Faculty Bibliography

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.

BACKGROUND AND PURPOSE: Laparoscopic and especially robot-assisted minimally invasive prostatectomy (MIP) has increased in popularity over the past decade. We analyzed how the increasing prevalence of MIP has affected the outcomes of MIP and open radical prostatectomy (RRP). METHODS: In the Nationwide Inpatient Sample, 23,473 patients undergoing MIP and 118,266 undergoing RRP between 2002 and 2008 are reported. We analyzed length of stay (LOS), hospital charges (THC), complication rates (CR), and socioeconomic characteristics. We used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to identify complication rates (RRP n=666, and MIP n=2205). RESULTS: The proportion of MIP increased from 1.4% in 2002 to 29.5% in 2008. Mean LOS decreased for MIP (2.4 days in 2002, 1.6 days in 2008) and RRP (3.1 days in 2002, 2.1 days in 2008). Mean THC for MIP decreased ($46k in 2002, $34k in 2008) and increased for RRP ($18k in 2002, $32k in 2008). After 2005, overall CRs of MIP were lower than for RRP. High-volume centers reported lower CRs for both procedures. MIP was associated with fewer transfusions and wound complications. Men living in ZIP codes with the top quartile of yearly mean household income were more likely to undergo MIP than RRP (P<0.001). Although there were more white patients receiving MIP and black or Hispanic patients more frequently underwent RRP, there was no statistically significant difference. CONCLUSIONS: Increasing use of MIP led to decreased hospital stay for all patients, increase charges for RRP, and decreased CRs for both MIP and RRP. In recent years, MIP was associated with fewer complications. Charges for RRP have increased over time to approach those for MIP, and patients with increased socio-economic status were more likely to undergo MIP.

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Infectious complication is a risk of bacille Calmette-Guerin instillation. Urine analysis in asymptomatic patients has been used as a measure to reduce infections. This study suggests that screening urine analysis prior to bacille Calmette-Guerin instillation did not affect the rate of urinary tract infections. OBJECTIVE: * To discover if the routine use of urine analysis decreases the rate of urinary tract infection (UTI) complications after bacille Calmette-Guerin (BCG) administration. METHODS: * A retrospective review of the outcomes of 202 patients undergoing BCG treatment for bladder cancer at two medical centres with different pre-BCG screening strategies was performed. * The medical records of 100 patients who received BCG by one urologist at Memorial Sloan-Kettering Cancer Center (MSKCC) were reviewed. No patient received a urine analysis immediately prior to BCG treatment. * Similarly, 102 patients who received BCG at Northwestern Memorial Hospital (NMH) were reviewed. Patients at NMH were screened by urine analysis for pyuria and bacteriuria before BCG treatment, and, if clinically indicated, BCG instillation was delayed for the results of the urine culture. * If the urine culture confirmed infection, then the patient was treated before restarting BCG instillation. RESULTS: * At MSKCC, 100 patients underwent 600 BCG treatments. * After BCG administration, symptomatic UTI occurred in three patients (3%), successfully treated with antibiotics. * No patients developed BCG sepsis or required hospitalization due to infection. * At NMH, 102 patients underwent 612 BCG treatments. * Pre-BCG urine analysis was positive for pyuria (defined as white blood cells >5 per high-power field) in 27.8%, and positive for bacteriuria (defined as any bacteria on microscopy) in 18.1%. * Based on the results of pre-screening urine analysis, BCG instillation was delayed 15 times (2.5%). * Overall, three patients (3%) had culture-proven UTIs after BCG instillation. * No patients developed BCG sepsis or required hospitalization in either group and there were no significant differences in the frequency of UTIs. CONCLUSIONS: * Urine analysis can safely be omitted before administration of BCG in asymptomatic patients. * Omission of urine analysis could save time and expense during the office-based treatment of bladder cancer.

