Neck Contracture Research Articles

Difficult Airway Management in Pediatric Patient with Neck Contracture

Background: A specific airway evaluation and physical examination should be performed in all pediatric patients undergoing anesthesia. Pediatric difficult airway problems can occur due to congenital, inflammation, trauma, or malignant disorders. Laryngeal mask airway (LMA) is an alternative breathing device for difficult airway cases. Case: We reported a 5-year-old girl, 12 kg of weight, with a diagnosis of Colli region contracture planned for contracture release. Physical examination revealed glasgow coma scale score 15, with a pulse of 98 beats per minute, a breath rate of 22 times per minute and SpO2 of 98% on the room air. In the airway evaluation, it was found that the lower mouth was pulled down by the contracture tissue, 2-fingers-wide of mouth opening, the mallampati score was difficult to evaluate, there was no obstruction and neck motion was limited due to contractures. In this report, intubation via video laryngoscope was failed due to the severely restricted neck motion caused by the contracture. The use of LMA became an alternative difficult airway management in this patient after failed intubation with a video laryngoscope. Conclusion: Preoperative evaluation for assessing and evaluating difficult airway in pediatric patients greatly determines the success of airway management. The use of airway devices such as LMA is still very helpful in cases of pediatric difficult airway.

The incidence of urethral stricture and bladder neck contracture with transurethral resection vs. holmium laser enucleation of prostate: A matched, dual-center study.

Urethral strictures (US) and bladder neck contracture (BNC) are common, long-term complications of transurethral prostate surgery. We aimed to compare transurethral resection of the prostate (TURP) and holmium laser enucleation of the prostate (HoLEP) regarding incidence of US or BNC and identify possible risk factors. A retrospective review of patients who underwent TURP and HoLEP with followup data of at least one year in two separate institutions was performed. The incidence of postoperative US or BNC in both groups was compared. Bivariate and multivariate analysis of risk factors in both cohorts with US or BNC were performed. The study included 208 patients: 101 and 107 patients in the TURP and HoLEP arms, respectively. The two groups were matched for age and prostate size. Eight (7.92%) and five (4.72%) patients in the TURP and HoLEP arms, respectively, developed US (p=0.3423), while two (1.87%) patients in the HoLEP arm had BNC (p=0.2634). Of the eight patients with the US in the TURP arm, six (9.8%) had bipolar TURP, while two (5%) had monopolar TURP. Multivariate analysis showed that larger prostate volume (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.05, 1.41, p=0.0066) and longer operative time (HR 1.84, 95% CI 1.76, 1.93, p=0.0015) were associated with risk of US/BNC. There is no significant difference between TURP and HoLEP regarding incidence of US or BNC, although there is a tendency towards a higher rate of US associated with bipolar TURP. Increased prostate volume and operative time are possible risk factors.

ATOMS (Adjustable Trans-Obturator Male System) in Patients with Post-Prostatectomy Incontinence and Previously Treated Urethral Stricture or Bladder Neck Contracture.

(1) Background: Male stress incontinence in patients with previously treated urethral or bladder neck stricture is a therapeutic challenge. The efficacy and safety of the adjustable trans-obturator male system (ATOMS) in these patients is unknown. (2) Methods: All patients with primary ATOMS implants in our institution between 2014 and 2021 were included. The outcomes of patients with previously treated urethral or bladder neck stricture (≥6 months before ATOMS implant) and stable 16Ch urethral caliber were compared to those without a history of stricture. The primary endpoint was the dry patient rate, defined as the pad test ≤ 20 mL/day, and complication rate, including device removal. The secondary variable was self-perceived satisfaction using the Patient Global Impression of Improvement (PGI-I) scale. Wilcoxon rank sum test, Fisher’s exact test and logistic regression were performed. (3) Results: One hundred and forty-nine consecutive patients were included, twenty-one (14%) previously treated for urethral or bladder neck stricture (seven urethroplasty, nine internal urethrotomy and five bladder neck incision). After ATOMS adjustment, 38% of the patients with treated stricture were continent compared to 83% of those without (p < 0.0001). After weighted matched observations using propensity score pairing, the proportion of continent patients without a previous stricture was 56% (p = 0.236). Complications occurred in 29% of the patients with stricture and in 20% of those without (p = 0.34). The severity of the complications was distributed evenly among the groups (p = 0.42). Regarding self-perceived satisfaction with the implant, 90% of the patients with stricture perceived the results satisfactorily (PGI-I 1–3) compared to 97% of the rest (p = 0.167). Stricture was associated with radiotherapy (p < 0.0001) and time from prostatectomy to implantation (p = 0.012). There was a moderate correlation between previous stricture and the severity of incontinence, both evaluated according to the 24-h pad test (Rho = 0.378; p < 0.0001) and the ICIQ-SF questionnaire (Rho = 0.351; p < 0.0001). Multivariate analysis for the factors predictive of failure after ATOMS adjustment revealed previous stricture (OR 4.66; 95% CI 1.2–18.87), baseline 24-h pad test (per 100 mL, OR 1.28; 95% CI 1.09–1.52) and final cushion volume (per mL, OR 1.34; 95% CI 1.19–1.55). This model predicted dryness with an AUC of 92%. After the PSMATCH procedure using a propensity score, the model remained unchanged, with the previous stricture (OR 8.05; 95% CI 1.08–110.83), baseline 24-h pad test (per 100 mL, OR 1.53; 95% CI 1.15–2.26) and final cushion volume (per mL, OR 1.45; 95% CI 1.17–2) being independent predictors and an AUC of 93%. (4) Conclusions: ATOMS can be used to treat male stress incontinence in patients with a history of stricture, although the effectiveness of the device is reduced. On the other hand, the security and perceived satisfaction were equivalent for both groups.

