Faculty Bibliography

OBJECTIVE: To determine a nationwide contemporary description of surgical Fournier gangrene (FG) and necrotizing fasciitis of the genitalia (NFG) outcomes because historically reported mortality rates for FG and NFG are based on small single-institution studies from the 1980s and the 1990s. METHODS: The National Surgical Quality Improvement Program is a risk-adjusted surgical database used by nearly 400 hospitals nationwide, which tracks preoperative, intraoperative, and 30-day postoperative clinical variables. Data are extracted from patient charts by an independent surgical clinical reviewer at each hospital. Using the National Surgical Quality Improvement Program data from 2005 to 2009, we calculated 30-day mortality rates and identified preoperative factors associated with increased mortality. RESULTS: A total of 650 patients were identified with surgery for FG or NFG. Fourteen patients with do not resuscitate orders placed preoperatively were excluded from analyses. For the remaining 636 patients, the overall 30-day mortality was 10.1% (64 of 636). Fifty-seven percent of patients (360 of 636) were men, 70% (446 of 636) were white, and 13% (81 of 636) were African American. Multivariate logistic regression indicated that increased age (odds ratio [OR], 1.041; P = .004), body mass index (OR, 1.045; P <.001), and preoperative white blood cell count (OR, 1.061; P = .001), and decreased platelet count (OR, 0.993; P <.001) were all associated with increased risk of death. CONCLUSION: We determined a surgical mortality rate for FG-NFG of 10.1%. This rate is about half of historically published estimates and similar to recent studies. The lower rate may indicate improvements in therapy. Increased age, body mass index, and white blood cell count, and decreased platelet count were all associated with an increased risk of 30-day mortality.

OBJECTIVE: To report our results from series of robotic-assisted laparoscopic augmentation enterocystoplasty (RALAE) performed in a completely intracorporeal fashion. METHODS: Patients who underwent RALAE with or without the creation of a catheterizable channel between 2006 and 2011 at the University of Texas, Houston and Northwestern Memorial Hospital were identified. Perioperative and follow-up data were analyzed. Preoperative and postoperative urodynamic data were analyzed when available. RESULTS: Twenty-two patients with neurogenic bladder underwent RALAE with or without the creation of a catheterizable channel. Fifteen patients underwent robotic augmentation enterocystoplasty alone, and 7 patients had creation of a catheterizable channel (4 Monti and 3 Mitrofanoff). There was 1 conversion to an open procedure in a patient undergoing concomitant creation of an appendicovesicostomy. Mean follow-up was 38.9 months (range, 6.2-72.1 months). Mean operative time was 365 minutes (range, 220-788 minutes); mean estimated blood loss was 110 mL (range, 30-250 mL). Median time to return of bowel function was 5 days (range, 2-17 days). Preoperative and postoperative urodynamic data were available for 13 patients. Mean cystometric capacity increased by 52%, and mean maximal bladder pressures decreased by 40. There were 5 minor complications (Clavien grade 1-2) and 4 major complications (Clavien grade 3-4). No patient experienced a wound infection. CONCLUSION: RALAE is a feasible approach that provides potential benefits over open bladder reconstruction in the neurogenic voiding dysfunction population.

INTRODUCTION: We assessed patient perceptions of regular intermittent self-dilation (ISD) among men with urethral strictures. METHODS: We constructed and distributed a visual analog questionnaire to evaluate ISD by men referred for management of urethral strictures at four institutions. Items assessed included the patient's length of time, frequency, difficulty and pain associated with ISD, as well as the interference of ISD with daily activity. The primary outcome was the patient's perceived quality of life (QOL). Multivariate analysis was performed to assess factors that affected this outcome. RESULTS: Eighty-five patients were included (median age 68 years) with median length of time on IC 3.0 years and median frequency of 1 catheterization per day. On a 1 to 10 scale, median difficulty with catheterization was 5.0+/- 2.7, median pain score was 3.0+/- 2.7, and interference with daily life was 2.0+/- 1.3. The overall QOL among stricture patients was poor (median score of 7.0+/- 2.6, poor QOL defined as 7 or greater). On univariate analysis, younger age (P < 0.01), interference (P=0.03), pain (P<0.01) and difficulty performing ISD (P = 0.03) correlated with a poor QOL in a statistically significant manner. On multivariate analysis, only difficulty catheterizing (P<0.01) and younger age (P=0.05) were statistically significant predictors. Patients with strictures involving the posterior urethra had a statistically significant increase in difficulty (P=0.04) and decrease in QOL (P=0.04). CONCLUSIONS: Most urethral stricture patients on ISD rate their difficulty and pain as moderate, and their inconvenience as low, but report a poor QOL.

