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Aim We sought to evaluate the effect of radiation therapy on post-prostatectomy urinary quality of life in prostate cancer patients. Background In some men with non-metastatic prostate cancer, radiation therapy is indicated following prostatectomy. The radiation toxicity and quality of life considerations are unique in the post-prostatectomy setting. Materials and methods A total of 106 patients receiving post-prostatectomy radiation therapy completed the Expanded Prostate Cancer Index Composite questionnaire before radiation and at 2-year follow-up. The primary outcomes of this study were the urinary domain summary score and subscale scores. Planned analysis was performed based on time interval from prostatectomy to radiation therapy. Results Among the 106 patients analyzed, the mean urinary domain summary score worsened at 2-year follow-up after radiation therapy, lowering from 77.23–72.51 (p = 0.0085). Similar worsening was observed in the subscales of function (p = 0.003), bother (p = 0.0397), and incontinence (p = 0.0003). Urinary incontinence showed the greatest observable change among subscales. While the summary score worsened (p = 0.0031) among patients receiving radiation therapy more than 1 year after prostatectomy, it did not show statistically significant change in those treated 1 year or less after prostatectomy. Conclusion Our results demonstrate that post-prostatectomy radiation therapy is associated with modest declines in reportable urinary quality of life. Patients receiving radiation therapy more than 1 year after prostatectomy showed greater worsening of urinary quality of life, which indicates that there may be no functional advantage to delaying radiation therapy beyond the initial postoperative period.

For chronic malignant and benign ureteral obstruction, the metal construction of the Resonance ureteral stent has been developed to maintain ureteral patency for up to 12 months, obviating the need for the frequent exchange required for conventional plastic ureteral stents. We report our experience placing tandem Resonance stents (TRS) in a single ureter of patients who failed management with a single Resonance stent. A retrospective review of patients who had TRS for management of ureteral obstruction between February 2014 and May 2017 was performed. Seven renal units from four patients with a median age of 62 years were managed with TRS. All but one renal unit was successfully managed with TRS initially. Hydronephrosis resolved in 80% of renal units at a median of 33 days, and creatinine reached its nadir a median of 38 days after placement, with a median improvement of 0.68 ng/mL. However, the median length of management with TRS was only 123.5 days with one exchange, and there was an overall success rate of 28.5% at 1 year. TRS placement is a feasible option for short-term management in a challenging population that would like to avoid nephrostomy and has failed other modalities.

To compare perioperative outcomes for patients undergoing holmium laser enucleation of the prostate (HoLEP) and robotic-assisted simple prostatectomy (RSP) for benign prostatic hypertrophy (BPH).Patient demographics and perioperative outcomes were compared between 600 patients undergoing HoLEP and 32 patients undergoing RSP at two separate academic institutions between 2008 and 2015.Patients undergoing HoLEP and RSP had comparable ages (71 vs 71, p = 0.96) and baseline American Urological Association Symptom Scores (20 vs 24, p = 0.21). There was no difference in mean specimen weight (96 g vs 110 g, p = 0.15). Mean operative time was reduced in the HoLEP cohort (103 minutes vs 274 minutes, p 0.001). Patients undergoing HoLEP had lesser decreases in hemoglobin, decreased transfusions rates, shorter hospital stays, and decreased mean duration of catheterization. There was no difference in the rate of complications Clavien grade 3 or greater (p = 0.33).HoLEP and RSP are both efficacious treatments for large gland BPH. In expert hands, HoLEP appears to have a favorable perioperative profile. Further studies are necessary to compare long-term efficacy, cost, and learning curve influences, especially as minimally invasive approaches become more widespread.

