Prior Endoscopic Procedures Research Articles

Repeat endoscopic endonasal transsphenoidal surgery for residual or recurrent cushing’s disease: safety, feasibility, and success

PurposeThe success and outcomes of repeat endoscopic transsphenoidal surgery (ETS) for residual or recurrent Cushing’s disease (CD) are underreported in the literature. This study aims to address this gap by assessing the safety, feasibility, and efficacy of repeat ETS in these patients.MethodsA retrospective analysis was conducted on 56 patients who underwent a total of 65 repeat ETS performed by a single neurosurgeon between January 2006 and December 2020. Data including demographic, clinical, laboratory, radiological, and operative details were collected from electronic medical records. Logistic regression was utilized to identify potential predictors associated with sustained remission.ResultsAmong the cases, 40 (61.5%) had previously undergone microscopic surgery, while 25 (38.5%) had prior endoscopic procedures. Remission was achieved in 47 (83.9%) patients after the first repeat ETS, with an additional 9 (16.1%) achieving remission after the second repeat procedure. During an average follow-up period of 97.25 months, the recurrence rate post repeat surgery was 6.38%. Sustained remission was achieved in 48 patients (85.7%), with 44 after the first repeat ETS and 4 following the second repeat ETS. Complications included transient diabetes insipidus (DI) in 5 (7.6%) patients, permanent (DI) in 2 (3%) patients, and one case (1.5%) of panhypopituitarism. Three patients (4.6%) experienced rhinorrhea necessitating reoperation. A serum cortisol level > 5 µg/dL on postoperative day 1 was associated with a reduced likelihood of sustained remission.ConclusionRepeat ETS is a safe and effective treatment option for residual or recurrent CD with satisfactory remission rates and low rates of complications.

Lipoaspirate Injection in Relapsing Idiopathic Subglottic Stenosis: Preliminary Results.

The management of idiopathic subglottic stenosis (iSGS) poses a clinical challenge due to high recurrence rates following both endoscopic and open approaches, often leading to tracheostomy. The activation of abnormal T-cells and cytokine pathways has been linked to iSGS pathogenesis. Autologous adipose tissue centrifugation yields lipoaspirate, offering optimal anti-inflammatory effects and biocompatibility widely utilized in various medical settings. This report presents the first 3 cases employing endoscopic dilation (ED) in combination with local lipoaspirate injection to address recurrent iSGS. A prospective observational study was conducted, involving multidisciplinary evaluation by the Tracheal Team at the University of Modena. Patients meeting specific criteria were directed to undergo ED + lipoaspirate injection. Three patients fulfilled the inclusion criteria. The mean number of prior endoscopic procedures performed was 8. Endoscopic examination revealed 90% stenosis in patient A, 60% stenosis in patient B, and 60% stenosis in patient C. All patients presented inflammatory tissue or incipient granulations at the stenotic site, with an average time of 6 months between previous procedures. After 15 months, none of the patients required further procedures, and endoscopic examination revealed a significant reduction or disappearance of inflammatory tissue with a stable airway lumen. The observed results are encouraging in terms of reducing local inflammation and halting stenosis progression, especially in cases of short-term relapsing iSGS.

FREE AIR FROM WHERE? SPONTANEOUS PNEUMOMEDIASTINUM AND SUBCUTANEOUS EMPHYSEMA IN A PATIENT WITH ULCERATIVE COLITIS IN THE ABSENCE OF COLONIC OR ESOPHAGEAL PERFORATION