Transurethral Incisions for Bladder Neck Contracture: Comparable Results without Intralesional Injections.

To present our 12-year experience using an endoscopic approach to manage bladder neck contracture (BNC) without adjunctive intralesional agents and compare it to published series not incorporating them, we retrospectively reviewed 123 patients treated for BNC from 2008 to 2020. All underwent 24 Fr balloon dilation followed by transurethral incision of BNC (TUIBNC) with deep incisions at 3 and 9 o’clock using a Collins knife without the use of intralesional injections. Success was defined as a patent bladder neck and 16 Fr cystoscope passage into the bladder two months later. Most with recurrent BNC underwent repeat TUIBNC. Success rates, demographics, and BNC characteristics were analyzed. The etiology of BNC in our cohort was most commonly radical prostatectomy with or without radiation (36/123, 29.3%, 40/123, 32.5%). Some had BNC treatment prior to referral (30/123, 24.4%). At 12-month follow-up, bladder neck patency was observed in 101/123 (82.1%) after one TUIBNC. An additional 15 patients (116/123, 94.3%) had success after two TUIBNCs. On univariate and multivariate analyses, ≥2 endoscopic treatments was the only factor associated with failure. TUIBNC via balloon dilation and deep bilateral incisions without the use of adjunctive intralesional injections has a high patency rate. History of two or more prior endoscopic procedures is associated with failure.

TREATMENT OUTCOMES OF BLADDER NECK CONTRACTURE AFTER TRANSURETHRAL PROSTATE SURGERY

(Introduction) A known complication of the surgical treatment of benign prostatic hyperplasia (BPH) is bladder neck contracture (BNC). BNC is often treated using transurethral incision of the bladder neck (TUI-BN); however, there are few reports on the outcomes of TUI-BN. Therefore, we examined the outcomes of patients who underwent TUI-BN after transurethral prostate surgery. (Material and methods) We retrospectively examined 25 patients who underwent TUI-BN between February 2015 and January 2021 for the following: (1) patients' characteristics; (2) the time from transurethral prostate surgery to TUI-BN; (3) the trigger of BNC diagnosis; (4) surgical procedure of BNC repair/perioperative course; (5) micturition function immediately after TUI-BN; and (6) Postoperative outcomes. (Results) The median age of the patients was 77 years, and the surgical procedures for BPH were transurethral resection of the prostate (TURP) in four cases, transurethral resection in saline plasma vaporization of the prostate (TURisP) in nine cases, and transurethral enucleation with bipolar (TUEB) in 12 cases. The median time to onset of BNC symptoms was 364 days, and 18 patients (72%) were diagnosed within 2 years. The trigger of BNC diagnosis was urinary symptoms in 21 cases, of which 16 patients had exacerbation of urination. The median duration of the surgical procedure of BNC repair was 14 min, and the incisions most frequently used (in 44% of cases) were at the 4 o'clock and 8 o'clock positions. Transient stress urinary incontinence was observed as a complication in three cases. In the 4 o'clock and 8 o'clock incisions, the maximum urine flow rate improved significantly (11.1 mL/s perioperatively vs. 20.9 mL/s postoperatively; P=0.004). These symptoms improved in 16 of the 21 symptomatic cases, and the maximum urine flow rate improved significantly (P< 0.01). The median observation period after surgery was 170 days; eight postoperative patients were lost to follow up. There were two cases of recurrence. (Conclusions) BNC is likely to develop within 2 years after transurethral prostate surgery. In this study, the success rate of the initial TUI-BN was 92%, as reoperation was required in two cases; however, the overall prognosis was good.

Is High Drain Volume after Retropubic Radical Prostatectomy an Indicator of Bladder Neck Contracture Development

Is High Drain Volume after Retropubic Radical Prostatectomy an Indicator of Bladder Neck Contracture Development

Extraperitoneal Laparoscopic Modified Y-V Plasty for the Treatment of Refractory Bladder Neck Contracture.