Although infrequent, when encountered vesicovaginal fistulas (VVF) are a difficult condition for both patients and physicians alike. After the first robotic repair was described in 2005, this has been an increasingly common treatment modality. At our institution between 2009 and 2014, eleven of these patients were evaluated and treated with robotic repair. However, fibrin sealant was used in place of the traditional tissue flap. Included are six patients who had previously undergone operative repair.After IRB approval was obtained, a retrospective study was undertaken to identify patients with VVF. Inclusion criteria were operative repair utilizing a da Vinci robotic system; there were no exclusion criteria. A total of eleven patients were identified, and in each case, a robot assisted laparoscopic approach was utilized and Tisseel fibrin sealant was used in lieu of tissue interposition.All patients underwent successful repair of their VVF without evidence of recurrence at a mean follow up of 15.6 months.Robotic vesicovaginal fistula repair with fibrin sealant seems to be a safe and viable alternative to the traditional repair utilizing a tissue flap.

INTRODUCTION In this case, we describe a bladder diverticulum due to apical vaginal suspension to the sacrospinous ligament presenting 11 years after surgery. This case report explores her signs and symptoms, diagnostic work-up, surgical intervention, and postoperative course. CASE DESCRIPTION A 71-year-old G2P2 presented with symptoms of urinary urgency. Work-up including cystoscopy and retrograde fistulogram revealed a bladder diverticulum extending to the level of the sacrospinous ligament. Her surgical history was significant for a sacrospinous ligament fixation 11 years before her symptoms. The iatrogenic bladder diverticulum was removed via robotic-assisted laparoscopic excision. Her postoperative course was benign beyond a urinary tract infection. Her urgency symptoms resolved after treatment. CONCLUSIONS Iatrogenic injuries can present distant from initial surgery. Permanent foreign material, including suture, may increase the risk of complications. A high level of suspicion is necessary to diagnose complications given the subtle presentation.

The urinary catheter is an ancient device for urinary drainage in patients. Placement of a urethral catheter is a common medical procedure that may have led to morbidity and mortality. Urethral catheterization is commonly performed by a nurse. Difficult catheter placement generates urology consultation. Difficult catheterization with a vision-guided urinary catheter may provide expedited and successful catheter placement by nursing personnel.A PubMed.gov and Ovid Medline search for articles on history of urinary catheter, difficult urinary catheterization, iatrogenic urethral injury, iatrogenic urethral injury and CAUTI, management of iatrogenic urethral injury, and techniques for urinary catheter placement was performed.The history of urinary catheters is reviewed. Technical advances in the last century are discussed. Indications for catheter placement are included. Outcomes and cost of complications of urinary catheters are discussed relative to present practice quality standards. Review of difficult urinary catheterization management algorithms developed with urological catheter improvements during the last decade is analyzed. Educational and technological advances to improve outcomes of urinary catheter use are addressed.Provider attention to issues of urinary catheterization is enhanced by education and additional skills for catheterization. Physician and nurse providers can use current technology with preparation to improve the catheterization care of patients.

Radical prostatectomy is commonly performed for the treatment of patients with prostate cancer. Several studies have demonstrated a reduction in penile size after open radical retropubic prostatectomy. The objective of this study is to describe changes in penile length after after robot-assisted laparoscopic radical prostatectomy (RALRP).We performed a randomized, open label, multicenter study in men with normal erectile function who underwent bilateral nerve-sparing radical prostatectomy. We evaluated changes in measured stretched penile length (SPL), a secondary end point of the study, in a subset of men from a single site who underwent RALRP by one surgeon. They were randomized to either intraurethral alprostadil 125 to 250 μg daily or oral sildenafil citrate 50 mg daily for 9 months. SPL was measured from pubic bone to coronal sulcus using a semirigid ruler before surgery and at 1, 3, 6, 9, 10, and 11 months.A total of 127 patients were enrolled and 94 completed the 11-month follow-up. The mean patient age was 56.5 years. Baseline mean SPL (cm) before surgery was 11.77 and decreased to 11.13 at 1 month (P0.0001). A trend toward recovery of SPL was seen at 3 and 6 months. Mean SPL was not significantly different from baseline at 9, 10, and 11 months.This report describes changes in SPL over time after RALRP for prostate cancer. The expected decrease in length was observed shortly after surgery, but, by 9 months, penile length had returned to the preoperative measurement.