Abstract INTRODUCTION The development of Spontaneous Pneumomediastinum and Subcutaneous Emphysema in patients with Inflammatory Bowel Disease (IBD) has often been associated with perforation related to toxic megacolon or prior endoscopic procedures. We describe a case of Ulcerative Colitis complicated by Clostridium difficile (C diff) colitis in which Spontaneous Pneumomediastinum and Subcutaneous Emphysema developed without any evidence of perforation. CASE REPORT A 20-year-old male with a past medical history of recently diagnosed Ulcerative Colitis presented for evaluation of rectal pain, dysphagia, hematochezia, fecal incontinence, and urinary hesitancy. He endorsed dysphagia with the inability to tolerate solids or liquids for 4 days. He was diagnosed with Ulcerative Colitis 5 months prior to presentation and had unintentionally lost 90 lbs over the past 2 months. His home medication regimen included infliximab started 2 weeks prior, mesalamine PO tablets and suppositories, and a prednisone taper initiated at 10 mg TID. Laboratory tests confirmed anemia, leukocytosis, thrombocytosis, and elevated ESR and CRP levels. Chest X-ray and CT scans of the neck and chest showed moderate pneumomediastinum and subcutaneous emphysema. Given the symptoms of dysphagia along with the imaging findings of pneumomediastinum and subcutaneous emphysema, there was concern for esophageal perforation. However, an Esophagram and Upper GI series were both unremarkable. Abdominal CT revealed colitis of the descending and sigmoid colon without any evidence of free air or free fluid. Fecal Occult Blood Test and C diff antigen and toxin assays were positive. He was treated with oral vancomycin, IV fluids, IV methylprednisolone, and total parenteral nutrition (TPN). His symptoms significantly improved with a decrease in stool frequency and bloody stools. TPN was weaned and he was able to tolerate an oral diet. A repeat CT scan of the chest showed a complete resolution of the pneumomediastinum. CONCLUSION There are only a few reported cases in the literature of spontaneous pneumomediastinum and subcutaneous emphysema in patients with IBD in the absence of colonic or esophageal perforation. The spontaneous isolated presentation of air leaking from a chronically diseased hollow organ remains rare. In our patient there was no evidence of perforation, therefore the pneumomediastinum and subcutaneous emphysema likely resulted from the release of free air from colonic micro-perforations caused by the severe inflammation related to his Ulcerative Colitis flare and C. diff infection. CT Chest demonstrating pneumomediastinum and subcutaneous emphysema of the neck CT Neck demonstrating subcutaneous emphysema

(311) Socioeconomic Risk-Adjustment with Area Deprivation Index (ADI) Predicts Delays to Urethroplasty for Patients with Urethral Stricture Disease

Abstract Introduction Treatment of urethral stricture disease with multiple repeated endoscopic procedures has been shown to be both ineffective and costly. While a number of patient and provider factors are known to be associated with likelihood of undergoing multiple endoscopic, little is known about non-clinical factors that can impact care. Objective As social inequalities such as living in a disadvantaged neighborhood are known to be associated with poorer overall health, worse health outcomes, and decreased quality of care, the aim of this study was to assess whether neighborhood deprivation is associated with delays to definitive care for urethral stricture disease. Methods This study identified patients treated by a single surgeon with urethroplasty between 9/4/2019 and 12/29/2021. Patients with a previous history of urethroplasty, under the age of 18, and those with insufficient follow-up data were excluded from the study. Area deprivation index (ADI) is a composite comprised of 17 factors describing income, education, employment and housing quality based on subject 9-digit ZIP code and obtained from the University of Wisconsin School of Medicine and Public Health Neighborhood Atlas. Scores are normalized to a percentile from 0 to 100, with higher numbers representing higher levels of disadvantage. Patient addresses were geocoded and assigned a national ADI rank based on residential census block group. For the present study, ADI rank was sub-grouped into least disadvantaged (lower 50%) and most disadvantaged (upper 50%). Multivariate logistic regression was performed to assess impact of ADI score on likelihood of receiving multiple endoscopic procedures prior to urethroplasty. Final model was assessed for multicollinearity and goodness of fit via Hosmer-Lemeshow goodness-of-fit test. Results 104 patients were included in the final analysis. 44% of patients had undergone multiple prior endoscopic procedures. Patients who had undergone ≥2 endoscopic procedures tended to be older, have higher ADI scores, and were more likely to be white. Median time to urethroplasty was significantly higher in those who had undergone multiple prior endoscopic procedures (88 mos vs 12 mos, p<0.001). On multivariate analysis adjusting for age, ADI classification, and insurance status, patients in the more disadvantaged group were significantly more likely to have undergone multiple endoscopic procedures prior to urethroplasty (OR 2.79), as were older patients (OR 1.04). Conclusions Neighborhood disadvantage as assessed by the ADI provides an alternative methodology to identify disparities in health services utilization in patients with urethral stricture disease. These findings highlight needs to increase provision of urologic resources and care to disadvantaged communities. Disclosure No