Bladder neck contracture (BNC) is a rare, late complication of transurethral resection of the prostate (TURP). Although the endoscopic procedure is the primary treatment for BNC, the recurrence rate remains high. Y-V plasty offers excellent surgical results for those individuals with refractory and recurrent BNC. Traditional open operations usually fail to provide satisfactory exposure to the operating field and lead to greater invasiveness. Interrupted sutures lead to prolonged operative time and increased anastomotic leakage. Laparoscopic modified Y-V plasty is performed through extraperitoneal access to the pelvis, which provides adequate exposure to the surgical view and avoids intra-abdominal injury. After incising the anterior bladder wall neck in a Y-shaped fashion, anastomosis is performed using two absorbable barbed sutures. The mucosa and submucosa layer of the bladder is closed to both sides with consecutive sutures in a V-shape before suturing serosa, and tunica muscularis are sutured to reinforce. The aforementioned procedures reduce leakage from the anastomosis and decrease operative time and patient trauma. Extraperitoneal laparoscopic modified Y-V plasty offers significant advantages over the open approach in terms of post-surgical recovery and invasiveness, making it a feasible and safe surgical option for patients with refractory BNC.

Effects of expanded frontal-parietal pedicled flap in reconstructing cervical scar contracture deformity in children after burns

Objective: To explore the effects of expanded frontal-parietal pedicled flap in reconstructing cervical scar contracture deformity in children after burns. Methods: A retrospective observational study was conducted. From January 2015 to December 2020, 18 male children with cervical scar contracture deformity after burns who met the inclusion criteria were admitted to Zhengzhou First People's Hospital, aged 4 to 12 years, including 10 cases with degree Ⅱ cervical scar contracture deformity and 8 cases with degree Ⅲ scar contracture deformity, and were all reconstructed with expanded frontal-parietal pedicled flap. The surgery was performed in 3 stages. In the first stage, a cylindrical skin and soft tissue expander (hereinafter referred to as expander) with rated capacity of 300 to 500 mL was placed in the frontal-parietal region. The expansion time was 4 to 6 months with the total normal saline injection volume being 2.1 to 3.0 times of the rated capacity of expander. In the second stage, expander removal, scar excision, contracture release, and flap transfer were performed, with the flap areas of 18 cm×9 cm to 23 cm×13 cm and the secondary wound areas of 16 cm×8 cm to 21 cm×11 cm after scar excision and contracture release. After 3 to 4 weeks, in the third stage, the flap pedicle was cut off and restored. The rated volume of placed expander, total normal saline injection volume, type of vascular pedicle of flap, survival of flap and reconstruction of scar after the second stage surgery were recorded. The neck range of motion and cervico-mental angle were measured before surgery and one-year after surgery. The appearance of neck, occurrence of common complications in the donor and recipient sites of children, and satisfaction of children's families for treatment effects were followed up. Data were statistically analyzed with paired sample t test. Results: All the patients successfully completed the three stages of operation. The rated volume of implanted expander was 300 mL in 6 children, 400 mL in 9 children, and 500 mL in 3 children, with the volume of normal saline injection being 630 to 1 500 mL. The type of vascular pedicle of flap was double pedicle in 13 cases and was single pedicle in 5 cases. All the flaps in 17 children survived well, and the secondary wounds after neck scar excision and contracture release were all reconstructed in one procedure. In one case, the distal blood supply of the single pedicled flap was poor after the second stage surgery, with necrosis of about 2.5 cm in length. The distal necrotic tissue was removed on 10 days after the operation, and the wound was completely closed after the flap was repositioned. In the follow-up of 6 months to 3 years post operation, the cervical scar contracture deformity in 18 children was corrected without recurrence. The flap was not bloated, the texture was soft, and the appearances of chin and neck were good. The range of motion of cervical pre-buckling, extension, left flexion, and right flexion, and cervico-mental angle in one year after operation were improved compared with those before operation (with t values of 43.10, 22.64, 27.96, 20.59, and 88.42, respectively, P<0.01). The incision in the frontal donor site was located in the hairline, the scar was slight and concealed. No complication such as cranial depression was observed in expander placement site, and the children's families were satisfied with the result of reconstruction. Conclusions: Application of expanded frontal-parietal pedicled flap in reconstructing the cervical scar contracture deformity in children after burns can obviously improve the appearance and function of neck, with unlikely recurrence of postoperative scar contractures, thus it is an ideal method of reconstruction.

Morbidity of salvage radical prostatectomy: limited impact of the minimally invasive approach.

We aimed to report the morbidity profile of salvage radical prostatectomy (SRP) after radiotherapy failure and assess the impact of minimally invasive surgery (MIS) on postoperative complications and functional outcomes. Between 1985 and 2019, a total of 293 patients underwent SRP; 232 underwent open SRP; and 61 underwent laparoscopic SRP with or without robotic assistance. Complications were recorded and classified into standardized categories per the Clavien-Dindo classification. Twenty-nine patients (10%) experienced grade 3 complications within 30days, 22 (9.5%) after open and 7 (11%) after MIS (p = 0.6). Between 30 and 90days after surgery, 7.3% of patients in the open group and 10% in the MIS group had grade 3 complications (p = 0.5). The most common complication was bladder neck contracture (BNC), representing 40% of the 30-90day complications. Within one year of SRP, 81 patients (31%, 95% CI 25%, 37%) developed BNC; we saw non-significant lower rates in MIS (25 vs 32%; p = 0.4). Functional outcomes were poor after SRP and showed no difference between open and MIS groups for urinary continence (16 vs 18%, p = 0.7) and erectile function (7 vs 13%, p = 0.4). 5year cancer-specific survival and overall survival was 95% and 88% for the entire cohort, respectively. Our outcomes suggest poor functional recovery after SRP, regardless of the operative approach. Currently there is no evidence favoring the use of open or MIS approach. Further studies are required to ensure comparable outcomes between these approaches.

