVE:A urethral stricture classification system based on stricture length (L), segment (S) and etiology (E) has been previously validated to have sufficient inter-rater reliab...

Neurogenic lower urinary tract dysfunction (NLUTD) is the accepted terminology used to describe bladder symptoms and dysfunction with neurogenic bladder (NGB). The patterns of NLUTD are varied and can span benign overactive bladder resulting in simple incontinence to a high-pressure bladder causing urosepsis, hydronephrosis, and renal failure. The degree and type of NLUTD depends upon the etiology underlying NGB, the severity of the disease or injury, and where and how the nervous system is affected. In this chapter, we will summarize common medical and surgical treatments for NLUTD.

Background: To evaluate the current practice patterns of practitioners managing high grade renal trauma and determine perceived need for a prospective trial on the management of renal trauma. Methods: We distributed an electronic survey to members of the American Association for the Surgery of Trauma (AAST) and The Society of Genitourinary Reconstructive Surgeons (GURS). The survey evaluated demographics, interventional radiology (IR) access, and renal trauma management. Descriptive statistics were utilized to analyze participants’ responses. Results: A total of 253 practitioners responded (age 48.4±10.4 years). The majority were acute care/trauma surgeons (ACS/TS) (63.2%), followed by urologists (34.4%) practicing at level 1 trauma centers (80.6%) in 39 US states. Most participants were in practice >10 years (62.8%); and had completed an ACS/TS (53.8%), or trauma/reconstructive urology (25.7%) fellowship. Ninety-five percent (241/253) found value in renal preservation with 74% utilizing IR embolization in the last year. However, there was wide variation in threshold for angiography, low rates of renal repair (24%) or packing (20%) and half reported performing a nephrectomy within the prior year. More than 80% believed there was value in a prospective trial to evaluate a protocol to decrease nephrectomy rates in renal trauma management. Conclusions: The majority of respondents had access to IR, reported comfort in renorrhaphy, and valued renal preservation. There was variation in thresholds for bleeding intervention, and nephrectomy was still a common management strategy. There is great interest among trauma surgeons and urologists for a prospective trial of renal trauma management aimed at decreasing nephrectomy when possible.

Transgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and in vitro maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.

Background: Female urethral stricture disease is under-recognized and is often treated with dilation despite poor definitive outcomes. Our objective was to describe a multi-institutional experience treating female urethral stricture disease with female dorsal onlay buccal mucosa graft (FD-BMG) urethroplasty outcomes. Methods: We retrospectively identified 39 consecutive FD-BMG urethroplasty operations performed by 6 reconstructive surgeons from 12/2007 to 1/2016. Surgical technique included dorsally-placed buccal mucosal grafts in all cases. Stricture recurrence was defined by cystoscopy. Results: Mean age was 50 (range, 29–81) years. Stricture etiology was unknown (49%), iatrogenic (36%), or trauma/straddle injury (15%). A majority of women (87%) women had undergone a prior stricture-related urethral procedure(s) before the surgeons’ index urethroplasty. Mean stricture length was 2.1 cm and mean caliber was 11 Fr. Mean postoperative follow-up was 33 (range, 7–106) months. Postoperative complications within 30 days were seen in 7 individuals (18%) and were all Clavien-Dindo grade II. Stricture recurrence was seen in 9 (23%) patients, with mean time to recurrence 14 months. No patients experienced de novo incontinence. Conclusions: FD-BMG urethroplasty is a safe and effective management option for female urethral strictures. Referral to a reconstructive center is encouraged to avoid repeated unnecessary endoscopic procedures that have poor definitive success.