Rendezvous Technique: Step by Step

Introduction: The treatment of complete ureteral stenosis varies depending on the severity and location of injury but can include ureteral stent placement and surgical repair. Long-term percutaneous nephrostomy (PN) drainage is another treatment option, but it leads to deterioration of the patient's quality of life. Therefore, as an alternative to surgery similar to ureteroureterostomy, the combined antegrade and retrograde approach, the so-called rendezvous technique, is required. Materials and Methods: A 52-year-old man with a history of prior flexible ureterorenoscopy for a 12 mm ureteral stone in the ureteropelvic junction presented with insidious onset complete ureteral stenosis. A nephrostomy tube was placed, and the patient was referred to our center. An anterograde and retrograde pyelography confirmed a diagnosis of ureteropelvic stenosis thought to be secondary to prior endoscopic procedure. A combined antegrade–retrograde rendezvous dilatation of stenosis was planned. A fiber-optic and digital ureteroscope were used through the left ureter and the nephrostomy tract, respectively, and allowed a careful visual examination of the ureteral lesion. The complete stenosis did not allow the passage of a 0.035″ Terumo guidewire. Transillumination and fluoroscopy were used to direct the retrograde lasering of the tissue to create the new ureteral path with thulium fiber laser technology. Laser settings were 1 J for pulsed energy and 5 Hz for pulsed frequency with short pulse. Results: After reaching the pelvis through the retrograde access, a Double-J ureteral catheter (8F) was placed to reduce the risk of restenosis and a nephrostomy tube. Laser time was 4 minutes and 38 seconds and total energy emitted was 1.39 KJ. The nephrostomy tube was removed after 48 hours. The procedure was well tolerated and after 3 days the patient was discharged with the Double-J. A retrograde pyelography was performed 1 month later showing contrast passage. Conclusions: Combined antegrade–retrograde rendezvous dilatation offers a safe and viable alternative to high-risk surgery in patients with complete ureteropelvic stenosis. A.S. and M.C. have nothing to disclose. O.T. is a consultant for Boston Scientific, Coloplast, EMS, IPG, Quanta and Rocamed, but has no specific conflicts relevant to this study. Runtime of video: 4 mins 46 secs Consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Evaluating Surgical Outcomes of Robot Assisted Simple Prostatectomy in the Retreatment Setting

ObjectiveTo report perioperative and postoperative outcomes in men who undergo salvage RASP (sRASP) following some other endoscopic outlet procedure for benign prostate enlargement (BPE) compared to those undergoing RASP for primary treatment (pRASP). MethodsA prospectively maintained database consisting of all RASP surgeries (December 2014-October 2019) performed at our institution by 3 different urologists was used. Patients who had received an endoscopic procedure for BPE prior to their RASP (sRASP) were compared to those who had not had a prior outlet procedure (pRASP). ResultsIn total, 310 men underwent RASP during the study period. Of those, 30 (9.7%) had undergone an endoscopic procedure prior to surgery. There were no significant differences in age, race, ASA, BMI, prostate volume, PSA or rates of preoperative retention (P> .05 for all). Men who were treatment-naive had significantly higher preoperative International Prostate Symptom Scores (IPSS) than men who had a prior procedure (18.3 ± 7.7 vs 13.6 ± 6.2, P = .008). However, there were no significant differences in functional or quality of life outcomes between the 2 groups (P > .05 for all). There were no significant differences in perioperative or post-operative outcomes between the 2 groups. Furthermore, rates of post-operative complications and incontinence were similar between groups (11% vs 10%, P = .9 and 2% vs 0%, P = 1 respectively). ConclusionPerforming a RASP after prior endoscopic procedure for BPE was found to be safe and effective. Success and complication rates were similar to patients with no prior procedures.

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.

The success of dorsal onlay buccal mucosal graft urethroplasty in challenging urethral stricture cases after multiple failed urethrotomies.

Urethroplasty is the gold standard treatment procedure for male patients with urethral stricture and is becoming increasingly popular among urologists worldwide. Procedure success rates have risen with increased experience. Here we aimed to examine the results of urethroplasty in challenging cases of urethral stricture and its effect on sexual function. Data were collected retrospectively from the patients who had undergone urethroplasty after multiple failed direct vision internal urethrotomy (DVIUs) from 2017 to 2020. All patients were monitored for a minimum of 12 months. Outcomes of urethroplasty were analyzed according to stricture location, length, and the number of prior DVIUs. Penile length and sensation, erectile, and ejaculatory function of the patients were evaluated pre- and postoperatively. The patient cohort consisted of 36 males with a mean age of 63 ± 3.2 years. The most prevalent stricture etiology was iatrogenic (83%). Patients who underwent three or more DVIUs before urethroplasty and stricture length >4 cm were included in the analysis. Accordingly, the overall success rate was 83% (30/36). When the success rate and the IIEF5 scores were assessed separately, there was no significant relationship between the number of DVIUs (P > 0.05). Similarly, no significant relationship was also found with the stricture length (P > 0.05). Appropriate and correctly applied surgical technique does not impair sexual activity, even in patients with severe urethral stricture, regardless of the length or location of the stricture and the number of prior endoscopic procedures.

