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Robert Shapiro,1,2 Alec Sunyecz,3 Stanley Zaslau,1,2 Manuel C Vallejo,1,4 Tyler Trump,2 Omar Dueñas-Garcia1 1Department of Obstetrics and Gynecology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA; 2Department of Urology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA; 3West Virginia University School of Medicine, Morgantown, WV, 26506, USA; 4Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, WV, 26506, USACorrespondence: Robert ShapiroHealth Science Center North, West Virginia University, PO Box 9001A, Morgantown, WV, 26506, USATel +1 304-293-5631Fax +1 304-293-5160Email rshapiro@hsc.wvu.eduBackground: In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 polyglactin, poliglecaprone) versus barbed (V-LocTM 90) suture. As a secondary outcome, we analyzed factors for suture preference between the two groups.Methods: A retrospective chart review was undertaken for surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p < 0.05 was significant.Results: Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p = 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index (BMI) was significantly higher in patients receiving a barbed suture repair (p = 0.005).Conclusion: Barbed suture may be comparable to standard braided suture for cystotomy repair. Barbed suture may offer a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.Keywords: barbed suture, cystotomy, minimally invasive surgery, obesity

Robert Shapiro,1,2 Omar Felipe Dueñas-Garcia,1 Manuel Vallejo,1 Tyler Trump,2 Makenzy Sufficool,3 Stanley Zaslau1,2 1Department of Obstetrics & Gynecology, West Virginia University School of Medicine, Morgantown, WV 26506, USA; 2Department of Urology, West Virginia University School of Medicine, Morgantown, WV 26506, USA; 3West Virginia University School of Medicine, Morgantown, WV 26506, USACorrespondence: Robert ShapiroDepartment of Obstetrics & Gynecology, West Virginia University School of Medicine, Morgantown, WV 26506, USAEmail rshapiro@hsc.wvu.eduIntroduction: Patients may develop recurrent urinary tract infections, pain syndromes, dyspareunia, and voiding difficulty after mid-urethral sling placement that can be treated by partial sling excision.Objective: The primary objective of this study was to evaluate the incidence of de novo incontinence and voiding difficulty after partial sling excision. A secondary objective was to assess risk factors associated with future incontinence surgery in this subset of patients.Methods: From 2009 to 2017, 95 female patients with subjective complaints of pelvic pain, dyspareunia, or voiding difficulty following synthetic mid-urethral sling placement for stress urinary incontinence underwent partial sling excision at a single institution. The incidence of urinary incontinence was assessed 6 months after partial sling excision. Patients were also assessed for resolution of voiding difficulty and future incontinence surgery. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p < 0.05 was significant.Results: About 72% of patients were more likely to be continent after partial sling excision irrespective of initial symptoms prior to surgery. No difference was seen in voiding difficulty between the continent and incontinent patients after partial sling excision (p=0.09). Patients with a retropubic mid-urethral sling were more likely to be continent after partial sling excision (p=0.03). Preoperative maximum flow rate > 16 mL/sec was associated as an independent variable to develop incontinence surgery after partial sling excision (p=0.009).Conclusion: In conclusion, partial sling excision poses a low risk for de novo urinary incontinence regardless of preoperative symptoms. Stress urinary incontinence may be less likely to reoccur in those patients having a retropubic approach. A preoperative maximum flow rate of > 16 mL/sec is a risk factor for future incontinence surgery after partial sling excision and should be taken into consideration when formulating a treatment plan.Keywords: sling excision, mesh, incontinence, mid-urethral sing