PURPOSE: Race and insurance status independently predict outcome disparities after trauma. Black patients, Hispanic patients, uninsured patients and patients who live farther from trauma centers have a worse outcome after trauma than others. To our knowledge it is unknown whether these factors have a role in the testicular salvage rate after testicular trauma. We used NTDB (National Trauma Data Bank(R)) to investigate whether socioeconomic status, race and rural location predict testicular salvage. MATERIALS AND METHODS: Patients who sustained testicular trauma were identified in NTDB, version 9.1. Procedure codes for orchiectomy vs testicular repair were used to determine the risk of testicular salvage. Rural location was determined by matching the injury with the urban influence code. Univariate analysis of the influence of patient age, injury severity, race, insurance status and rural location was performed. Multivariate longitudinal analysis was done to identify orchiectomy predictors. RESULTS: Of 635,013 trauma cases 980 (0.2%) involved testicular injury. Of these patients 108 (11.0%) underwent orchiectomy and 58 (5.9%) underwent testicular repair. Self-paying patients had a statistically higher rate of orchiectomy than those with private insurance (79.2% vs 48.0%, p = 0.006). Black patients had a statistically higher rate of orchiectomy than white patients (75.8% vs 53.7%, p = 0.009). No difference in the orchiectomy rate was seen between Hispanic and nonHispanic patients (68.0% vs 65.8%, p = 0.84). In terms of rurality the incidence location was similar for orchiectomy and testicular repair, including urban 46.3% and 39.7%, rural 6.5% and 3.5%, suburban 2.8% and 1.7%, and wilderness 0.9% and 3.5%, respectively (p = 0.55). No statistically significant differences were found in age (31 vs 29 years, p = 0.42), injury severity score (5.8 vs 5.8, p = 0.99), hospital stay (8.4 vs 6.7 days, p = 0.41), intensive care unit stay (14.4 vs 9.6 days, p = 0.41) or ventilator days (18.2 vs 10.2, p = 0.24) for orchiectomy and testicular repair cases. CONCLUSIONS: Although age, injury severity score, hospital stay, intensive care unit stay and days of ventilator support are similar for patients who underwent orchiectomy vs testicular repair, the orchiectomy rate was higher for uninsured and black patients. Further studies are needed to elucidate the reasons for this disparity. Standardized protocols to manage testicular injury may decrease these disparities.

OBJECTIVE: To use the national Surveillance, Epidemiology, and End Results (SEER) cancer registry to describe the natural history, national incidence and treatment patterns for ductal prostate cancer (PCa) over the last 20 years, as the available literature on ductal PCa is limited to small case series because of few patient numbers. PATIENTS AND METHODS: From the SEER registry, 693 men with ductal PCa were identified from 1970. The demographics, clinical features and cause of death data were collected from men with ductal and acinar histological types. RESULTS: The incidence of ductal PCa has increased over each decade, but the overall percentage of ductal relative to acinar PCa has remained stable. Men with ductal PCa were more likely to present with advanced disease (30% T3 with ductal PCa, compared with 7% with acinar PCa). Men with ductal PCa underwent similar rates of radical surgery, lower rates of radiotherapy but a higher frequency of outlet (transurethral resection) procedures. Men with ductal PCa had a significantly greater rate of death from PCa (12% vs 4%) than men with acinar PCa. Comparing PCa-specific mortality, men with ductal PCa had similar rates of death to men with Gleason 4 + 4 grade acinar PCa. CONCLUSIONS: Despite a stable incidence, ductal PCa remains an aggressive PCa usually presenting with advanced clinical stage and resulting in a high rate of PCa-specific mortality similar to Gleason 4 + 4 acinar PCa. Patients would probably benefit from combined modalities including radical surgery, radiotherapy and palliative outlet procedures.

PURPOSE: We evaluated the spectrum of symptoms in men with urethral stricture presenting for urethroplasty. MATERIALS AND METHODS: We identified 214 men who underwent anterior urethroplasty by a single surgeon (CMG) from March 2001 to June 2010. We retrospectively reviewed the initial patient history. All voiding and sexual dysfunction symptoms were recorded. RESULTS: The most common presenting voiding complaints were weak stream in 49% of cases and incomplete emptying in 27%. Overall 21% of men did not present with voiding symptoms specifically addressed by the American Urological Association symptom index. The most common of these symptoms were spraying of urinary stream in 13% of men and dysuria in 10%. No symptoms were reported in 10% of men. Men with lichen sclerosus were more likely to present with obstructive symptoms (76% vs 55%) while men with penile urethral stricture were more likely to present with urinary stream spraying (17% vs 6%, each p <0.05). Sexual dysfunction was reported by 11% of men, most commonly in those with failed hypospadias repair (23% vs 9%) and lichen sclerosus (24% vs 10%, each p <0.05). CONCLUSIONS: While the American Urological Association symptom index captures the most common voiding complaints of men with urethral stricture, 21% of those who presented for urethroplasty did not have voiding symptoms assessed by the index. A validated, disease specific instrument is needed to fully capture the presenting voiding symptoms and sexual dysfunction complaints of men with urethral stricture disease.