PD31-10 PATIENT AND STRICTURE VARIABLES ASSOCIATED WITH FAILURE AFTER URETHROPLASTY FOR BULBAR URETHRAL STRICTURES

You have accessJournal of UrologyCME1 May 2022PD31-10 PATIENT AND STRICTURE VARIABLES ASSOCIATED WITH FAILURE AFTER URETHROPLASTY FOR BULBAR URETHRAL STRICTURES Kevin Flynn, Shawn Grove, Nejd Alsikafi, Joshua Broghammer, Jill Buckley, Sean Elliott, Jeremy Myers, Andrew Peterson, Keith Rourke, Thomas Smith, Alex Vanni, Lee Zhao, and Bradley Erickson Kevin FlynnKevin Flynn More articles by this author , Shawn GroveShawn Grove More articles by this author , Nejd AlsikafiNejd Alsikafi More articles by this author , Joshua BroghammerJoshua Broghammer More articles by this author , Jill BuckleyJill Buckley More articles by this author , Sean ElliottSean Elliott More articles by this author , Jeremy MyersJeremy Myers More articles by this author , Andrew PetersonAndrew Peterson More articles by this author , Keith RourkeKeith Rourke More articles by this author , Thomas SmithThomas Smith More articles by this author , Alex VanniAlex Vanni More articles by this author , Lee ZhaoLee Zhao More articles by this author , and Bradley EricksonBradley Erickson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002582.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urethroplasty is the gold standard treatment for urethral stricture disease (USD) with historically high success rates. Still, failures occur and reasons for failure are not always readily apparent. While variations in technique (i.e. dorsal/ventral buccal placement, excisional/non-transection) may play some role, studies have yet to show clear superiority of one modern technique over another when performed by surgeons facile with a specific technique. Herein we look at patient and stricture variables, and their association with bulbar stricture urethroplasty (BU) failure, from a large multi-institutional surgical outcomes study group. METHODS: The Trauma and Urologic Reconstruction Network of Surgeons (TURNS) prospective database was used to create a cohort of bulbar (S1a/S1b; no posterior or penile urethral extension) urethral strictures that underwent single-stage BU from 2010 to 2018 with minimum 3-year clinical follow-up (database + retrospective chart review) not associated with hypospadias. Patient (BMI, age) and stricture (length, etiology, prior endoscopic procedures, location) variables were analyzed for association with failure (secondary repair and/or inability to traverse repair with flexible cystoscope) using both uni- and multivariable methods. RESULTS: At a median follow-up time was 65.1 months there were 195 (13.2%) failures amongst the 1480 patients undergoing BU. The uni- and multi-variable predictors of failure are shown in the Table. All variables other than age were associated with failure in univariable models. In the multivariable model, factors statistically associated with failure included higher BMI, pre-urethroplasty endoscopic procedure count, recurrent strictures and inflammatory strictures, with distal bulbar extension and radiation history nearing significance. CONCLUSIONS: A multitude of readily obtainable patient and stricture variables were found to be independently associated with BU failure in this large cohort of patients with long follow-up, including stricture length, pre-urethroplasty endoscopic count, BMI and stricture etiology, validating associations previously noted in smaller cohorts. Source of Funding: NIDDK 1R21DK115945-01 © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e545 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Flynn More articles by this author Shawn Grove More articles by this author Nejd Alsikafi More articles by this author Joshua Broghammer More articles by this author Jill Buckley More articles by this author Sean Elliott More articles by this author Jeremy Myers More articles by this author Andrew Peterson More articles by this author Keith Rourke More articles by this author Thomas Smith More articles by this author Alex Vanni More articles by this author Lee Zhao More articles by this author Bradley Erickson More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP22-14 A MIXED METHODS APPROACH TO EXPLORING PATIENT MOTIVATIONS FOR DELAYING DEFINITIVE TREATMENT OF URETHRAL STRICTURE DISEASE