Transurethral Incision of the Bladder Neck at Three Points with a Needle-Type Electrode for Bladder Neck Contracture.

PurposeThis study aims to evaluate the efficacy of transurethral incision of the bladder neck (TUIBN) at three points with a needle-type electrode for treatment of bladder neck contracture (BNC).Materials and MethodsBetween January 2016 and April 2021, the bladder necks of 53 patients with BNC after surgery were incised by the needle-type electrode at the 5, 7, and 12 O’clock positions. Patient’s preoperational characteristics, peri- and postsurgical outcomes, such as time of operation, postoperative bladder irrigation, and postoperative hospital stay, and data of the international prostate symptom score (IPSS), maximum flow rate (Qmax), and postvoid residual (PVR) were recorded 3 and 6 months after surgery.ResultsAll 53 cases of BNC were successfully treated in 35.00 (25.00, 45.00) min with 18.00 (14.00, 21.00) h for postoperative bladder irrigation with little intraoperative bleeding (less than 50 mL). The postoperative hospital stay ranged from 2 to 8 days, a mean of 3.50 (3.00, 5.00) days. No major intraoperative or postoperative complications were observed. All cases that underwent follow-up assessment at 3 and 6 months after the surgery showed significantly decreased IPSS and PVR and increased Qmax compared to preoperation ones (p ≤ 0.001). Of these 53 patients, there was no recurrence in severe BNC patients, but 5 of 53 (9.4%) BNC patients developed BNC again within 6 months and required repeated TUIBN. Thirty patients comprised five recurrent cases with a follow-up period of more than 1 year.ConclusionsTUIBN at three points provides a safe, effective, and reliable option in treating patients with BNC.

Risk factors for the postoperative bladder neck contracture in patients with small-volume prostatic hyperplasia

This study was to explore the risk factors for postoperative bladder neck contracture (BNC) after transurethral operation of prostate in patients with small-volume prostatic obstruction. Clinicopathologic data at our center from February 2016 to January 2020 were retrospectively collected and analyzed. Clinicopathological characteristics between patients with and without BNC were compared. Multivariate logistic regression was used to determine the risk factors for postoperative BNC. There were a total of 39 patients (8.53%) with postoperative BNC. Multivariate logistic regression analysis demonstrated that preoperative bladder neck diameter (BND), intravesical prostatic protrusion (IPP), surgical methods (transurethral resection of prostate (TURP)/anatomical endoscopic enucleation of the prostate (AEEP)), and postoperative urinary tract infection (UTI) were independent risk factors for postoperative BNC in patients with small-volume prostatic obstruction (P<0.05). The incidence of postoperative BNC in patients undergoing AEEP was significantly decreased compared with those undergoing TURP. The optimal cut-off value of preoperative IPP was 6.10mm while the optimal cut-off value of preoperative BND was 2.52cm. Larger preoperative bladder neck and higher preoperative IPP lead to decreased incidence of postoperative BNC in patients with small-volume prostatic obstruction. Active management of postoperative UTI could effectively prevent the occurrence of postoperative BNC. Compared with TURP, complete AEEP would contribute to reduce BNC in patients with small-volume prostatic obstruction.

180-W GreenLight laser photoselective vaporization with multiple triamcinolone acetonide injections for the treatment of bladder neck contractures.

Bladder neck contracture (BNC), one of the most challenging complications after transurethral resection of the prostate (TURP) and photoselective vaporization of the prostate (PVP), lacks effective treatment. In the present study, our experience in treating BNC using GreenLight laser vaporization with triamcinolone acetonide (TA) injections was shared. This is a retrospective cohort study that included 46 patients with BNC after TURP and PVP in our center. GreenLight laser surgeries (180W) were carried out and TA was administrated simultaneously. TA injections were repeated every week for three times after surgeries. The perioperative and postoperative parameters were reviewed and compared. Bladder neck tissues were examined by immunohistochemical staining to explore the expressions of collagen I, matrix metalloproteinase-3 (MMP-3), and transforming growth factor-β (TGF-β) after treatments. The chief complaint symptoms of all patients were significantly relieved after our treatments. None of them showed BNC recurrence during the follow-up. Complications were rare and mild. Postoperative assessments including maximal urinary flow rate (P < 0.01), International Prostate Symptom Score (P < 0.01), quality of life index (P < 0.01), and post-void residual volume (P < 0.001) were significantly better than baseline values, respectively. Immunohistochemical staining showed significantly lower expressions of collagen I (P < 0.001), MMP-3 (P < 0.001), and TGF-β (P < 0.001) after treatments. In conclusion, 180-W GreenLight laser with repeated TA injections demonstrated the safety and long-term efficacy in treating BNC, by inhibiting the expressions of fibrotic factors. Our procedure was a promising treatment for BNC after PVP and TURP.