Minimally invasive adrenalectomy is the preferred surgical approach for small, benign adrenal neoplasms. Posterior retroperitoneoscopic adrenalectomy is associated with potential surgical advantages. We sought to investigate the feasibility and early outcomes for robot-assisted posterior adrenalectomy, which has not been previously reported.Patients were selected for adrenalectomy based on standard clinical indications. The study was conducted under a protocol approved by the Institutional Review Board. Patients with adrenal masses larger than 7.0 cm, or with a body mass index (BMI) greater than 40, were excluded. Patient demographics, clinical and pathologic data, operative times, and patient outcomes were collected prospectively.Six consecutive patients underwent robot-assisted posterior retroperitoneoscopic adrenalectomy (RAPRA) between June 23, 2009 and January 21, 2010. Five women and one man, ages 45 to 75 years (mean 55.5 years), with a mean BMI of 30, were included. There were three right adrenal tumors and three left adrenal tumors. Mean operative time was 121 minutes with a mean robot time of 57 minutes for the five patients in whom the entire adrenal dissection was performed robotically. There was essentially no morbidity and no mortality.This study represents the first report of RAPRA, and demonstrates the feasibility of performing this procedure with good patient outcomes.

To our knowledge we report the first large, randomized, prospective penile rehabilitation clinical trial to compare the effectiveness of nightly intraurethral alprostadil vs sildenafil citrate after nerve sparing prostatectomy.We performed a prospective, randomized, open label, multicenter American study in men with normal erectile function who underwent bilateral nerve sparing radical prostatectomy. The International Index of Erectile Function erectile function domain was the primary end point. Subjects initiated nightly treatment within 1 month of surgery with intraurethral alprostadil or oral sildenafil citrate (50 mg) for 9 months. After 1-month washout and before sexual activity subjects self-administered sildenafil citrate (100 mg) for a total of 6 attempts in 1 month. Secondary end points were the global assessment question, sexual encounter profile, Erectile Dysfunction Inventory of Treatment Satisfaction and measured stretched penile length.Of 139 men who started intraurethral alprostadil and 73 who started sildenafil citrate, 97 and 59, respectively, completed the trial. There were no statistically significant differences in International Index of Erectile Function erectile function domain and intercourse success rates to intraurethral alprostadil. The global assessment question was significantly better only at 6 months for intraurethral alprostadil (p0.028). At completion there were no differences between treatments for any of the end points.This is the first study to directly compare the ability of alprostadil and a phosphodiesterase-5 inhibitor to enhance penile recovery subsequent to bilateral nerve sparing radical prostatectomy. The use of nightly subtherapeutic intraurethral alprostadil is well tolerated after radical prostatectomy. The benefit to return of erectile function of nightly sildenafil citrate and subtherapeutic intraurethral alprostadil appears to be comparable within the first year of surgery.

Possible tradeoffs between efficiency of water transport and mechanical strength were examined in stems of two congeneric pairs of co-occurring chaparral shrubs. First, since previously published results indicated that Adenostoma sparsifolium (Rosaceae) had greater specific conductivity (k s or hydraulic conductivity per xylem transverse area) than A. fasciculatum, it was hypothesized that A. sparsifolium would have greater vessel lumen area per square millimeter of xylem area, and less mechanical strength, than A. fasciculatum. Secondly, since Ceanothus megacarpus (Rhamnaceae) is a non-sprouter (unable to sprout from the root crown following fire or other major disturbance) whereas C. spinosus is a sprouter and thus able to form new stems following disturbance, it was hypothesized that C. megacarpus would have greater mechanical strength, but lower k s, than C. spinosus. Both hypotheses were supported. Based upon computer-aided image analyses, A. sparsifolum had significantly higher mean and maximum vessel diameters (16.4, 40.5 vs. 14.6, 35.7 μm), a 34% greater percent vessel lumen area, and a two-fold greater measured and theoretical k s than A. fasciculatum. This corresponded to 14% lower stem density (wet weight/volume) and less mechanical strength, with a 37% lower modulus of elasticity (MOE) and a 30% lower modulus of rupture (MOR) than A. fasciculatum. Similarly, C.␣spinosus had a significantly higher maximum vessel diameter (52.7 vs. 41.8 μm) and a 92% higher theoretical k s (and 43% higher measured k s) than C. megacarpus. This corresponded to a 9% lower stem density and 20% lower MOR than for C. megacarpus. Thus, at least within these two congeneric pairs of chaparral shrubs growing together in the same habitat, there may be tradeoffs between mechanical strength and conductive efficiency of the stem xylem which correspond to differences in transport physiology and life history traits of sprouter versus non-sprouter species.