You have accessJournal of UrologyCME1 May 2022MP22-14 A MIXED METHODS APPROACH TO EXPLORING PATIENT MOTIVATIONS FOR DELAYING DEFINITIVE TREATMENT OF URETHRAL STRICTURE DISEASE Abimbola Ayangbesan, George Koch, Helen Gambrah, Rohan Bhalla, Jackson Cabo, Stephen Hill, and Niels Johnsen Abimbola AyangbesanAbimbola Ayangbesan More articles by this author , George KochGeorge Koch More articles by this author , Helen GambrahHelen Gambrah More articles by this author , Rohan BhallaRohan Bhalla More articles by this author , Jackson CaboJackson Cabo More articles by this author , Stephen HillStephen Hill More articles by this author , and Niels JohnsenNiels Johnsen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002561.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urethroplasty (UPL) for urethral stricture disease (USD) has high success and satisfaction rates, yet many patients trial endoscopic management with either dilation or urethrotomy. Access to care, surgeon expertise and counseling, and patient health literacy all play a role in the decision to defer UPL. Mixed methods research using both qualitative and quantitative data may allow for a more comprehensive understanding of patient's motivations to defer UPL. We hypothesize that decreased access to care and the logistical ease of endoscopic procedures will be associated with delayed UPL. METHODS: Retrospective review of our institutional UPL database was performed. Patients were categorized based on whether or not they had undergone at least two endoscopic procedures prior to UPL. Demographic data were collected, including median household income (MHI). Multivariable logistic regression using an a priori model was used to determine the odds of undergoing ≥2 prior endoscopic procedures. Telephone interviews were conducted with patients who had undergone ≥2 procedures in order to better understand their experiences and to identify motivations for delaying UPL. RESULTS: One hundred and five patients who underwent UPL from September 2019 to July 2021 were included in the study. Of these, 50 (47.6%) had previously undergone ≥2 endoscopic procedures (IQR 3-5), with 6 patients undergoing ≥10 procedures. On multivariable analysis, age at UPL (OR 1.03 [95% CI 1.01-1.06] p=0.02) and referral from non-teaching facility (OR 2.90 [95% CI 1.07-7.83] p=0.04) were predictors of delayed definitive treatment. Conversely, MHI >$100,000 was protective (OR 0.07 [95% CI 0.01-0.72] p=0.03). When interviewed, 83% of patients expressed a desire to have undergone UPL sooner and 61% were unaware of the lower success rates for repeated endoscopic treatments. Reasons for delaying UPL included not wanting to be admitted overnight due to being sole provider for family members, scheduling conflicts/times constraints, and fear of a more involved recovery. CONCLUSIONS: Predictors of delayed definitive treatment included age and referral from non-teaching facility, while higher MHI was protective. Most patients who underwent multiple endoscopic procedures prior to UPL expressed a desire to have pursued definitive management sooner. Patients in the delayed group cited logistical issues with a more involved procedure, as well as fear of longer recovery. These results illustrate the need for improved patient counseling and access to care for urethral stricture patients. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e376 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Abimbola Ayangbesan More articles by this author George Koch More articles by this author Helen Gambrah More articles by this author Rohan Bhalla More articles by this author Jackson Cabo More articles by this author Stephen Hill More articles by this author Niels Johnsen More articles by this author Expand All Advertisement PDF DownloadLoading ...

Transurethral reconstruction of fossa navicularis strictures with dorsal inlay buccal mucosa graft urethroplasty.

To describe a single stage, glans-sparing urethroplasty technique for fossa navicularis strictures using a transurethral dorsal inlay buccal mucosa graft. We conducted a retrospective review of a prospectively maintained urethral stricture database to identify all fossa navicularis strictures reconstructed with a single stage, transurethral dorsal inlay buccal mucosa graft urethroplasty (5/2015-6/2020). Primary outcomes were anatomic success, defined as the ability to pass a 17 Fr flexible cystoscope, and functional success, defined as the lack of obstructive voiding symptoms and no need for further procedures. Secondary outcomes were postoperative complications and patient satisfaction. Sixteen patients were included. Mean age was 63.1years (43.9-75.6) and mean stricture length was 1.7cm (1.4-2.0). Stricture etiology included internal trauma (62.5%), idiopathic (25.0%), and lichen sclerosus (12.5%). Prior endoscopic procedures were done in 75% of patients. Over a median follow-up of 28.8months (IQR 17.6-38.0), anatomic success was 15/16 (93.8%) and functional success was 16/16 (100%). The single anatomic recurrence was at 4.2months postoperatively. No additional procedures were required. Urinary tract infection occurred in 25% (4/16). There were no instances of de novo erectile dysfunction, chordee, or wound infection. All patients would recommend urethroplasty to others and all patients were either very satisfied (83.3%) or satisfied (16.7%) with the procedure. Penile sensitivity was unchanged in 83.3%, increased in 8.3% and decreased in 8.3%. Transurethral dorsal inlay buccal mucosa graft urethroplasty is a viable option for reconstruction of fossa navicularis strictures that avoids splitting the glans and results in excellent cosmesis.

Accurately Defining the Incidence and Associations of 90-Day Complications after Urethroplasty: Adverse Impact of Patient Comorbidities, Preoperative Bacteriuria and Prior Urethroplasty.