Objective: To determine if a discrepancy exists in the number and type of cases logged between female and male urology residents., Materials and Methods: ACGME case log data from 13 urology residency programs was collected from 2007 to 2020. The number and type of cases for each resident were recorded and correlated with resident gender and year of graduation. The median, 25th and 75th percentiles number of cases were calculated by gender, and then compared between female and male residents using Wilcoxon rank sum test., Results: A total of 473 residents were included in the study, 100 (21%) were female. Female residents completed significantly fewer cases, 2174, compared to male residents, 2273 (P = .038). Analysis by case type revealed male residents completed significantly more general urology (526 vs 571, P = .011) and oncology cases (261 vs 280, P = .026). Additionally, female residents had a 1.3-fold increased odds of logging a case in the assistant role than male residents (95% confidence interval: 1.27-1.34, P < .001)., Conclusion: Gender-based disparity exists within the urology training of female and male residents. Male residents logged nearly 100 more cases than female residents over 4years, with significant differences in certain case subtypes and resident roles. The ACGME works to provide an equal training environment for all residents. Addressing this finding within individual training programs is critical., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To evaluate the effectiveness and safety of a novel wearable neuromodulation system incorporating embedded electromyographic evaluation, representing the first closed-loop wearable therapy for bladder control., Methods: This 12-week, multicenter, open-label, single-arm study of subjects with overactive bladder assessed response of bladder diary parameters and quality of life (QOL) metrics. Subjects used the transcutaneous tibial neuromodulation system, either once or three times weekly, with evaluations at weeks 1, 4, 8, and 12. Enrolled subjects (N = 96) were assessed for changes in urinary frequency, urgency, and urgency urinary incontinence episodes, and QOL changes using various questionnaires., Results: In the intent-to-treat population (N = 96, mean age 60.8 ± 13.0years, 88.5% female), significant reductions in 3-day diary parameters were observed for daily voids, incontinence, and urgency episodes at 12weeks. QOL improvements exceeded the minimal clinically important difference for all QOL questionnaires. Long-term results remained robust at 12months. Device-related adverse events were mild and there were no device-related serious adverse events. Mean therapy compliance at 12weeks was 88.5%. High satisfaction rates were reported for the device overall., Conclusion: The Avation device demonstrates promising efficacy in treating adults with overactive bladder and urge urinary incontinence. At 12weeks, both diary parameters and QOL indicators showed significant improvement and remained robust at 12months. The device had a favorable safety profile with high compliance and patient satisfaction. This novel, closed-loop wearable tibial neuromodulation system represents a significant advancement in bladder control therapy, offering a noninvasive, patient-centered alternative with improved accessibility and ease of use., Competing Interests: Declaration of Competing Interest Colin Goudelocke Study Investigator Funded by Sponsor (Avation). Jennifer Sobol Study Investigator Funded by Sponsor (Avation). Denise Poulos Study Investigator Funded by Sponsor (Avation). Ekene Enemchukwu Study Investigator Funded by Sponsor (Avation). Stanley Zaslau Study Investigator Funded by Sponsor (Avation). Rohit Dhir Study Investigator Funded by Sponsor (Avation)., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Sacral neuromodulation (SNM) is a commonly performed procedure for various conditions. Infection rates range as high as 10% and often require operative explantation with resultant increased cost and morbidity. Pouches impregnated with antibiotic have been utilized in cardiovascular procedures with decreasing infectious complications. TYRX is an antibiotic pouch utilizing minocycline and rifampin manufactured by Medtronic. The objective of this study is to investigate the utility of antimicrobial pouches for patients undergoing SNM., Methods: We retrospectively analyzed our patients undergoing SNM using an antimicrobial pouch and compared them with a historic cohort. Additional variables of interest included post-operative infection, diagnosis of diabetes, weight, and revision case or virgin implant., Results: A total of 170 cases were identified, ranging from March 2017 to November 2022. Overall infection rate was 2.9% with 0 in the antimicrobial pouch cohort (0%) versus 5 in the historic cohort (5.5%; p = 0.04). Groups were similar in terms of body habitus. The group receiving an antimicrobial pouch was noted to be older with a higher percentage of female patients. 85 patients received an antimicrobial pouch and 85 did not. Of the infections, 4 occurred in revision cases (6.9%) and 1 in a virgin implant (0.9%; p = 0.03). No difference was noted in infection rate with regard to a diagnosis of diabetes or body habitus., Conclusion: The use of antimicrobial pouches in SNM is associated with a decreased rate of infectious complications. Revision cases displayed a higher rate of infectious complications., (© 2023. The International Urogynecological Association.)