Assessing the Complications of Monopolar Transurethral Resection of the Prostate (M-TURP) Using Clavien-Dindo Complications Grading System

Benign prostatic hyperplasia (BPH) is one of the most common diseases of ageing men, which increase starting from age 40. Monopolar transurethral resection of the prostate (M-TURP) is the gold standard surgical treatment for BPH between 30 to 80cc. This study is designed to assess complications of TURP based on the Clavien-Dindo post-op complication grading system. A descriptive prospective study of prevalence of complications of M-TURP from May1, 2019 to April 30, 2021 in Tikur Anbessa Specialized Hospital. In this study, 174 patients were assessed pre-operatively, intra-operatively and post-operatively. All BPH patients with bothersome LUTS, bladder stone, recurrent UTI, recurrent acute urinary retention (AUR), renal insufficiency, or failed medical therapy had undergone TURP. We collected it by revising patient's icare/charts and cell phone call. About 174 patients were studied with mean age were 63 years. Intra op complications were noticed in seventeen (9.8%) patients, the most common one was prostate capsule perforation seen in 9 (5.2%) cases followed by severe bleeding in 3(1.7%) patients which needs transfusion and urethral injury. Urinary tract infections developed in eleven (7.8%) of patients. Bulbar urethral stricture and bladder neck contracture developed in 9 (5.2%) and 3 (1.7%) patients each, respectively. Re TURP was done for 7 (4%) of patients. In this study, the overall complication rate of TURP with Clavien-Dindo grading system was 29.3%. Around 96% of the complications were Clavien-Dindo grade I, II and III; managed conservatively or with minimally invasive surgery. This shows M-TURP is a relatively safe procedure.

MP57-07 IMPACT OF THE MINIMALLY INVASIVE APPROACH ON MORBIDITY OF SALVAGE RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 May 2022MP57-07 IMPACT OF THE MINIMALLY INVASIVE APPROACH ON MORBIDITY OF SALVAGE RADICAL PROSTATECTOMY Marlon Perera, Antoni Vilaseca, Amy Tin, Daniel Nguyen, Renato Carradi, Adam Touijer, Nicole Benfante, Daniel Sjoberg, Vincent Laudone, Peter Scardino, James Eastham, and Karim Touijer Marlon PereraMarlon Perera More articles by this author , Antoni VilasecaAntoni Vilaseca More articles by this author , Amy TinAmy Tin More articles by this author , Daniel NguyenDaniel Nguyen More articles by this author , Renato CarradiRenato Carradi More articles by this author , Adam TouijerAdam Touijer More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Daniel SjobergDaniel Sjoberg More articles by this author , Vincent LaudoneVincent Laudone More articles by this author , Peter ScardinoPeter Scardino More articles by this author , James EasthamJames Eastham More articles by this author , and Karim TouijerKarim Touijer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002640.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We aimed to report the morbidity profile of salvage radical prostatectomy (SRP) and assess the impact of minimally invasive surgery (MIS) on postoperative complications and functional outcomes. METHODS: A total of 293 patients underwent SRP; 232 underwent open SRP and 61 underwent laparoscopic SRP with or without robotic assistance. Complications were recorded and classified into standardized categories. Cancer-specific survival (CSS) and overall survival (OS) were estimated with the Kaplan-Meier method. RESULTS: Twenty-nine patients (10%) experienced grade 3 complications within 30 days, 22 (9.5%) after open and 7 (11%) after MIS (difference=-2%; 95% C.I. -11%, 7%; p=0.6). Between 30 to 90 days after surgery, 7.3% of patients in the open group and 10% in the MIS group had grade 3 complications (difference=-2.5%; 95% C.I. -11%, 6%; p=0.5). The most common complication was bladder neck contracture (BNC), representing 40% of the 30–90 day complications. Within one year of SRP, 81 patients (31%, 95% C.I. 25%, 37%) developed BNC; we saw non-significant lower rates in MIS (25% vs 32%; p=0.4). Five year CSS and OS was 95% and 88% for the entire cohort, respectively. CONCLUSIONS: Our outcomes suggest poor functional recovery after SRP, regardless of the operative approach. Currently there is no evidence favoring the use of open or MIS approach. Further studies are required to ensure comparable outcomes between these approaches. Source of Funding: This work was supported by the Sidney Kimmel Center for Prostate and Urologic Cancers at MSK, the NIH/NCI grant P50 CA092629, and the NIH/NCI Cancer Center Support Grant to Memorial Sloan Kettering Cancer Center (P30 CA008748). Marlon Perera is sponsored by the Australian-America Fulbright Commission administered through a 2021-2022 Fulbright Future Scholarship funded by The Kinghorn Foundation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e983 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marlon Perera More articles by this author Antoni Vilaseca More articles by this author Amy Tin More articles by this author Daniel Nguyen More articles by this author Renato Carradi More articles by this author Adam Touijer More articles by this author Nicole Benfante More articles by this author Daniel Sjoberg More articles by this author Vincent Laudone More articles by this author Peter Scardino More articles by this author James Eastham More articles by this author Karim Touijer More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP57-18 RATE OF BLADDER NECK CONTRACTURE AFTER OPEN AND MINIMALLY INVASIVE RADICAL PROSTATECTOMY OVER 18 YEARS AT THE VETERANS HEALTH ADMINISTRATION