The purpose of this study was to determine the incidence of 90-day complications after urethroplasty and identify factors associated with them. A single-institution, 2-surgeon retrospective review was performed on patients undergoing urethroplasty from August 2003-June 2020. Variables included the incidence, type and Clavien-Dindo grade of complications, patient age, individual comorbidities, comorbidity component of the Charlson Comorbidity Index (CCI), smoking status, obesity (body mass index ≥35 kg/m2), bacteriuria, type of urethroplasty, stricture etiology, length, location, prior endoscopic procedures, previous urethroplasty and preoperative suprapubic catheterization. The primary outcome was the incidence of significant 90-day complications defined as Clavien grade ≥2. Descriptive statistics were used to summarize the results and binary logistic regression was used to examine the factors associated with 90-day complications. Of the 1,611 patients included in the analysis, 90-day complications (Clavien ≥2) occurred in 7.9% (128/1,611) and were wound related (3.5%), urinary tract infection (3.4%), cardiovascular (0.4%), catheter-related (0.2%), hematuria (0.1%) or retention (0.1%). On univariable binary logistic regression stricture location (p=0.04), stricture length (p=0.009), CCI (p <0.0001), prior urethroplasty (p=0.01) and bacteriuria (p=0.002) were associated with complications, while age (p=0.3), etiology (p=0.2), smoking (p=0.2), obesity (p=0.3), failed endoscopic treatment (p=0.8), indwelling suprapubic catheter (p=0.7) and type of urethroplasty (p=0.09) were not. On multivariable analysis, increasing CCI (Odds Ratio 1.31, 95% CI 1.10-1.56; p=0.003), prior urethroplasty (OR 1.86, 95% CI 1.09-3.17; p=0.02) and preoperative bacteriuria (OR 1.67, 95% CI 1.14-2.45; p=0.009) remained associated with 90-day complications. Patients with increased comorbidities, prior urethroplasty and preoperative bacteriuria are at higher risk for complications after urethroplasty and should be counseled accordingly in a shared decision-making model of care.

The evolution of urethral stricture and urethroplasty practice over 15 years: A single-center, single-surgeon, 1319 urethroplasty analysis.

The management of urethral stricture has evolved over the last several decades. We sought to analyze urethral stricture and urethroplasty trends at a tertiary referral center over a 15-year period. Patients undergoing urethroplasty by a single surgeon from August 2003 to July 2018 were analyzed. Patient demographics, urethroplasty techniques, and outcomes were collected in a prospectively maintained database and were categorized into three five-year tertiles based on date of surgery. These tertiles were subsequently retrospectively analyzed for trends and changes in practice. A total of 1319 urethroplasties were completed over the study period. During the first five years (T1), 299 urethroplasties were performed, with 431 and 589 performed in T2 and T3, respectively. Mean overall patient age was 46.8 years, which increased significantly over time (p<0.001). Idiopathic strictures were most common (n=516, 39.1%) and unchanged over time, while proportionately radiation-induced strictures increased (n=9, 3.0% [T1], n=22, 5.1% [T2], n=51, 8.7% [T3]; p=0.001) as did iatrogenic and lichen sclerosus strictures. Mean stricture length (4.7 cm [T1], 4.8 cm [T2], 4.0 cm [T3]; p<0.001) and the mean number of prior endoscopic procedures (3.4 [T1], 3.9 [T2], and 2.5 [T3]; p<0.001] decreased over time. Single-stage urethroplasty with buccal mucosa was the most common technique performed (n=656, 49.7%) that increased in prevalence (p=0.009), while both flap and staged techniques decreased (p=0.008, p=0.004, respectively). Overall success rate was 90.1% (n=1106), which improved significantly with time (n=248, 86.7% [T1], n=359, 90.0% [T2], n=499, 93.4% [T3]; p=0.001). We observed that patients and treatment of urethral stricture evolved over 15 years in practice, with an increase in patient age, radiation, and iatrogenic and lichen sclerosus strictures, while demonstrating a decrease in stricture length and the number of prior endoscopic procedures performed. Increased use of single-stage urethroplasty using buccal mucosa was observed, which may have contributed to an increase in urethroplasty success over time.

Surgery for chronic pancreatitis in Finland is rare but seems to produce good long-term results.

BACKGROUNDAbdominal pain in chronic pancreatitis (CP) may require invasive interventions. Surgical procedures are rare, and little is known about the long-term results.AIMTo study the nationwide frequency of pancreatic surgery for CP in Finland, and postoperative symptoms and quality of life (QoL).METHODSAll patients in Finland with a diagnosis of CP who had undergone pancreatic surgery during 2000-2008 were selected from a national register. Only patients with CP as an indication for pancreatic surgery were included. Medical records were studied and questionnaires QLQ-C30, PAN26 and AUDIT, and symptom questionnaires were sent out.RESULTSDuring the 9-year period, pancreatic surgery for CP was performed on 30 patients [77% men, median age 45 (21-62) years]. Eighty-three percent underwent endoscopic procedures before surgery. Surgery was performed a median 2 (0-10) years after the original CP diagnosis, and 17% developed postoperative complications. Primary pain relief after surgery was reported in 70% of cases. Need for strong pain medication was lower after surgery. Eight of 21 (38%) returned the questionnaires and 88% reported that surgery had reduced their pain and 63% were almost or entirely pain-free at a median 14 (10-18) years after surgery. QoL results did not differ from those in our control Finnish CP group.CONCLUSIONSurgery for CP is rare in Finland and most patients had prior endoscopic procedures. Patients who returned the questionnaires reported less pain and good QoL during the 14-year follow-up.