Objective: To evaluate longitudinal trends in surgical case volume among junior urology residents. There is growing perception that urology residents are not prepared for independent practice, which may be linked to decreased exposure to major cases early in residency., Methods: Retrospective review of deidentified case logs from urology residency graduates from 12 academic medical centers in the United States from 2010 to 2017. The primary outcome was the change in major case volume for first-year urology (URO1) residents (after surgery internship), measured using negative binomial regression., Results: A total of 391,399 total cases were logged by 244 residency graduates. Residents performed a median of 509 major cases, 487 minor cases, and 503 endoscopic cases. From 2010 to 2017, the median number of major cases performed by URO1 residents decreased from 64 to 49 (annual incidence rate ratio 0.90, P < .001). This trend was limited to oncology cases, with no change in reconstructive or pediatric cases. The number of major cases decreased more for URO1 residents than for residents at other levels (P-values for interaction <.05). The median number of endoscopic cases performed by URO1 residents increased from 85 to 194 (annual incidence rate ratio 1.09, P < .001), which was also disproportionate to other levels of residency (P-values for interaction <.05)., Conclusion: There has been a shift in case distribution among URO1 residents, with progressively less exposure to major cases and an increased focus on endoscopic surgery. Further investigation is needed to determine if this trend has implications on the surgical proficiency of residency graduates., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Inferior vena cava filters are effective for the management of thromboembolic disease but can erode into adjacent organ systems in rare instances. Endovascular retrieval of eroded filters has been the preferred management for this complication. We present a case for which endovascular retrieval was not appropriate because of filter orientation and erosion into the ureter and describe successful management using open retrieval of a permanent filter with erosion into the renal collecting system requiring reconstruction. Although minimally invasive retrieval is preferred over open repair, this approach should be considered when filter erosion is not amenable to endovascular retrieval., (© 2023 The Authors.)

Aims: Sacral neuromodulation (SNM) is an advanced therapy option for the treatment of overactive bladder (OAB), nonobstructive urinary retention, and fecal incontinence. The aim of this ongoing prospective, multicenter, global, postmarket study is to confirm safety and clinical performance of the InterStim TM Micro system for SNM in all indications. Reported here are the results for the OAB cohort through 6-month follow-up., Methods: Eligible OAB subjects that had a successful therapy evaluation were enrolled after implant of an InterStim Micro implantable pulse generator (IPG). Subjects completed voiding diaries and the Overactive Bladder Quality of Life questionnaire (OAB-q) at baseline and follow-up visits occurring at 3 months and 6 months postimplant. Safety was evaluated as device-, procedure-, or therapy-related adverse events. The primary objective for the OAB cohort was to demonstrate an improvement in OAB-q Health Related Quality of Life (HRQL) total score at 3 months postimplant compared to baseline., Results: Sixty-eight OAB subjects were enrolled and implanted with an InterStim Micro IPG. Of those, 67 and 66 subjects completed the 3- and 6-month follow-up visits, respectively. The OAB-q HRQL demonstrated a statistically significant improvement from baseline to 3-month follow-up with an average increase of 33 ± 24 points (n = 67, p < 0.001). The change was also observed at 6-months with an average increase of 31 ± 23 points (n = 65) compared to baseline. Eighty-two percent of subjects achieved the minimally important difference in HRQL score at 3- and 6-month, respectively, with a change of 10 points or greater. The majority of subjects reported that their bladder condition was better at 3-month (92.5%, 62/67) and 6-month (89%, 59/66) compared to before they were treated with SNM therapy delivered by the InterStim Micro system. For subjects with urgency urinary incontinence (UUI), the average change from baseline to follow-up in UUI episodes/day was -3.6 (95% CI: -4.7, -2.6; n = 62) at 3-month and -3.7 (95% CI: -4.7, -2.7; n = 61) at 6-month. Among subjects with urgency-frequency (UF), the average change from baseline to follow up in voids/day was -4.5 (95% CI: -6.3, -2.7; n = 52) at 3-months and -4.4 (95% CI: -6.0, -2.7; n = 52) at 6-month. The cumulative incidence of device-, procedure-, or therapy- related adverse events was 7.4% (5/68). Out of these five related adverse events, there was one serious adverse event (1.5%, implant site pain) at the time of database snapshot., Conclusions: These data confirm the safety and clinical performance of the InterStim Micro device for subjects with OAB by demonstrating a significant improvement in OAB-q HRQL score at 3-month. Similar improvements were observed at 6 months in addition to an incidence of adverse events that is comparable to previously reported rates for SNM., (© 2023 Wiley Periodicals LLC.)