PurposePerineal urethrostomy is a viable option for many complex urethral strictures. However, to our knowledge no comparison with anterior urethroplasty regarding patient reported outcome measures has been published. We compared these groups using a large multi-institution database.Materials and methodsWe performed a retrospective study of anterior urethroplasty in the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) database. The anterior urethroplasty cohort was defined by long strictures greater than 6 cm. We compared demographic, clinical, urinary and sexual characteristics using validated patient reported outcome measures between patients treated with long stricture anterior urethroplasty and those who underwent perineal urethrostomy.ResultsOf the 131 patients 92 treated with long stricture anterior urethroplasty and 39 treated with perineal urethrostomy met study inclusion criteria. The cumulative incidence of failure at 2 years was 30.2% (95% CI 18.3-47.3) for long stricture anterior urethroplasty and 14.5% (95% CI 4.8-39.1) for perineal urethrostomy (p = 0.09). Compared to baseline metrics, patients who underwent long stricture anterior urethroplasty and perineal urethrostomy had similar improvements in urinary function and stable sexual function after surgery.ConclusionsPatients reported improvement in urinary function after perineal urethrostomy with no deleterious effect on sexual function. These patient reported outcome measures were comparable to those of long stricture anterior urethroplasty. Perineal urethrostomy failure rates were similar to those of long stricture anterior urethroplasty.

To analyze outcomes of posterior urethroplasty following pelvic fracture urethral injuries (PFUI) and to determine risk factors for surgical complexity and success. Patients who underwent posterior urethroplasty following PFUI were identified in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database. Demographics, injury patterns, management strategies, and prior interventions were evaluated. Risk factors for surgical failure and the impact of ancillary urethral lengthening maneuvers (corporal splitting, pubectomy and supracrural rerouting) were evaluated. Of the 436 posterior urethroplasties identified, 122 were following PFUI. 83 (68%) patients were acutely managed with suprapubic tubes, while 39 (32%) underwent early endoscopic realignment. 16 (13%) patients underwent pelvic artery embolization in the acute setting. 116 cases (95%) were completed via a perineal approach, while 6 (5%) were performed via an abdominoperineal approach. The need for one or more ancillary maneuvers to gain urethral length occurred in 4 (36%) patients. Of these, 44 (36%) received corporal splitting, 16 (13%) partial or complete pubectomy, and 2 (2%) supracrural rerouting. Younger patients, those with longer distraction defects, and those with a history of angioembolization were more likely to require ancillary maneuvers. 111 patients (91%) did not require repeat intervention during follow-up. Angioembolization (p = 0.03) and longer distraction defects (p = 0.01) were associated with failure. Posterior urethroplasty provides excellent success rates for patients following PFUI. Pelvic angioembolization and increased defect length are associated with increased surgical complexity and risk of failure. Surgeons should be prepared to implement ancillary maneuvers when indicated to achieve a tension-free anastomosis.

Neurogenic bladder significantly impacts individuals after spinal cord injury. We hypothesized that there would be differences in bladder related symptoms and quality of life for 4 common bladder management methods.In this prospective observational study we measured neurogenic bladder related quality of life after spinal cord injury. Study eligibility included age 18 years or greater and acquired spinal cord injury. Bladder management was grouped as 1) clean intermittent catheterization, 2) an indwelling catheter, 3) surgery (bladder augmentation, a catheterizable channel or urinary diversion) and 4) voiding (a condom catheter, involuntary leaking or volitional voiding). The primary outcomes were the NBSS (Neurogenic Bladder Symptom Score) and the SCI-QoL Difficulties (Spinal Cord Injury Quality of Life Measurement System Bladder Management Difficulties). Secondary outcomes were the NBSS subdomains and satisfaction with urinary function. Multivariable regression was done to establish differences between the groups, separated by level.Of the 1,479 participants enrolled in the study 843 (57%) had paraplegia and 894 (60%) were men. Median age was 44.9 years (IQR 34.4-54.1) and median time from injury was 11 years (IQR 5.1-22.4). Bladder management was clean intermittent catheterization in 754 cases (51%), an indwelling catheter in 271 (18%), surgery in 195 (13%) and voiding in 259 (18%). In regard to primary outcomes, in cases of paraplegia and tetraplegia an indwelling catheter and surgery were associated with fewer urinary symptoms on the NBSS compared to clean intermittent catheterization while voiding was associated with more symptoms. In paraplegia and tetraplegia cases surgery was associated with fewer bladder management difficulties according to the SCI-QoL Difficulties. In regard to secondary outcomes, surgery was associated with improved satisfaction in individuals with paraplegia or tetraplegia.In individuals with spinal cord injury fewer bladder symptoms were associated with an indwelling catheter and surgery, and worse bladder symptoms were noted in voiding individuals compared to those on clean intermittent catheterization. Satisfaction with the urinary system was improved after surgery compared to clean intermittent catheterization.