OBJECTIVE: To use the National Trauma Data Bank (NTDB) to evaluate bicycling-related genitourinary (GU) injury. Bicycling is a popular recreational and competitive sport with recognized risks. GU injuries associated with bicycling is unknown. METHODS: Patient cases were extracted from the NTDB, version 9.1, using the mechanism of injury Ecode for pedal cyclist and ICD-9 codes for GU injuries. The type of GU injuries, patient demographics, Injury Severity Score, surgical management, outcomes, and disposition were analyzed. RESULTS: Of 635,013 trauma cases evaluated, 16,585 were identified as trauma because of bicycle injury. GU injuries were sustained in 358 (2%) patients; 86% were male, with a mean age of 29 years. The most commonly injured GU organ was the kidney (75%), followed by bladder and urethra (15%), and penis and scrotum (10%). These injuries resulted in nephrectomy (0.4%), cystorrhaphy (11.3%), scrotorrhaphy (42.1%), testicular repair (3.1%), and penile repair (7.5%). Most common associated injuries included vertebral fracture (35%), pelvic fracture (25%), spleen (19%), and open head wound (15%). Patients who sustained a vertebral fracture commonly sustained a concomitant bladder and urethra (37.7%) or a renal injury (22.6%). CONCLUSION: GU injury is an infrequent occurrence with bicycle trauma, occurring in 2% of bicycle injuries, with kidneys being the most commonly injured GU organ. Physicians treating bicyclists who sustained a vertebral fracture should be aware of a possible concomitant renal or bladder injury. Young males appear to be principally at risk for GU injury.

PURPOSE: Testicular torsion causes considerable morbidity in the pediatric population but the societal burden is poorly quantified. We determined the modern incidence of testicular torsion as well as the current rates of orchiectomy and attempted testicular salvage, and identified the risk factors for testicular loss. MATERIALS AND METHODS: A cohort analysis was performed of 2,443 boys (age 1 month to less than 18 years) and 152 newborns who underwent surgery for testicular torsion in the 2000, 2003 and 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database. Patient and hospital characteristics predictive of orchiectomy vs attempted testicular salvage were analyzed. RESULTS: There was a bimodal distribution of testicular torsion with peaks in the first year of life and in early adolescence. The overall mean age +/- SD at presentation was 10.6 +/- 5.8 years. The estimated yearly incidence of testicular torsion for males younger than 18 years old was 3.8 per 100,000. Orchiectomy was performed in 41.9% of boys undergoing surgery for torsion. The adjusted odds ratio for orchiectomy was highest for children in the youngest age quartile (younger than 10 years old, OR 1.58, 95% CI 1.25-2.00). Additional independent predictors of orchiectomy included Medicaid insurance (OR 1.39, 95% CI 1.14-1.69), black race (OR 1.33, 95% CI 1.04-1.71), nonemergency room admission source (OR 1.97, 95% CI 1.60-2.42) and surgery at a children's hospital or unit (OR 1.64, 95% CI 1.36-1.98). CONCLUSIONS: Testicular torsion is uncommon but the rate of orchiectomy is high, especially in the youngest patients.

BACKGROUND AND PURPOSE: Robot-assisted laparoscopic radical prostatectomy (RALRP) is the most expensive, yet most common, surgical treatment for patients with prostate cancer. Furthermore, its popularity continues to grow despite the lack of evidence for functional and oncologic superiority over other treatments. As a result, we modified operating room (OR) processes to determine if the times and costs that are associated with RALRP in an academic setting could be reduced. PATIENTS AND METHODS: Four modifications in OR processes were implemented: Trainee adherence to time-oriented surgical goals; use of a dedicated anesthesia team; simultaneous processing by nursing and urology house staff during case turnover; and identification and elimination of unused disposable instruments. Total surgical, anesthesia, and OR turnover times were measured. Payroll, surgical supply, OR time, and anesthesia costs were also measured. One hundred RALRP cases before and after the modifications were implemented were compared. RESULTS: Patients undergoing RALRP were similar both before and after the modifications were implemented. Total surgical, anesthesia, and turnover times were reduced by 17.4 (6.8%, P=0.041), 4.5 (19.1%, P=0.006), and 12.1 (28.1%, P=0.005) minutes, respectively. Payroll, surgical supply, and OR costs were reduced by $330 (25%), $609 (15.7%), and $1638 (27.7%), respectively. There was no fiscally significant change in anesthesia costs. CONCLUSIONS: Using simple modifications, it is possible that RALRP efficiency can be improved by decreasing its associated times and costs. These modifications were implemented in an academic setting but may be used in any institution. These modifications represent an initial attempt to improve RALRP cost-competitiveness with other treatment modalities.

Nanotechnology is poised to have a substantial influence on biomedicine. A unique example of a nanotechnology that has progressed from proof-of-concept to human clinical trials is the use of ultrasmall superparamagnetic iron oxide nanoparticles as a cell-specific contrast agent for MRI. When injected systemically, these particles are taken up by macrophages of the reticuloendothelial system and accumulate in lymph nodes. This passive, cell-specific targeting of the iron oxide nanoparticles to lymph nodes, and the differential cellular content of benign versus malignantly infiltrated nodes make this method suitable for cancer staging. By using lymphotropic nanoparticle enhanced MRI, differences in benign versus malignant infiltration of lymph nodes can be visualized, which adds accuracy to standard MRI beyond criteria based solely upon the size and shape of lymph nodes. This technology has been used to assess lymph node metastases in a large number of human cancer types. In this Review, we focus on lymphotropic nanoparticle enhanced MRI and its application for the staging of genitourinary malignancies.