Introduction and Hypothesis: Overactive bladder (OAB) affects up to 43% of women. Treatment ranges from lifestyle modification to invasive therapies. Nearly 75% of patients report using the internet to gain health information creating a need for interpretable, online resources. This study is aimed at evaluating the readability of online resources for OAB treatment in the US population., Methods: Google and Bing were queried regarding "sacral neuromodulation," "peripheral tibial nerve stimulation (PTNS)," and "bladder botox." The first 20 results from each search engine were assessed, representing over 90% of accessed search results. Websites were categorized as institutional/reference, commercial, nonprofit, or personal. The Gunning fog (GF), Simple Measure of Gobbledygook (SMOG), and Dale-Chall (DC) validated readability scores were used to assess results., Results: Sacral neuromodulation yielded 27 eligible results. The associated mean readability scores correlated with levels of college senior (GF), high school junior (SMOG), and college level (DC). PTNS yielded 31 eligible results. The associated mean readability scores correlated with levels of college senior (GF), high school senior (SMOG), and college level (DC). Bladder botox yielded 17 eligible results. The associated mean readability scores correlated with levels of college sophomore (GF), high school junior (SMOG), and college level (DC). There was no difference between the therapies regarding readability. Sixty-one percent of websites were institutional/reference, 24% were commercial, 13% were nonprofit, and 2% were personal., Conclusions: High levels of reading comprehension are required by the general US population to understand OAB information obtained through the internet. These findings highlight a need for simplification of online resources pertaining to OAB., (© 2022. The International Urogynecological Association.)

Diffuse large B-cell lymphoma (DLBCL) of the genitourinary tract is a rare diagnosis. A 66-year-old male with a history of multiple myeloma and prostate cancer presented with gross hematuria and concern for urinary clot retention. Imaging demonstrated an incidental mass in the left kidney and urinary bladder. Resection of the urinary bladder tumor and biopsy of the kidney revealed Epstein-Barr Virus positive DLBCL. Significant lymphadenopathy was found during staging, and this lymphoma was classified as stage IV. The patient was referred to medical oncology, initiated on chemotherapy, and scheduled for follow up with urology for the renal mass., Competing Interests: The authors declare that they have no conflicts of interest to disclose., (© 2023 The Authors. Published by Elsevier Inc.)

Background: Massive herniation of the bladder presents a rare diagnostic challenge. Rarely, bladder herniation is complicated by the development of bladder calculi. We present a therapeutic approach for this situation., Case Presentation: A 90-year-old presented with recurrent urinary tract infections secondary to bladder calculi in the setting of inguinoscrotal bladder herniation. He subsequently underwent successful trans -scrotal percutaneous cystolitholapaxy as a creative approach to an unusual presentation., Conclusion: Massive inguinoscrotal herniation of the bladder is a rare clinical entity with significant morbidity and mortality. Intervention requires a balance of patient health status and anatomy, lending to creative approaches as necessary., (© 2021 The Authors.)

Background: Vesicovaginal fistula is a rare and distressing urological condition. It is especially prevalent in developing countries with the predominant etiology secondary to obstructed labor. Radiation therapy in female patients with cervical cancer is a risk factor for vesicovaginal fistula formation in the United States. Case Presentation . A 53-year-old woman with a history of cervical cancer and radiation presented with continuous urinary incontinence. Following diagnostic vaginoscopy, a 1 cm vesicovaginal fistula was diagnosed at the vaginal apex. The patient elected for surgical repair. She subsequently underwent successful transvaginal fistula closure using colpocleisis to optimally address the systemic factors of poor wound healing associated with irradiated tissue. Because of the adjacent tissue having been compromised by pelvic radiation, we opted to use a biologic graft made of human cadaveric pericardial tissue (CPT) instead of a native tissue flap to provide additional support for the fistula repair., Conclusion: A transvaginal approach for surgical repair of vesicovaginal fistula can be successful in patients with a prior history of pelvic radiation. Transvaginal colpocleisis is a viable option to augment vesicovaginal fistula repair for patients with significant comorbidities when sexual intercourse is no longer desired., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Ahmad Dahman et al.)