Multi-Institutional Study of Dorsal Onlay Urethroplasty of the Membranous Urethra after Endoscopic Prostate Procedures: Operative Results, Continence, Erectile Function and Patient Reported Outcomes

(1) Background: To critically evaluate dorsal onlay buccal mucosal graft urethroplasty (DOBMGU) for posterior urethral stenosis repair following transurethral resection and other endoscopic prostate procedures. (2) Methods: A retrospective multi-institutional review of patients with membranous or bulbomembranous urethral stenosis for whom treatment with DOBMGU was conducted after receipt of prostate endoscopic procedures. Baseline data, peri-operative care, post-operative care and patient-reported outcomes were analyzed. The primary outcomes were procedural failure and development of de novo stress urinary incontinence (SUI). The secondary outcomes were changes in voiding, sexual function and patient satisfaction. (3) Results: A total of 107 men with a mean age of 69 ± 9.5 years and stenosis length of 3.5 ± 1.8 cm were included. Prior endoscopic procedures among participants were 47 patients (44%) with monopolar TURP, 33 (30.8%) with bipolar TURP, 16 (15%) with Greenlight laser, 9 (8.4%) with Holmium laser enucleation and 2 (1.9%) with bladder neck incision. At a mean follow-up time of 59.3 ± 45.1 months, stenosis recurred in 10 patients (9.35%). Multivariate analysis confirmed that postoperative complications (OR 12.5; p = 0.009), history of radiation (OR 8.3; p = 0.016) and ≥2 dilatations before urethroplasty (OR 8.3; p = 0.032) were independent predictors of recurrence. Only one patient (0.9%) developed de novo SUI. Patients experienced significant improvement in PVR (128 to 60 cc; p = 0.001), Uroflow (6.2 to 16.8 cc/s; p = 0.001), SHIM (11.5 to 11.7; p = 0.028), IPSS (20 to 7.7; p < 0.001) and QoL (4.4 to 1.7; p < 0.001), and 87 cases (81.3%) reported a GRA of + 2 or better. (4) Conclusions: DOBMGU is an effective and safe option for patients with posterior urethral stenosis following TURP and other prostate endoscopic procedures. This non-transecting approach minimizes external urinary sphincter manipulation, thus limiting postoperative risk of SUI or erectile dysfunction.

Management of Urosymphyseal Fistula and Pelvic Osteomyelitis: A Comprehensive Institutional Experience and Improvements in Pain Control

BackgroundUrosymphyseal fistula (USF) is an uncommon but painful and devastating condition typically occurring after radiotherapy for pelvic malignancy, with a delayed diagnosis and a risk of opioid dependence. ObjectiveTo characterize our institutional experience and determine the impact of intervention for USF on pain control and opioid use. Design, setting, and participantsWe evaluated data for 33 adult patients diagnosed with USF and managed at a quaternary institution between 2009 and 2021. Outcome measurements and statistical analysisWe assessed chronic opioid use, pain scores, prior therapy for pelvic malignancy, prior endoscopic procedures, microbiology and histology congruence, and postoperative complications. For comparative analyses we used a χ2 test or Fisher’s exact test for categorical variables and a Wilcoxon signed-rank test for continuous variables. Results and limitationsNearly 94% of the patients had received prior pelvic radiotherapy and >80% occurred in 2016–2021 but were not diagnosed until a median of 10 mo (interquartile range [IQR] 3.5–19.5) following endoscopic procedure(s). Osteomyelitis was suspected in 78.8% of imaging reports and nearly 70% had a positive preoperative urine culture. Over 90% of patients underwent cystectomy, pubic bone debridement or resection, and a soft-tissue pedicle flap. Preoperative urine cultures were concordant with 60% of intraoperative tissue/bone cultures. Histologic osteomyelitis was identified in 85% and concordant with 80% of preoperative imaging. Clavien-Dindo grade ≥3 complications occurred in 15.6%. The median pain score decreased from 4 (IQR 0–8) preoperatively to 0 (IQR 0) postoperatively (p < 0.001). Chronic opioid use decreased from 39.4% to 21.2% (p = 0.02). ConclusionsPelvic osteomyelitis may complicate USF and commonly manifests with severe, persistent pain. USF incidence may be increasing or at least increasingly recognized, but diagnosis is delayed. Definitive management results in significant improvements in pain perception and a decrease in chronic opioid use. Patient summaryWe examined features of urinary fistulas, which are abnormal openings or connections between part of the urinary tract and another structure. Patients with a urinary fistula involving the pelvic bones can present with severe pain, but diagnosis of the condition is often delayed. Removal of some pelvic bone with bladder removal or repair can result in a decrease in long-term pain and in the use of opioid drugs for pain relief.