You have accessJournal of UrologyCME1 May 2022MP57-18 RATE OF BLADDER NECK CONTRACTURE AFTER OPEN AND MINIMALLY INVASIVE RADICAL PROSTATECTOMY OVER 18 YEARS AT THE VETERANS HEALTH ADMINISTRATION Mitch Hayes, Michael Conlin, Helen Hougen, and Ryan Kopp Mitch HayesMitch Hayes More articles by this author , Michael ConlinMichael Conlin More articles by this author , Helen HougenHelen Hougen More articles by this author , and Ryan KoppRyan Kopp More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002640.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The rate of vesicourethral anastomotic stricture (VUAS) rate is higher amongst patients who undergo open radical prostatectomy (RP) compared to robotic RP at high-volume academic centers. We sought to compare the VUAS rate between minimally invasive (MIS) and open RP cohorts amongst United States veterans. METHODS: We queried the Veterans Affairs (VA) Corporate Data Warehouse for patients who underwent retropubic RP between 2003 and 2021 by CPT code (55840, 55845, 55866) were included. Patients who did not have a biopsy at the VA. Possible selected covariates were age, preoperative prostate specific antigen (PSA), agent orange exposure, body mass index (BMI), selected comorbidities based on ICD codes, and MIS surgery defined by the CPT code 55866. The primary outcome was undergoing a transurethral incision of a postoperative bladder neck contracture (TUIBNC) within 2 years of surgery by CPT code (52640). The secondary outcome was undergoing any incontinence procedure within 2 years of RP by male sling and artificial urinary sphincter CPT codes. Multivariate logistic regression was performed on the primary and secondary outcome. Stepwise selection was used for model building and restricted cubic spline terms were used for continuous variables. All statistics were performed in R, version 4.0.5. RESULTS: 32,776 patients were included in the analysis. Median patient age was 62 years old and median PSA was 6.04. 57.8% underwent open RP, and 42.3% underwent MIS RP. Overall TUIBNC and incontinence procedure cases within 2 years of surgery were 292 (0.9%) and 725 (2.2%), respectively. Median time to TUIBNC was 8.0 months. On multivariate analysis, after adjusting for age, PSA, and a history of congestive heart failure (CHF), the risk of TUIBNC remained higher with open surgery (OR 7.1, CI 4.7-11.4 p <0.001). Figure 1 shows the rate of MIS RP, open RP, and TUIBNC over time. On multivariate analysis, after adjusting for age, BMI, a history of myocardial infarction, CHF, and diabetes, incontinence surgery within 2 years of surgery was higher after open RP (OR 1.29, CI 1.08-1.53, p 0.004). CONCLUSIONS: Compared to MIS RP, open RP was associated with a 7-fold increase in rate of VUAS and a 1.3-fold increase in the rate of incontinence requiring a procedure within 2 years of surgery at the VA. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e989 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mitch Hayes More articles by this author Michael Conlin More articles by this author Helen Hougen More articles by this author Ryan Kopp More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP52-09 SAFETY OF TRANSURETHRAL ENDOSCOPIC TREATMENT IN MEN WITH AN ARTIFICIAL URINARY SPHINCTER: A 15 YEAR ANALYSIS

You have accessJournal of UrologyCME1 May 2022MP52-09 SAFETY OF TRANSURETHRAL ENDOSCOPIC TREATMENT IN MEN WITH AN ARTIFICIAL URINARY SPHINCTER: A 15 YEAR ANALYSIS Corey Weinstein, and Jaspreet Sandhu Corey WeinsteinCorey Weinstein More articles by this author , and Jaspreet SandhuJaspreet Sandhu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002627.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Incontinence after prostate treatment (IPT) is an uncommon but highly bothersome complaint for patients. Placement of an artificial urinary sphincter (AUS) is the gold standard treatment for IPT. Transurethral endoscopic treatment (TET) after AUS is typically avoided due to the presumed increased risk of AUS cuff erosion after passage of a cystoscope after AUS placement. We set out to determine the rate of erosion in patients undergoing TET after placement of an artificial urinary sphincter (AUS). METHODS: Patients with AUS devices implanted by two surgeons between January 1, 2006 and January 1, 2021 were examined. Patients undergoing a transurethral procedure were included; those that underwent TET for a work-up of a non-functioning AUS were excluded from analysis. Follow up was calculated by last assessment in the outpatient setting. RESULTS: 124 patients were identified that met inclusion criteria, 71 of which were in patients with a history of radiation therapy (RT). 179 AUS were implanted during the study period. Median follow up was 62.4 months. Mean number of TET was 2.5. Procedures included incision of bladder neck contracture, transurethral resection of bladder tumor, cystolitholapaxy, ureteroscopy, and surveillance cystoscopy. There were 10 device erosions (8%) during the follow up at an average of 26.5 months post AUS placement, 9 of which occurred in patients with a history of RT. CONCLUSIONS: TET is safe in patients post-AUS particularly in radiation naïve patients, and the rate of erosion in patients undergoing TET is similar to reported rates of erosion in all AUS patients within the literature. Further research with multi-institutional collaboration is necessary to better understand the risks of erosion in patients with an AUS device undergoing TET. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e889 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Corey Weinstein More articles by this author Jaspreet Sandhu More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP52-11 BLADDER NECK CONTRACTURES STABILIZE AFTER ARTIFICIAL URINARY SPHINCTER PLACEMENT