Purpose: A minimum number of index procedures is required for graduation. Without thresholds for surgical technique, it is unclear if robotic and open learning is balanced. We assessed the distribution of robotic and open surgeries performed by residents upon graduation., Materials and Methods: Voluntary Accreditation Council for Graduate Medical Education resident case logs from 11 institutions were de-identified and trends in robotic and open major surgeries were compared using Wilcoxon rank sum and 2-sample t-tests., Results: A total of 89,199 major cases were recorded by 209 graduates from 2011 to 2017. The median proportion of robotic cases increased from 2011 to 2017 in reconstruction (4.7% to 15.2%), oncology (27.5% to 54.2%) and pediatrics (0% to 10.9%) (all values p <0.001). Robotic and open cases remained most divergent in reconstruction, with a median of 12 robotic (IQR 9-19) to 70 open cases (IQR 55-106) being performed by residents in 2017. Similar observations occurred in pediatrics. In oncology the number of robotic procedures superseded that of open in 2016 and rose to a median of 148 robotic (IQR 108-214) to 121 open cases (IQR 90-169) in 2017, with the driver being robotic prostatectomy. Substantial differences in surgical technique were observed between institutions and among graduates from the same institution., Conclusions: Although robotic volume is increasing, the balance of surgical technique and the pace of change differ in reconstruction, oncology and pediatrics, as well as among individual institutions and graduates themselves. This raises questions about whether more specific guidelines are needed to ensure equity and standardization in training.

The surgical treatments for neurogenic bladder are extremely variable. The lack of specific treatment guidelines makes this disease process even more challenging to treat. We present a case of a 55-year-old female with neurogenic bladder secondary to spinal cord injury (SCI). Her incontinence was conservatively managed with indwelling Foley drainage. Despite continued upsizing of the Foley catheters, the patient continued to have urinary leakage. The patient subsequently underwent a transvaginal bladder neck closure (BNC) with suprapubic bladder neck diversion (SPC). The urethra was successfully closed and uniquely supported with the use of cadaveric pericardial tissue (CPT). This surgical approach of neurogenic bladder provides durable continence with short operative times, minimal patient morbidity, decreased hospital length, and low risk of progressive renal dysfunction. BNC with SPC can provide an excellent management solution for neurogenic bladder from spinal cord injury refractory to conservative management., Competing Interests: The authors declare that they have no conflicts of interest.

A urethral diverticulum is a relatively uncommon finding. The estimated prevalence is approximately 1-5% in the general population. While the definitive treatment is surgical correction, there are limited studies guiding the best approach to repair. This is the case of a 48-year-old female who initially presented with vaginal discharge, dysuria, and dyspareunia. MRI revealed the diagnosis of suspected urethral diverticulum. The patient was treated with surgical correction with the aid of needle localization prior to the procedure. After the diverticulum was excised, the resulting defect in the urethra was successfully closed with cadaveric pericardial tissue. A urethral diverticulum should be considered in the differential diagnosis when a patient presents with symptoms such as recurrent urinary tract infections (UTIs) vaginal mass, dysuria, dyspareunia, or vaginal discharge. The use of cadaveric tissue augments the surgical technique for repair.

Fournier's gangrene isolated to the penis is exceedingly rare. It is an urologic emergency that requires emergent parenteral antibiotics as well as aggressive irrigation and debridement. While human bite wounds can be overlooked as a serious cause of injury and infection, they can result in highly dangerous, polymicrobial infections in affected patients. Here, we report a case of penile Fournier's gangrene caused by a human bite wound managed with broad spectrum antibiotics, irrigation and debridement, penile reconstruction, and skin grafting with successful preservation of a normal penile structure and function.

Acute and chronic stress have been reported to have differing effects on physical activity in rodents, but no study has examined a chronic stress protocol that incorporates stressors often experienced by rodents throughout a day. To examine this, the effects of the Unpredictable Chronic Mild Stress (UCMS) protocol on voluntary running wheel activity at multiple time points, and/or in response to acute removal of chronic stress was determined. Twenty male Balb/c mice were given access and accustomed to running wheels for 4 weeks, after which they were randomized into 2 groups; exercise (EX, n = 10) and exercise with chronic stress using a modified UCMS protocol for 7 hours/day (8:00 a.m.-3:00p.m.), 5 days/week for 8 weeks (EXS, n = 10). All mice were given access to running wheels from approximately 3:30 p.m. to 7:30 a.m. during the weekday, however during weekends mice had full-time access to running wheels (a time period of no stress for the EXS group). Daily wheel running distance and time were recorded. The average running distance, running time, and work each weekday was significantly lower in EXS compared to EX mice, however, the largest effect was seen during week one. Voluntary wheel running deceased in all mice with increasing age; the pattern of decline appeared to be similar between groups. During the weekend (when no stress was applied), EXS maintained higher distance compared to EX, as well as higher daily distance, time, and work compared to their weekday values. These results indicate that mild chronic stress reduces total spontaneous wheel running in mice during the first week of the daily stress induction and maintains this reduced level for up to 8 consecutive weeks. However, following five days of UCMS, voluntary running wheel activity rebounds within 2-3 days.