INTRODUCTION AND OBJECTIVES:In those unable to volitionally void after spinal cord injury (SCI), clean intermittent catheterization (CIC) is considered the gold standard in bladder management. Desp...

INTRODUCTION AND OBJECTIVES:Radiologic factors are important for predicting bleeding interventions after high-grade renal trauma (HGRT). We aimed to assess the associations between laceration size ...

INTRODUCTION AND OBJECTIVES:The objective of this study is to evaluate the outcomes of bladder augmentation in the adult population in a multicenter study. A secondary objective is to compare outco...

INTRODUCTION AND OBJECTIVES:Severe urinary adverse effects of radiation are seen in 17% of women treated for gynecologic malignancies. This incidence continues to climb through at least 25 years po...

INTRODUCTION AND OBJECTIVES:The American Association for the Surgery of Trauma (AAST) injury scale is the most widely used grading system for renal trauma. However, reproducibility of the AAST grad...

INTRODUCTION AND OBJECTIVES:The Neurogenic Bladder Symptom Score (NBSS) is a 24-item questionnaire that assesses symptom burden in patients with SCI, multiple sclerosis, or spina bifida. It has bee...

INTRODUCTION AND OBJECTIVES:Urethroplasty has been associated with erectile dysfunction (ED), likely due to the close proximity of the cavernous neurovascular bundle to the membranous and bulbar ur...

INTRODUCTION AND OBJECTIVES:Bowel dysfunction and severe bowel symptoms are common in Spinal Cord Injured (SCI) patients. The aim of this study was to investigate predictors for severe bowel sympto...

INTRODUCTION AND OBJECTIVES:Perineal urethrostomy is a viable option for many complex urethral strictures; however, no comparison with anterior urethroplasty (AU) or complex AU regarding patient re...

INTRODUCTION AND OBJECTIVES:In cutaneous catheterizable ileocecocystoplasty (CCIC), the bladder is augmented with cecum and ascending colon and the catheterizable channel is created using tapered t...

INTRODUCTION AND OBJECTIVES:Endoscopic treatment of urethral stricture disease (USD) continues to be the most common treatment of USD despite its poor success compared to urethroplasty. AUA guideli...

Excretory phase computed tomography (CT) scan is used for diagnosis of renal collecting system injuries and accurate grading of high-grade renal trauma. However, optimal timing of the excretory phase is not well established. We hypothesized that there is an association between excretory phase timing and diagnosis of urinary extravasation and aimed to identify the optimal excretory phase timing for diagnosis of urinary extravasation.The Genito-Urinary Trauma Study collected data on high-grade renal trauma (grades III-V) from 14 Level I trauma centers between 2014 and 2017. The time between portal venous and excretory phases at initial CT scans was recorded. Poisson regression was used to measure the association between excretory phase timing and diagnosis of urinary extravasation. Predictive receiver operating characteristic analysis was used to identify a cutoff point optimizing detection of urinary extravasation.Overall, 326 patients were included; 245 (75%) had excretory phase CT scans for review either initially (n = 212) or only at their follow-up (n = 33). At initial CT with excretory phase, 46 (22%) of 212 patients were diagnosed with urinary extravasation. Median time between portal venous and excretory phases was 4 minutes (interquartile range, 4-7 minutes). Time of initial excretory phase was significantly greater in those diagnosed with urinary extravasation. Increased time to excretory phase was positively associated with finding urinary extravasation at the initial CT scan after controlling for multiple factors (risk ratio per minute, 1.15; 95% confidence interval, 1.09-1.22; p0.001). The optimal delay for detection of urinary extravasation was 9 minutes.Timing of the excretory phase is a significant factor in accurate diagnosis of renal collecting system injury. A 9-minute delay between the early and excretory phases optimized detection of urinary extravasation.Diagnostic tests/criteria study, level III.