To determine the feasibility of bladder cryoablation (BC) applied laparoscopically, percutaneously, and transurethrally in a porcine survival study. The expected and observed area of cell death after BC was also examined.Nine pigs were divided equally into the three treatment groups. Cryoablation was performed with two freeze-thaw cycles after the bladder had been insufflated with CO2. Each animal was observed for 7 days after the procedure for treatment-related complications. After cystectomy, each specimen was examined pathologically to determine the degree and dimension of cell death achieved.BC applied via the laparoscopic and percutaneous approach is feasible and safe. No BC-related complications occurred in these two groups. A complication resulting from BC developed in all three animals that were treated cystoscopically, including two intraperitoneal bladder perforations at the time of BC necessitating immediate sacrifice, and one enterovesical fistula discovered at cystectomy. Transmural necrosis was demonstrated in seven of seven animal specimens that survived to the end of the protocol. The observed diameter of tissue necrosis was highly predictable based on the reported cryoprobe isotherms given by the manufacturer.All locations within the bladder can be successfully and predictably treated with cryoablation. Of the three approaches, laparoscopically administered BC appears to be the most safe and consistent method. Transurethral BC was not safe with the equipment available without laparoscopic assistance to prevent bowel complications.

The presence of urothelial carcinoma in situ (CIS) at the distal ureteral margin has been identified as a risk factor for upper tract recurrence after radical cystectomy. Management of this finding is controversial. The objective of this study was to determine if follow-up with ureteroscopy could aid in early detection of recurrences in these patients.We collected prospective clinical-pathologic data for all patients who underwent radical cystectomy between 1999 and 2004. Patients with CIS at the distal ureteral margin were followed with endoscopy of the urinary diversion and bilateral ureteroscopy in addition to standard imaging and cytologic evaluation every 6 months. Recurrence was defined as detection of any malignant urothelial cells.In 250 consecutive cystectomies, eight patients were identified with CIS that involved a ureteral margin of 12 renal units. Ureteroscopy was successful in all cases, and there were no complications. Imaging was diagnostic in one patient, all cytologic examinations from the diversion were nondiagnostic, and ureteroscopy was positive in all recurrences. Six patients had recurrences at a median follow-up of 52.7 months; five needed laparoscopic nephroureterectomy, and one had disease controlled with percutaneous mitomycin C. Five patients were disease free at last follow-up, and one patient died with brain metastasis at 30 months.Patients with CIS that involves the ureteral margin are at increased risk for upper tract recurrence and progression. Aggressive follow-up with scheduled ureteroscopy may identify recurrences at an earlier stage. Development of additional markers for risk stratification and protocols for adjuvant treatment are needed.

Objective Recently, several large series of robot-assisted laparoscopic radical prostatectomy (RALP) have described a low incidence of bladder neck contractures (BNC). We have had a similar experience at our institution. Our objective is to describe our experience with BNC after RALP and a novel relationship to the use of Hem-o-lok Clips (HOLC). Methods We reviewed a database of patients who underwent RALP at our institution from January 2004 to September 2007 and identified patients with BNC or complications related to the use of HOLC. We performed a retrospective chart review to attempt to determine the cause of each BNC. We also performed a PubMed search and review of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database. Results Of 524 patients undergoing RALP, 4 had a BNC develop, 2 of the BNCs were associated with HOLC migration and erosion into the vesicourethral anastomosis, and 1 was found to have HOLC migration within the bladder. A fifth patient had an anastomotic leak develop secondary to a HOLC that migrated into the bladder neck. Two similar cases of HOLC-related migration have been reported to MAUDE. Conclusions When early BNC or unexplained urinary retention occurs after RALP, one should have a high index of suspicion for migration of HOLC. Clip use should be minimized on tissue immediately adjacent to the anastomosis, and every effort should be made to retrieve loose clips after the procedure.