It is estimated that almost half of patients affected with Crohn disease (CD) experience a dermatologic manifestation of the condition. Metastatic CD (MCD) is a rare dermatologic entity, with as few as 100 cases reported in the literature. As such, MCD presents a clinical dilemma in diagnosis and management. The etiology of MCD is not well defined; however, prevailing theories agree that the underlying mechanism is an immunologic response to gut antigens. Diagnosis requires a high index of suspicion and usually is made by exclusion of other processes. Treatment success has been reported with the use of antibiotics, immunosuppressants, and sometimes surgical treatment. We review the etiology/epidemiology, diagnostic criteria, and treatment of this uncommon condition.

Introduction and Hypothesis: Polypropylene (PP) mesh has come under increased scrutiny owing to previous FDA safety communications regarding the risks of mesh in trans-vaginal surgery and ensuing class action litigation for post-operative complications. Additional concerns have been raised regarding a possible link between implanted PP mesh and the long-term development of malignancy. Until recently, no research was specifically committed to the exploration of such a link. Our objective was to provide an overview of the recent literature focusing on any association between the use of PP mesh for midurethral sling procedures and the development of malignancy., Methods: Multiple online research databases were searched for information related to any possible carcinogenic potential of PP mesh., Results: There was no increased incidence in the development of malignancy after midurethral sling procedures using PP mesh in any of the studies., Conclusion: Given the scarcity of evidence suggesting otherwise, the likelihood of PP mesh causing malignancy is exceptionally low. However, with few studies and an unknown latency period between exposure and diagnosis, more observational data would prove useful to exclude causality.

Background: Synthetic mid-urethral mesh slings are the most common primary surgical treatment for stress urinary incontinence (SUI) and have been designated as the standard of care by the American Urogynecologic Society. In recent years, synthetic mesh has come under increased scrutiny by the Federal Drug Administration (FDA) due to concerns over patient safety. This has led to more surgeons and patients preferring Burch colposuspension to treat SUI., Case: We discuss two cases of suture erosion into the urethra and bladder. They presented with irritative voiding symptoms and recurrent urinary tract infections. Both were discovered years after a Burch colposuspension., Conclusion: As reported in the literature as early as 1999, erosion is a complication associated with many types of incontinence surgery and not unique to mesh based sling operations. Burch colposuspension should not be favored solely to avoid erosion and patients should be counseled accordingly., Teaching Point: Cystourethroscopy performed intraoperatively or postoperatively is essential for early diagnosis and treatment of complications related to incontinence surgery.

Paratesticular sarcomas are a rare entity and provide a unique clinical challenge due to their slow growing, often painless natural course. Adding to this challenge is the complex anatomy of the scrotum that allows these masses to mimic other conditions, including inguinal hernia, cysts, or fluid collections. We report such a case and our approach to an 83-year-old male with dedifferentiated liposarcoma of the spermatic cord with a history of inguinal hernia. In doing so, we highlight the need for thorough evaluation of scrotal masses and the management of these rare, though well-described, tumors.

Objective: To determine the age of pediatric patients who underwent surgical intervention for undescended testicles (UDT) at our institution., Methods: We retrospectively reviewed all pediatric patients who underwent orchiopexy and/or diagnostic laparoscopy for undescended or non-palpable testicles with our pediatric urologist from January 2013-March 2014. Patients were separated into those undergoing surgical intervention at 6-12 months, 13-24 months, 25-48 months, and >48 months of age., Results: 70 patients underwent surgical intervention. Only 15 patients (21.4%) underwent surgical intervention within the recommended time period of 6-12 months. Orchiopexy was performed on 21 patients (30.0%) from 13-24 months, 12 patients (17.1%) from 25-48 months, and 22 patients (31.5%) after 48 months of age., Conclusions: Current American Urologic Association (AUA) recommendations advocate orchiopexy between 6-12 months of age. Improved parent and primary care education and access to pediatric urological evaluation of UDT will hopefully improve the timeliness of intervention within our state.