PURPOSE:To assess the functional Queryoutcome of patients with cystoscopic recurrence of stricture post-urethroplasty and to evaluate the role of cystoscopy as initial screening tool to predict future failure. METHODS:Cases with cystoscopy data after anterior urethroplasty in a multi-institutional database were retrospectively studied. Based on cystoscopic evaluation, performed within 3-months post-urethroplasty, patients were categorized as small-caliber (SC) stricture recurrence: stricture unable to be passed by standard cystoscope, large-caliber (LC) stricture accommodating a cystoscope, and no recurrence. We assessed the cumulative probability of intervention and the quality of life scores in association with cystoscopic recurrence 1-year post-urethroplasty. Patients with history of hypospadias, perineal urethrostomy, urethral fistula, and meatal pathology were excluded. RESULTS:From a total of 2630 men in our cohort, 1054 patients met the inclusion criteria: normal (n = 740), LC recurrence (n = 178), and SC recurrence (n = 136) based on the first cystoscopic evaluation performed at median 111 days postoperatively. Median follow-up was 350 days (IQR 121-617) after urethroplasty. Cystoscopic recurrence was significantly associated with secondary interventions (2.7%, 6.2%, 33.8% in normal, LC, and SC groups, respectively). Quality of life variables were not statistically significantly different among the three study groups. CONCLUSIONS:Many patients with cystoscopic recurrence do not need an intervention after initial urethroplasty. Despite good negative predictive value, cystoscopy alone may be a poor screening test for stricture recurrence defined by patient symptoms and need for secondary interventions.

Purpose: Subjective measures of success after urethroplasty have become increasingly valuable in postoperative monitoring. We examined patient reported satisfaction following anterior urethroplasty using objective measures as a proxy for success.Materials and Methods: Men 18 years old or older with urethral strictures undergoing urethroplasty were prospectively enrolled in a longitudinal, multi-institutional urethroplasty outcomes database. Preoperative and postoperative assessment included questionnaires to assess lower urinary tract symptoms, pain, satisfaction and sexual health. Analyses controlling for stricture recurrence (defined as the inability to traverse the reconstructed urethra with a flexible cystoscope) were performed to determine independent predictors of dissatisfaction.Results: At a mean followup of 14 months we found a high 89.4% rate of overall postoperative satisfaction in 433 patients and a high 82.8% rate in those who would have chosen the operation again. Men with cystoscopic recurr...

Purpose of review This article summarizes recent evidence describing perioperative and long-term surgical complications of the Indiana pouch and similar continent catheterizable urinary diversions. Recent findings The perioperative morbidity and long-term complications are better defined in recent literature describing the Indiana and similar pouches. Both perioperative and long-term surgical complications for the Indiana and similar pouches are extremely variable between studies, but ranges between 1-32% and 6-69%, respectively. Significant perioperative surgical risks include bowel leak, deep wound and organ space infection, ureteral leak and/or stenosis, and death. Common long-term surgical risks include: ureteral stenosis, problems with the catheterizable (efferent) channel, and the treatment of pouch or other urinary calculi. Summary Perioperative and long-term surgical complications have only recently been reported in a consistent manner for continent catheterizable urinary diversions. Understanding perioperative and long-term surgical complications allows for comparison of studies and more importantly allows surgeons to provide accurate information about complications and risk to patients.

