Faculty Bibliography

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.

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.