The most recent American Urologic Association (AUA) guidelines concerning prostate-specific antigen (PSA) screening have caused much controversy. One particular guideline, in regard to testing elderly men, is the center of intense debate. Currently, the AUA recommends against PSA screening in men aged 70 and older. West Virginia faces the challenge of a population aging at a rate that far exceeds the projected national rate. With such a substantial future proportion of older men, and increased life expectancy within this group, careful consideration of PSA screening in elderly men is warranted. Given the uncertainty surrounding the basis for the AUA guidelines, and the increased quality of life and remaining life expectancy for older men, we propose a view that supports PSA screening in carefully selected elderly men, and offer background to assist clinicians in arriving at a sound clinical decision in concert with the patient.

Urethral prolapse in a premenopausal adult female is exceedingly rare. This paper describes a case of strangulated urethral prolapse presenting as a urethral mass in an unusual demographic and reviews the literature on etiology and management. Only a few cases have occurred in women of reproductive age. The etiology is likely multifactorial. Treatment with surgical excision provides good results in the majority of cases.

Myelolipomas are rare tumors consisting of both adipose and hematopoietic tissue and are typically found within the adrenal gland. Extra-adrenal involvement is rare, especially those tumors involving the perirenal space and collecting system. We report a case of a patient with an incidentally discovered perirenal mass that was initially concerning for a retroperitoneal liposarcoma. Following surgical resection and pathological analysis, the lesion was found to be an extra-adrenal myelolipoma. This case report and review of the literature demonstrates the importance of the proper work-up and management of perirenal lipoma variants while addressing the issues of tissue biopsy, surgical intervention, and pre- and post-operative surveillance.

Introduction: Urinary fistulae develop as abnormal connections between the gastrointestinal (GI) and genitourinary (GU) tracts, and occur in multiple disease processes including diverticulitis, malignancy, and Crohn's disease. Crohn's disease is now the most common cause of fistula formation between the ileum and bladder and the third most common cause of fistulae between the colon and the bladder. Few articles provide a comprehensive review of this process., Materials and Methods: We performed a PubMed search using such terms as "fistula" and "Crohn's disease" and/or "enterovesical fistula." We reviewed references from selected papers and relevant articles were used for information-gathering and cited accordingly., Results: Fistulae in Crohn's disease generally occur due to preformed abscess formation or bowel perforation from the development of aphthous ulcers. The most common type of urinary fistula is enterovesical, due to the close proximity of the ileum and bladder dome. Computed tomography and cystoscopy are the most common diagnostic tools utilized. Surgical treatment is usually definitive; however medical treatment has been used with some success as well., Conclusion: Urinary fistulae represent an uncommon, yet serious problem to patients with Crohn's disease. Patient symptoms and imaging direct the practitioner to proper diagnosis, with direct visualization via cystoscopy confirming the presence of a urinary fistula. Treatment is aimed at relieving symptoms and may be medical or surgical depending on the clinical presentation.

Testicular torsion is an emergent condition requiring prompt surgical intervention to avoid permanent testicular compromise and death. As its symptoms overlap with other disease processes, diagnosis is sometimes difficult. When considering the presenting symptoms, one must be careful not to ignore unusual causes of torsion and misdiagnose the patient. In this case report we describe an unusual etiology of testicular torsion (traumatic) with an atypical patient presentation (mildly painful) which presented many obstacles before proper diagnosis and treatment.

Background: Inositol Hexaphosphate (IP6) is a naturally occurring polyphosphorylated carbohydrate that is found in food sources high in fiber content. We hypothesized that IP6 would inhibit the cell growth rate of bladder cancer in vitro., Methods: T24 and TCCSUP bladder cancer cell lines were treated with titrating doses of IP6 (0.3, 0.6 and 0.9 mM/well). Cell viability and vascular endothelial growth factor levels were measured., Results: Significant reductions (p < 0.001) in cellular growth were noted in both cell lines at all doses and time points tested, with the exception of 0.3 mM IP6 at 24 hours in the T24 cell line. The percent inhibition of vascular endothelial growth factor was significantly higher than that observed in the TCCSUP cell line at 48 and 72 hours with 0.3 mM IP6 (p < 0.001). The T24 cells exhibited the same level of inhibition at 24 and 48 hours with 0.6 mM dose of IP6 and at 72 hours with the 0.3 mM dose (p < 0.001)., Conclusions: In vitro treatment of bladder cancer with the common dietary polyphosphorylated carbohydrate IP6 significantly decreased cellular growth by anti-angiogenic mechanisms. We feel that this data warrants further investigation and consideration for initiation of clinical trials to evaluate the safety and clinical utility of this agent.