sparing laparoscopic radical prostatectomy (LRP). METHODS: A single-institution multi-surgeon double-blind RCT of nightly vs. on-demand sildenafil 50mg after nerve-sparing LRP: 100 potent men (International Index of Erectile Function-EF (IIEF-EF) scores >25) were randomized to nightly sildenafil 50mg + prn placebo, or nightly placebo + prn sildenafil 50mg (max. 6 tabs/mo.), for 1 yr. IIEF analyses were at 0, 1, 3, 6, 9, 12 mos., and after a 1-mo. no-PDE5i washout. The quality of nerve-sparing was assessed via a subjectuve nerve-sparing score (NSS) for each bundle (0 none 4 excellent), for a total NSS = 0 8/ptnt. Mixed linear regression modeling was used to compare the effects of treatment group and NSS on IIEF. RESULTS: The nightly and on-demand sildenafil groups were matched at baseline for age (54.3 vs. 54.6), IIEF-EF (29.4 vs. 29.3), type of surgery (laparoscopic or robot-assisted) and race (90 vs. 88% white), all p>0.4, though NSS was higher in the nightly sildenafil group (7.1 vs. 6.5, p=0.02). There was no effect of treatment group (p=0.82) or NSS (p=0.51) on the time-course of return to erectile function (IIEF-EF score) (Figure) nor was there an interaction between these parameters (p=0.79). The % return to baseline function in the nightly vs. on-demand sildenafil groups was 57% & 63% (p=0.46) at 12 mos., and 47% & 65% (p=0.02) at 13 mos. (after washout), respectively. There was no significant effect of treatment group on recovery of potency (IIEF-EF > 21), or on single IIEF items assessing erectile firmness, attempted intercourse frequency, or confidence at any timepoint. CONCLUSIONS: On-demand sildenafil was equivalent to nightly sildenafil at all time points and was superior, in some analyses, after drug washout. This trial does not support the use of chronic (nightly) administration of sildenafil compared to a prn sildenafil regimen in the post-prostatectomy setting.

INTRODUCTION AND OBJECTIVE: Observational cross sectional and prospective longitudinal studies have reported the loss of penile size after radical prostatectomy. This observation is supported by histologic studies in animals and humans after cavernous nerve injury demonstrating cavernous smooth muscle fibrosis and apoptosis. As part of a concurrent, multi-center, intraurethral alprostadil (IUA) vs. sildenafil citrate (SC), penile rehabilitation study, with identical inclusion, treatment and outcome measures, we compared the stretched penile length (SL) in men undergoing nerve sparing open radical prostatectomy (ORP) and robotic radical prostatectomy (ROP). METHODS: A multi-center randomized prospective comparative penile rehabilitation study of the effect of 9 months of nightly IUA vs. SC on subjects having ORP and ROP. Medication was started within one month of surgery. SL was measured preoperatively and at catheter removal, 2, 3, 6, 9 and 11months after surgery. SL was measured according to published techniques by 4 observers at the site performing ORP (NYU) and 2 at the site performing ROP (GWU). No inter and intrainstitutional validation of measurements was carried out. RESULTS: A total of 208 patients were enrolled. 51 pts withdrew from the study (25%). Pts were randomized 2/1 to IUA vs. SC. (131/67). Mean age (59.2) and baseline IIEF score (29) were the same at both centers. SL was virtually identical at both centers for visits 1-3. There was a significant difference in SL between ORP and ROP in SL 3-11 month follow up visits, in both treatment arms. These findings all reached a p-value less than .0001 from months six to eleven. CONCLUSIONS: Significant penile shortening occurred immediately after ORP and ROP. There appeared to be a progressive significant difference between RAP and RRP in SL loss that was detected at 3 months and beyond. This difference may be due to surgical technique or represent a combination of site specific measurement techniques or drug compliance variation between medications and institutions. Further study of this phenomenon is needed.