You have accessJournal of UrologyCME1 May 2022MP52-11 BLADDER NECK CONTRACTURES STABILIZE AFTER ARTIFICIAL URINARY SPHINCTER PLACEMENT Kevin Krughoff, Hayley Premo, and Andrew C. Peterson Kevin KrughoffKevin Krughoff More articles by this author , Hayley PremoHayley Premo More articles by this author , and Andrew C. PetersonAndrew C. Peterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002627.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The optimal treatment for the combination of stress urinary incontinence (SUI) and bladder neck contracture (BNC) is often vexing to the reconstructive urologist. Anecdotal clinical experience from our group indicates that many BNCs stabilize after AUS placement. We hypothesize that AUS placement may decrease BNC recurrence. METHODS: Men with BNC and voiding LUTS or AUR are treated at our institution with dilation, DVIU or TUR. Men with SUI electing AUS placement undergo simultaneous BNC treatment if symptomatic or if the bladder neck is ≤ 12 French and precludes catheter insertion. We queried our prospectively maintained QI database for all patients seen at our institution from 2001-2021 with a history of SUI and intervention for BNC. A total of 174 records were reviewed. Those with a urethral stent (n=6) or less than 2 months follow up (n=9) were excluded. The odds of recurrence and time between recurrences were compared between those with and without an AUS in place using logistic regression and the Wilcoxon Rank-Sum test. Recurrence rates and recurrence free survival were compared using multivariate Cox regression. RESULTS: The analytic cohort of 159 was comprised of 60 patients who underwent AUS placement and 99 who did not. Baseline characteristics were similar except for a 15% higher prevalence of pelvic radiation in the AUS group (p=0.06). A total of 278 BNC interventions were carried out in the non-AUS group (median 2 per patient) and 83 in the AUS group (median 2 per patient). After any given BNC intervention, the odds of recurrence were 75% lower (OR 0.25, CI: 0.15-0.42, p<0.01) when an AUS was placed. On sub-analysis according to number of prior interventions, AUS placement was associated with a 90% lower odds of recurrence (OR 0.10, CI: 0.03-0.27, p<0.01) and 2.6 years (p=0.02) longer time to recurrence after one intervention. After two interventions, the odds were 61% less (OR 0.39, CI: 0.16-0.97, p=0.04) and time to recurrence was 1.3 years longer (p=0.01). Recurrence rates were 70% and 75% lower at these same time points when adjusting for prior radiation, prostatectomy, receipt of CIC teaching, smoking, age, diabetes and coronary artery disease (Figure 1). CONCLUSIONS: Our data indicate that placement of the AUS seems to be associated with improved bladder neck stability. Source of Funding: Boston Scientific Fellowship Grant © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e891 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Krughoff More articles by this author Hayley Premo More articles by this author Andrew C. Peterson More articles by this author Expand All Advertisement PDF DownloadLoading ...

Pleasurable ways to spontaneously expulse distal ureteral stones: A systematic review and meta-analysis of randomized controlled trials

ABSTRACT Introduction Numerous non-invasive ways of managing distal ureteral stones have been recommended, such as administering treatments to inhibit receptors responsible for ureteral tone and peristaltic movement frequency. Nitric oxide, which is released during penile erection, causes smooth muscle relaxation by inhibiting the non-adrenergic non-cholinergic (NANC) nerves of the distal ureter and ureterovesical junction. Bladder neck contraction followed by relaxation, occurring during orgasm and ejaculation could also facilitate the passage of stones. However, the exact role of sexual activities involving these mechanisms has yet to be established. Objective This review aimed to evaluate the efficacy of sexual acts, including sexual intercourse and masturbation, to promote distal ureteral stones expulsion based on the findings of relevant randomized controlled trials (RCT)s. Methods A systematic search adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed in the Embase, Scopus, and Medline databases in July 2021. The initial search generated 50 articles. The articles were screened based on the eligibility criteria. Their quality was assessed using the Cochrane Risk of Bias (RoB) tool 2 for randomized trials. Measured outcomes included stone expulsion rate, expulsion time, analgesic injections frequency, and the need for a ureteroscopic (URS) lithotripsy. A fixed effects model was used for analyzing parameters with homogeneity among studies, whereas a random effects model was used for heterogenous studies. The odds ratio (OR) and mean difference (MD) among studies were displayed in forest plots using the Review Manager software version 5.4.1. Results A total of five RCTs with an overall low risk of bias, consisting of 406 subjects, were included in this review. Four studies evaluated sexual intercourse and one study evaluated masturbation. Both interventions were instructed to be performed for three to four times a week. The stone expulsion rate was higher in the sexual activity group compared to the control group at the two-week follow-up (OR 5.77 95%CI 3.70 - 9.01, p&amp;lt;0.00001) and four-week follow-up (OR 4.44 95%CI 2.73 - 7.23, p&amp;lt;0.00001) with a significantly lower expulsion time of the sexual activity group (MD -3.79 95% CI -6.38 - -1.20, p=0.004). The number of subjects requiring additional analgesic injections (MD -0.62 95% CI -1.03 - -0.21, p=0.003) and URS lithotripsy (OR 0.22 95% CI 0.13 – 0.37, p&amp;lt;0.00001) was also lower in the sexual activity group compared to the control group. Conclusions Performing sexual intercourse or masturbation for three to four times a week is beneficial for promoting spontaneous expulsion of distal ureteral stones. It could also reduce the use of analgesic injections and the need for a URS lithotripsy.