Uroflowmetry (UF) is a simple, noninvasive method to evaluate voiding function in patients experiencing lower urinary tract symptoms.1,2 It is often combined with other metrics, including the International Prostate Symptom Score, in the initial diagnosis and follow-up of benign prostatic hyperplasia (BPH), and other causes of obstruction.3 In patients with urethral stricture disease (USD) who have undergone urethroplasty, UF is one of the most frequently used tests to monitor for stricture recurrence.4 However, UF’s use as a stand-alone tool to screen for recurrence following urethroplasty has never been rigorously validated. It has been well established that the maximum flow rate (Qm) in patients with USD is significantly diminished relative to age-matched normal controls.5,6 This knowledge has been extrapolated to the post-urethroplasty setting, where commonly used cutpoints of a postoperative Qm of less than 10 mL/s or a postoperative Qm of less than 15 mL/s are used as indicators of urethral stricture recurrence.5–7 Similarly, when UF data are available both pre- and postoperatively, a change in Qm following surgery of less than 10 mL/s has also been suggested as a predictor of recurrence.8 The goal for each of these UF parameters is to minimize the invasiveness of postoperative screening while maximizing the ability to find recurrences. The purpose of this study is to rigorously evaluate the capability of individual UF parameters, such as Qm and average flow rate (Qa), as well as a novel hybrid measure (Qm-Qa) to monitor for urethral stricture recurrence. Use of Qm-Qa has not been described in prior literature and attempts to provide a simple method to quantify the shape of the voiding curve. The study tested two hypotheses: (1) when compared to the gold-standard cystoscopy, UF parameters will have high test (screening) sensitivity and specificity, and (2) the sensitivity and specificity of UF to screen for stricture recurrence will be diminished in older patients.

Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) are common among aging men and impact quality of life. Recently, there has been an interest in alternative mechanisms of BPH and LUTS, specifically the role of chronic prostatic inflammation. Statin medications, known for their cholesterol-lowering properties, also possess certain anti-inflammatory effects, which may be of interest in the treatment and/or prevention of BPH and LUTS. Prior studies of statins have yielded conflicting results. These were limited by cross-sectional designs or limited follow-up, small sample sizes, and inability to control for confounding. One prior randomized control trial found no difference between atorvastatin vs. placebo in the treatment of BPH and LUTS after 6 months. Additional randomized trials with longer follow-up time evaluating the impact of statins on incident BPH and LUTS are required to assess the therapeutic potential of statins and develop a better understanding of alternative mechanisms for BPH and LUTS.

PURPOSE: Approximately 10% to 20% of patients will have a recurrence after urethroplasty. Initial management of these recurrences is often by urethral dilation or direct vision internal urethrotomy. In the current study we describe the outcomes of endoscopic management of stricture recurrence after bulbar urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed bulbar urethroplasty data from 5 surgeons in the TURNS (Trauma and Urologic Reconstruction Network of Surgeons). Men who underwent urethral dilation or direct vision internal urethrotomy for urethroplasty recurrence were identified. Recurrence was defined as the inability to pass a 17Fr cystoscope through the area of reconstruction. The primary outcome was the success rate of recurrence management. Comparisons were made between urethral dilation and direct vision internal urethrotomy, and then between endoscopic management of recurrences after excision and primary anastomosis urethroplasty vs substitutional repairs using time to event statistics. RESULTS: In 53 men recurrence was initially managed endoscopically. Median time to urethral stricture recurrence after urethroplasty was 5 months. At a median followup of 5 months the overall success rate was 42%. Success after urethral dilation was significantly less than after direct vision internal urethrotomy (1 of 10 patients or 10% vs 21 of 43 or 49%, p

Background: Pelvic fracture urethral injuries (PFUI) occur in up to 10% of pelvic fractures. It remains controversial whether initial primary urethral realignment (PR) after PFUI decreases the incidence of urethral obstruction and the need for subsequent urethral procedures. We present methodology for a prospective cohort study analyzing the outcomes of PR versus suprapubic cystostomy tube (SPT) after PFUI. Methods: A prospective cohort trial was designed to compare outcomes between PR (group 1) and SPT placement (group 2). Centers are assigned to a group upon entry into the study. All patients will undergo retrograde attempted catheter placement; if this fails a cystoscopy exam is done to confirm a complete urethral disruption and attempt at gentle retrograde catheter placement. If catheter placement fails, group 1 will undergo urethral realignment and group 2 will undergo SPT. The primary outcome measure will be the rate of urethral obstruction preventing atraumatic passage of a flexible cystoscope. Secondary outcome measures include: subsequent urethral interventions, post-injury complications, urethroplasty complexity, erectile dysfunction (ED) and urinary incontinence rates. Results: Prior studies demonstrate PR is associated with a 15% to 50% reduction in urethral obstruction. Ninety-six men (48 per treatment group) are required to detect a 15% treatment effect (80% power, 0.05 significance level, 20% loss to follow up/death rate). Busy trauma centers treat complete PFUI approximately 1–6 times per year, thus our goal is to recruit 25 trauma centers and enroll patients for 3 years with a goal of 100 or more total patients with complete urethral disruption. Conclusions: The proposed prospective multi-institutional cohort study should determine the utility of acute urethral realignment after PFUI.