INTRODUCTION: The epidemiology of priapism is not well characterized. A small number of studies based on inpatient data or small population samples have estimated the incidence to range from 0.34 to 1.5 cases per 100,000 males. AIM: To estimate the current epidemiology and impact on resource utilization of priapism in the United States (US). MAIN OUTCOME MEASURES: Rate of emergency department encounters for priapism in the US. METHODS: Emergency department (ED) visits for priapism were analyzed using discharge data from the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP). Priapism encounters were identified by ICD9 code. Priapism encounters were analyzed for patient and hospital characteristics, associated diagnoses, and hospital charge. Established weighting in the sample was used to calculate nationwide estimates. RESULTS: A total of 8,738 ED encounters for priapism were identified between 2006 and 2009 in the NEDS. This translated to an estimated 39,964 encounters out of a total of 496,195,793 ED visits, or 8.05 per 100,000 ED visits (95% confidence interval [CI] 7.59-8.51). 21.1% of patients had a concurrent diagnosis of sickle cell disease (SCD). 72.1% of all patients were discharged home from the ED, while only 49.6% of patients with SCD were discharged home. A concurrent diagnosis of SCD was associated with an odds ratio (OR) of 3.84 (95% CI 3.65-4.05) for admission to the hospital when controlling for age, region, hospital and payer type. The mean hospital charge was $1,778 per encounter if discharged home and $41,909 per encounter if admitted. The estimated mean total annual charge for priapism was $123,860,432 with 86.8% of charges attributed to inpatient admissions. CONCLUSIONS: Our estimate of the rate of ED visits for priapism was significantly higher than prior estimates with a SCD concurrence rate lower than previously estimated. Stein DM, Flum AS, Cashy J, Zhao LC, and McVary KT. Nationwide emergency department visits for priapism in the United States. J Sex Med **;**:**-**.

PURPOSE: We propose a novel risk stratified followup protocol for use after urethroplasty and explore potential cost savings. MATERIALS AND METHODS: Decision analysis was performed comparing a symptom based, risk stratified protocol for patients undergoing excision and primary anastomosis urethroplasty vs a standard regimen of close followup for urethroplasty. Model assumptions included that excision and primary anastomosis has a 94% success rate, 11% of patients with successful urethroplasty had persistent lower urinary tract symptoms requiring cystoscopic evaluation, patients in whom treatment failed undergo urethrotomy and patients with recurrence on symptom based surveillance have a delayed diagnosis requiring suprapubic tube drainage. The Nationwide Inpatient Sample from 2010 was queried to identify the number of urethroplasties performed per year in the United States. Costs were obtained based on Medicare reimbursement rates. RESULTS: The 5-year cost of a symptom based, risk stratified followup protocol is $430 per patient vs $2,827 per patient using standard close followup practice. An estimated 7,761 urethroplasties were performed in the United States in 2010, assuming that 60% were excision and primary anastomosis, and with more than 5 years of followup the risk stratified protocol was projected to yield an estimated savings of $11,165,130. Sensitivity analysis showed that the symptom based, risk stratified followup protocol was far more cost-effective than standard close followup in all settings. Less than 1% of patients would be expected to have an asymptomatic recurrence using the risk stratified followup protocol. CONCLUSIONS: A risk stratified, symptom based approach to urethroplasty followup would produce a significant reduction in health care costs while decreasing unnecessary followup visits, invasive testing and radiation exposure.

INTRODUCTION: To explore the association of artificial urinary sphincter (AUS) cuff sizes and placement techniques with the development of postoperative urinary retention. MATERIALS AND METHODS: We analyzed the outcomes of AUS cases performed by a single surgeon at a tertiary referral center from 2007-2010. Outcomes relating to urinary retention and suprapubic tube placement were analyzed in three groups: those with 3.5 cm cuff placement, >/= 4 cm cuff placement, and transcorporal cuff (TC) placement of any size. RESULTS: Among 139 patients who underwent AUS placement from 2007-2010, 117 cases met inclusion criteria - 42 men received a 3.5 cm cuff, 53 received a >/= 4 cm cuff, and 22 received a TC cuff (all >/= 4 cm). TC patients had a significantly higher rate of urinary retention compared to the >/= 4 cm group [7/22 (32%) versus 4/53 (8%), p = 0.02] as well as a higher rate of SPT placement [6/22 (27%) versus 1/53 (2%), p = 0.007]. CONCLUSIONS: Transcorporal cuff placement is associated with a significantly higher rate of urinary retention and suprapubic tube placement compared to traditional 4 cm cuff placement.

BACKGROUND: Penetrating external genital injuries, although uncommon, may present complex problems for the urologic and trauma surgeon. A paucity of data exists on the incidence, clinical characteristics, and management outcomes of these injuries because few institutions have the volume to report their experience. METHODS: Penetrating external genital trauma presenting from 2004 to 2011 was retrospectively reviewed. Patient characteristics, operative and nonoperative management, and outcomes were analyzed while validating current guidelines. Surgical management is described in detail, and overall incidence and trends were calculated. RESULTS: A total of 28,459 trauma patients were reviewed, of which 8,076 sustained penetrating injuries and 162 sustained penetrating external genital trauma. Penetrating external genital trauma was 0.57% of all trauma and 2.0% among penetrating trauma. Gunshot wounds accounted for the most common mechanism of injury (93%). Injury to the scrotum occurred in 78% and of these injuries, 63% resulted in a testicular injury, with bilateral testicular injuries occurring in 8%. Testicular reconstruction was performed in 65%. Penile injuries occurred in 28%, and urethral injuries occurred in 13%. For penile injuries, 62% were explored immediately. Urethral injuries were managed by immediate primary urethral repair (43%) or urinary diversion with delayed reconstruction (57%). In total, nonoperative management was performed in 26% of scrotal and 38% of penile injuries. The incidence of penetrating external genital injuries has remained constant during our study period, averaging 20.2 cases per year (R(2) = 0.99). The testicular salvage rate varied from 55% to 75% per year (R(2) = 0.06). CONCLUSION: Penetrating external genital injuries occur at an incidence of 0.57% where scrotal injury from gunshot wounds is the most common form. Testicular preservation is possible in the majority of testicular injuries. Penile injuries were less likely to require surgical exploration compared with scrotal injuries likely because physical examination is better at confirming only superficial injury. Select patients with superficial scrotal or penile injuries may undergo nonoperative management with minimal morbidity. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level IV.