Persistent storage symptoms following Y-V plasty reconstruction for the treatment of refractory bladder neck contracture.

Refractory bladder neck contracture (BNC) following transurethral prostatectomy is rare and difficult to manage. Success rate of endoscopic treatment decline considerably after repeated treatments. Bladder neck reconstruction are often the last resort to treat refractory BNC failing endoscopic treatments. In general, experience is limited with this type of bladder neck reconstruction, particularly in adult patients. This study aims to determine the success rate, functional and patient-reported outcomes (PRO) of open Y-V plasty in treatment of refractory BNC after transurethral prostatectomy. The study also aims to determine the rate, and potential predictors of persistent storage symptoms after Y-V plasty. Between January 2016 and February 2021, 18 consecutive patients with refractory BNC who underwent open Y-V plasty were included in this study. All patients presented with voiding dysfunction after two or more failed attempts of endoscopic treatments followed by a 3-month period of outpatient serial dilation program. Clinicopathological data were extracted from medical records including baseline demographics, aetiology of BNC, previous endoscopic treatment, operative time, length of stay, complications, uroflow findings, International Prostate Symptom Score (IPSS) and OAB-V8. Primary outcome was the success of open YV plasty, defined as no need for further instrumentation such as indwelling catheterization, urethral dilatation, urethrotomy, or open surgery. Simple linear regression analysis was performed to determine predictor factors for postoperative OAB-V8. Variables that showed p < 0.25 were included in the multiple linear regression analysis. Most common aetiology of BNC was transurethral resection of prostate gland (n = 18, 100%). Mean age at surgery age (SD) was 65.5 (7.3) years. Mean follow-up was 14.8 (7) months. Success rate was 100%. Postoperative Qmax improved significantly [pre-OP 6.7 (8.1) ml/s vs.post-OP was 14.8 (7.3) ml/s, p < 0.001]. Mean postvoid residual decreased significantly [pre-OP 223.3 (254.3) ml vs.post-OP 45.1 (71.0) ml, p < 0.01)]. Persistent storage symptoms were reported in 61% of patients. BMI and baseline IPSS score are significant predictors for the postoperative OAB V8 change (adjusted b (95% confidence interval) = 1.037 (0.2-1.9), 0.64 (0.28-0.99), respectively, R2 = 0.59). Y-V plasty reconstruction for refractory BNC represents a feasible and successful option with high success rate and favorable outcomes. While functional and patient-reported outcomes had significantly improved post-operatively, persistent storage symptoms after this procedure still exist. BMI and baseline IPSS score are significant predictors for persistent storage symptoms after bladder neck reconstruction.

Surgical Complications in the Management of Benign Prostatic Hyperplasia Treatment.

There are a variety of treatment options for men with symptomatic benign prostatic hyperplasia (BPH); transurethral resection of the prostate (TURP) remains the gold standard surgical treatment. The field continues to evolve with the introduction of new energy and laser technologies, increasing adoption of enucleation techniques, in addition to the advent of minimally invasive surgical technologies (MIST) that enable office-based treatments. The choice in surgical management has become very nuanced depending on a variety of patient and anatomic factors. There continues to be high success rates for surgical treatment of BPH; however, the risk profiles vary across the various surgical treatments. We sought to evaluate contemporary series and summarize the experience of complications associated with BPH treatment and management of these complications. A comprehensive literature review was performed, and identified 79 manuscripts, published between 2005 and 2021 characterizing the diagnosis and management of complications following BPH surgery. Commonly cited issues included bleeding, ureteral orifice injury, bladder neck injury, rectal injury, TURP syndrome, bladder neck contractures, urethral stricture disease, refractory OAB symptoms, and complications unique to new modalities of treatment. The practicing urologist has multiple surgical options to choose from in treating patients with symptomatic BPH. The surgical management of BPH is generally well tolerated with high objective success rates that allow for significant improvement in urinary quality of life. It is critical to understand the potential complications associated with these various treatment options, which will enable trainees and practicing urologists to better counsel patients and manage these potential complications.