The Neurogenic Bladder Research Group (NBRG) registry is a multicenter prospective observational study. This manuscript is retrospective based on a cross-sectional survey. To assess patient subjective assessment of urinary tract infection (UTI) frequency and severity are associated with the degree of use of catheters or incontinence products. Multiple hospitals across the United States. Eligibility included: age > 18 years and acquired SCI. Over 1.5 years, 1479 eligible participants were enrolled. We excluded those with surgical reconstruction or diversion of the bladder. In total, 1282 participants were grouped by bladder management: (1) indwelling catheter (IDC), (2) clean intermittent catheterization (CIC), (3) external devices (pads/condom), and (4) volitional voiding (Void). UTI frequency was classified as 0, 1–3, 4–6, or > 6 over the prior year. UTI severity was determined by hospitalization for UTI in the prior year. Multivariate regression compared these factors across groups. UTIs were least frequent in Void followed by pads/condom, CIC, and IDC (all p ≤ 0.001). UTI severity followed a similar pattern. Controlling for covariates, the adjusted odds of UTI frequency (Void = reference) were 2.28 (1.38–3.76) for pads/condom, 3.42 (2.25–5.18) for CIC, and 4.3 (2.59–6.70) for IDC (all p ≤ 0.001). Patient subjective assessment of UTI frequency is highest with IDC, followed by CIC, pads/condom, and lowest with spontaneous voiding. The odds of hospitalization for UTI were three times higher for IDC than spontaneous voiding. UTI risk should be considered when counseling patients about bladder management options. These associations do not imply causation but warrant further investigation in a prospective manner. Patient-Centered Outcomes Research Institute (PCORI) Award (CER14092138).

OBJECTIVE Clean intermittent catheterization (CIC) is a preferred method of bladder management for many patients with spinal cord injury (SCI), but long-term adherence is low. The aim of this study is to identify factors associated with low urinary quality of life (QoL) in SCI adults performing CIC. METHODS Over 1.5 years, 1479 adults with SCI were prospectively enrolled through the Neurogenic Bladder Research Group registry, and 753 on CIC with no prior surgeries were included. Injury characteristics, complications, hand function, and Neurogenic Bladder Symptom Score (NBSS) were analyzed. The NBSS QoL question (overall satisfaction with urinary function) was dichotomized to generate comparative groups (dissatisfied vs neutral/satisfied). RESULTS The cohort was 32.9% female with a median age of 43.2 (18-86) years, time since the injury of 9.8 (0-48.2) years, and 69.0% had an injury at T1 or below. Overall 36.1% were dissatisfied with urinary QoL. On multivariable analysis, female gender (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.15-2.31; P = 0.016), earlier injury (OR, 0.95 per year; 95% CI, 0.93-0.97; P

To examine the rate of urethral trauma and pubic symphysis diastasis in saddle horn injury, which occurs when horseback riders are bucked into the air and land with their perineum striking the rigid saddle horn, compared to pelvic fracture from other mechanisms.A retrospective review was performed of male patients presenting to our level-1 trauma center with pelvic ring fractures between January 1, 2001 and December 30, 2016. Demographics, injury severity score, mechanism of injury (saddle horn vs other), pubic symphysis diastasis, and lower genitourinary (GU) injuries (bladder and urethra) were identified in the trauma registry. Chart review confirmed accuracy of lower GU trauma.A total of 1195 males presented with pelvic ring fractures, average age 43 years (SD 19 years). Of these, 87 of 1195 (7%) presented with lower GU injuries. Saddle horn injuries had a higher rate of lower GU injuries, 12/60 (20%) versus 75 of 1135 (7%) [P = .001]. In those with lower GU injuries, 47 of 87 (54%) had urethral injury. The rate of urethral injury was significantly higher in the saddle horn cohort, 10 of 12 (83%) versus 37 of 75 (49%) [P = .03]. Furthermore, rate of pubic symphysis diastasis was higher amongst saddle horn injuries, 12 of 12 (100%) versus other mechanisms 39 of 75 (52%) [P = .001].We found that urethral injury and pubic symphysis diastasis were higher in patients with saddle horn injury compared to other mechanisms of pelvic ring disruption. Clinicians should be aware of these associations when treating pelvic fracture following equestrian injuries.