Squamous cell carcinoma (SCC) of the bladder is a relatively uncommon cause of bladder cancer accounting for <5% of bladder tumors in the western countries. SCC has a slight male predominance and tends to occur in the seventh decade of life. The main presenting symptom of SCC is hematuria, and development of this tumor in the western world is associated most closely with chronic indwelling catheters and spinal cord injuries. A 39-year-old Caucasian female presented with bladder and lower abdominal pain, urinary frequency, and nocturia which was originally believed to be interstitial cystitis (IC) but was later diagnosed as SCC of the bladder. Presentation of SCC without hematuria is an uncommon presentation, but the absence of this symptom should not lead a practitioner to exclude the diagnosis of SCC. This case is being reported in an attempt to explain the delay and difficulty of diagnosis. Background on the risk factors for SCC of the bladder and the typical presenting symptoms of bladder SCC and IC are also reviewed.

There are multiple reports of foreign bodies inserted into the lower urinary tract. We report the case of an incidentally discovered foreign body identified within the bladder in a male patient presenting with a radio antenna protruding from the urethra attached to a head set. On workup patient was found to have an additional foreign body within the bladder and second radiolucent object within the urethra. This case demonstrates the importance of complete evaluation of the lower urinary tract during workup of inserted foreign bodies and the value of the bedside ultrasound as a diagnostic tool in distinguishing between rectal and genitourinary tract insertion.

Sacral neuromodulation (SNM) has become a standard treatment option for patients suffering from urinary urge incontinence, urgency-frequency, and/or nonobstructive urinary retention refractory to conservative and pharmacologic treatment. Since its initial development, the manufacturer of InterStim therapy (Medtronic, Inc., Minneapolis, MN, USA), has introduced technical modifications, while surgeons and researchers have adapted and published various innovations and alterations of the implantation technique. In this article, we feature our SNM technique including patient selection, comprehensive dialogue/evaluation, procedure details, and appropriate follow up. Although there is often great variability in patients with lower urinary tract dysfunction, we maintain that great success can be achieved with a systematic and methodical approach to SNM.

Paraganglioma of the urinary bladder is a rare tumor that often presents with hypertensive crisis during micturition. We herein present the unusual case of a 45-year-old female with metastatic paraganglioma treated with robotic assisted partial cystectomy and pelvic lymphadenectomy. We review the literature regarding the evaluation and management of paraganglioma of the bladder.

Exercise and physical activity have been linked to the prevention of certain types of cancer such as colon and breast. As prostate cancer is the most common malignancy diagnosed in the male population, there is obvious interest in determining a possible effect of exercise on disease prevention and improvement of disease-related outcomes. Thus far, data has been conflicting and there has been no clear determination of prostate cancer prevention through exercise. However, as prostate cancer treatment carries many side effects which may be bothersome and health-threatening, researchers have examined the effects of exercise training on reducing treatment-related complications and improving outcomes and quality of life (QOL). In this review, we discuss the impact of exercise on reducing side effects of prostate cancer treatment and improving cancer-specific and overall survival outcomes, as well as improving QOL in prostate cancer patients.

Introduction: Post-vasectomy pain syndrome (PVPS), defined as chronic epididymal pain that is continuous or recurrent in the absence of proven epididymal or testicular infection, has become more common as the number of vasectomies performed rises. With more than four million vasectomies performed annually, the prevention and treatment of this condition becomes more important. Multiple theories have been proposed as a potential etiology of this condition, and along with this have come multiple modalities of treatment. With the uncertainty surrounding the etiology of this syndrome, the aims of treatment are varied and are described and analyzed in this review., Materials and Methods: A literature review was conducted to ascertain the various theories explaining the source of the discomfort in this syndrome, along with several treatment modalities, both medical and surgical., Conclusions: Options for the management of PVPS are rapidly expanding. Among the existing surgical options that include spermatic cord denervation and vasovasostomies, testosterone has emerged as a potential medical therapy with some promising results. Our review of the literature reveals the etiology of PVPS is still uncertain, as multiple theories still prevail. However, progress has been made in the development of additional medical therapies that could provide some relief for patients who are unwilling to accept the risks of surgery. Nevertheless, the importance of counseling patients of the risks of PVPS with vasectomy cannot be overstated. Through review of the pathophysiology of this condition and treatment options including conservative approaches, topical therapies, denervation of the spermatic cord, and surgical approaches, a comprehensive therapeutic approach can be offered to affected patients.