Objective To examine the rate of urethral trauma and pubic symphysis diastasis in saddle horn injury, which occurs when horseback riders are bucked into the air and land with their perineum striking the rigid saddle horn, compared to pelvic fracture from other mechanisms. Methods A retrospective review was performed of male patients presenting to our level-1 trauma center with pelvic ring fractures between January 1, 2001 and December 30, 2016. Demographics, injury severity score, mechanism of injury (saddle horn vs other), pubic symphysis diastasis, and lower genitourinary (GU) injuries (bladder and urethra) were identified in the trauma registry. Chart review confirmed accuracy of lower GU trauma. Results A total of 1195 males presented with pelvic ring fractures, average age 43 years (SD 19 years). Of these, 87 of 1195 (7%) presented with lower GU injuries. Saddle horn injuries had a higher rate of lower GU injuries, 12/60 (20%) versus 75 of 1135 (7%) [P = .001]. In those with lower GU injuries, 47 of 87 (54%) had urethral injury. The rate of urethral injury was significantly higher in the saddle horn cohort, 10 of 12 (83%) versus 37 of 75 (49%) [P = .03]. Furthermore, rate of pubic symphysis diastasis was higher amongst saddle horn injuries, 12 of 12 (100%) versus other mechanisms 39 of 75 (52%) [P = .001]. Conclusion We found that urethral injury and pubic symphysis diastasis were higher in patients with saddle horn injury compared to other mechanisms of pelvic ring disruption. Clinicians should be aware of these associations when treating pelvic fracture following equestrian injuries.

AIMS Clean intermittent catheterization (CIC) is recommended after spinal cord injury (SCI) because it has the least complications, however, CIC has a high discontinuation rate. We hypothesized that bladder botulinum toxin injection or augmentation cystoplasty may improve satisfaction with CIC. METHODS The NBRG registry is a multicenter, prospective, observational study asking SCI participants about neurogenic bladder (NGB) related quality of life (QoL). In this study, participants performing CIC as primary bladder management were categorized into 3 groups: (1) CIC alone (CIC); (2) CIC with botulinum toxin (CIC-BTX); and (3) CIC with augmentation cystoplasty (CIC-AUG). Outcomes included primary: Neurogenic Bladder Symptom Score (NBSS) and SCI-QoL Bladder Management Difficulties, and secondary: NBSS subdomains (Incontinence, Storage & Voiding, Consequences) and the NBSS final question (satisfaction with urinary function). Multivariable regression, controlling for multiple factors was used to establish differences between the three groups. RESULTS Eight hundred seventy-nine participants performed CIC as primary bladder management and had the following characteristics: mean age 43.4 (±12.9) and years from injury 13.7 (±10.7), tetraplegia in 284 (32%), and 543 (62%) were men. Bladder management was CIC in 593 (67%), CIC-BTX in 161 (19%), and CIC-AUG in 125(15%). Primary outcomes: CIC-AUG had associated improved total NBSS versus CIC(-3.2(-5.2 to -1.2), P = 0.001 and CIC-BTX(-3.9(-6.3 to -1.6), P = 0.001), CIC-AUG also had better SCI-QoL Difficulties scores versus CIC(-4(-5.48 to -2.53, P

OBJECTIVE:To understand the prevalence of chronic perineal pain, activity limitations, and patient satisfaction after urethroplasty. METHODS:From 2014 to 2016, we prospectively enrolled men undergoing urethroplasty for bulbar urethral strictures. Patients, before and after surgery, completed questions from the Core Lower Urinary Tract Symptom Score assessing pain frequency in the bladder and penis or urethra, as well as nonvalidated questions assessing perineal pain. Overall satisfaction with their current urinary condition and pain-related activity limitations at home, work, or during exercise were also measured. Patients with

Background: Collecting system injury and urinary extravasation is an important yet understudied aspect of renal trauma. We aimed to examine the incidence of urinary extravasation and also the rates of ureteral stenting after high-grade renal trauma (HGRT) in adults. Methods: A search strategy was developed to search Ovid Medline, Embase, CINAHL, and Cochrane Library. Two reviewers screened titles and abstracts, followed by full-text review of the relevant publications. Studies were included if they indicated the number of patients with HGRT [the American Association for the Surgery of Trauma (AAST) grades III–IV or equivalents] and number of patients with urinary extravasation. A descriptive meta-analysis of binary proportions was performed with random-effects model to calculate the incidence of urinary extravasation and rates of ureteral stenting. Results: After screening, 24 and 20 studies were included for calculating urinary extravasation and stenting rates, respectively. Most studies involved blunt injury and were retrospective single-center case series. Incidence of urinary extravasation was 29% (95% CI: 17–42%) after HGRT (grade III–V), and 51% (95% CI: 38–64%) when only grade IV–V injuries were combined. Overall, 29% (95% CI: 22–36%) of patients with urinary extravasation underwent ureteral stenting. Conclusions: Approximately 30% of patients with HGRT are diagnosed with urinary extravasation and 29% of those with urinary extravasation undergo ureteral stenting. Understanding the rate of urinary extravasation and interventions is the first step in creating a prospective trial designed to demonstrate when ureteral stenting and aggressive management of urinary extravasation is needed.

Given the poor understanding of the pathophysiology of genital lichen sclerosus (GLS) and a lack of accepted definitive diagnostic criteria, we proposed to survey pathologists regarding their understanding of GLS. We hypothesized that significant disagreement about GLS will exist.All urologists participating in the Trauma and Urologic Reconstruction Network of Surgeons identified genitourinary (GUP) and dermatopathologists (DP) at their respective institutions who were then invited to participate in an online survey regarding their experience with diagnosing GLS, GLS pathophysiology and its relationship to urethral stricture disease.There were 23 (12 DP, 11 GUP) pathologists that completed the survey. The most agreed upon criteria for diagnosis were dermal collagen homogenization (85.7%), loss of the normal rete pattern (33.3%) and atrophic epidermis (28.5%). No pathologists believed GLS had an infectious etiology (19% maybe, 42% unknown) and 19% believed GLS to be an autoimmune disorder (42% maybe, 38% unknown); 19% believed LS to be premalignant, but 52% believed it was associated with cancer; 80% believed that LS could involve the urethra (DP (92%) versus GUP (67%); p = 0.272). Of those diagnosing urethral GLS, 80% of DUP believed that GLS must first involve the glans/prepuce before involving the urethra, while all GUP believed that urethral disease could exist in isolation (p = 0.007).There was significant disagreement in this specialized cohort of pathologists when diagnosing GLS. A logical first step appears to be improving agreement on how to best describe and classify the disease. This may lead to improve treatments.

To critically review and summarize existing literature assessing the effectiveness of hyperbaric oxygen therapy (HBOT) for the treatment of radiation-induced urologic injury. Though 5 of the included 13 studies were published in the last 2–3 years, the only randomized controlled study was performed in 2012. Recent studies have confirmed the safety and efficacy of HBOT as well as identified risk factors for success vs. failure of HBOT for hemorrhagic radiation cystitis (HRC). Of the 602 patients that received HBOT for HRC, 84% had a partial or complete resolution. In the 7 studies that utilized RTOG/EORTC, 75% of patients saw an improvement in hematuria of at least one grade (out of possible 5 total). Of the 499 patients with documented follow-up, 14% experienced recurrence, with a median time to recurrence of 10 months (6 to 16.5 months).