S1641 Utility of Colon Capsule Endoscopy in Diagnosis of Colorectal Cancer

INTRODUCTION: Colonoscopy is the gold standard for diagnosis of colorectal cancers. Recent advances in endoscopic technologies has introduced Video capsule endoscopy, which has become widely used to evaluate small bowel and large mucosa for obscure bleeding and even mass lesions. This has led to colon capsule endoscopy (CCE). CCE was introduced in late 2000s and has gained popularity due to non-invasive, and efficacious method in diagnosis of colon lesions. CASE DESCRIPTION/METHODS: We present a case of a 68 yo man with hematochezia for three months. His PMHx includes A fib (takes coumadin). He had intermittent bleeding with bowel moments where he noticed fresh bleed in toilet bowel. He denied any abdominal pain, constipation, diarrhea, or weight loss. His physical exam was benign. His hemoglobin was 14.5 g/dl. No prior endoscopic procedures. He was offered colonoscopy however patient was not amenable to the procedure. Therefore, we offered colon capsule endoscopy (CCE). The CCE was of good quality. Colon was well visualized and showed an ulcerated lesion in the distal rectosigmoid area, occupying more than 70% of the lumen, measuring at least 5 cm in diameter that was concerning for cancer. With this finding, patient was agreeable to proceeded with colonoscopy. Colonoscopy to the ileum (BBPS 3,3,3) showed a rectosigmoid mass seen on capsule colonoscopy at 16 cm from the anal verge. Lesion was non obstructing and occupied 70% of the luminal circumference. Multiple biopsies were taken. Biopsies were consistent with moderately differentiated adenocarcinoma. He was referred to general surgery and oncology. He underwent Lower Anterior Resection. Path showed locally advanced rectal cancer. DISCUSSION: With this case, we intent to highlight the utility of CCE as a screening and diagnostic tool for Colorectal cancer. CCE has emerged as a promising new modality for colonic evaluation. As this procedure is non-invasive, and painless, there is no need for sedation. The patient’s do not need to be off of anticoagulation and take significant time of for colonoscopy that usually requires one to two days of leave. Hence, it a good diagnostic and screening tool for appropriate candidates who do not wish to undergo routine colonoscopy. The limitations include unable to do biopsies, polypectomies and provide therapeutic options for patients with mass lesions, polyps or bleeding. Therefore, CCE can be utilized to decide if colonoscopy is warranted in individuals based on CCE findings.Figure 1.: Colon Capsule Endoscopy imaging of rectosigmoid tumor.Figure 2.: Colon Capsule Endoscopy imaging of rectosigmoid tumor.Figure 3.: Colonoscopy image of circumferential mass lesion in rectosigmoid identified on colon capsule endoscopy.

Outpatient buccal mucosal graft urethroplasty outcomes are comparable to inpatient procedures.

We sought to compare outcomes between inpatient and outpatient buccal mucosal graft (BMG) urethroplasty among a large tertiary referral center series. A retrospective review of consecutive patients who underwent BMG urethroplasty between 2007 and 2018 was performed, including only first stage and one stage graft procedures. Patients were divided into inpatient and outpatient groups. Demographic and outcome data were collected and analyzed, with success defined as no need for further endoscopic or open reoperative management. Of 143 patients undergoing BMG urethroplasty during the study period, 87 cases (60.8%) were performed on an inpatient basis, and 56 (39.2%) on an outpatient basis. Patient characteristics such as age, BMI, prior endoscopic procedures and co-morbid factors were similar between inpatient and outpatient groups. Perioperative characteristics such as estimated blood loss were also similar between groups, but the inpatient cohort had a longer operative time (157.6 vs. 123.1 min, P<0.0001). Operative success was comparable in the two groups (74.7% inpatient vs. 76.8% outpatient, P=0.7) as were rates of complications (29.9% inpatient vs. 26.8% outpatient, P=0.07). BMG urethroplasty can be safely performed in an ambulatory setting without increased complications or compromised outcomes.

Analysis of a 7‐year national online audit of the management of open reconstructive urethral surgery in men

ObjectiveTo conduct an audit of the management of urethral pathology in men presenting for reconstructive urethral surgery in the UK.MethodsBetween 1 June 2010 and 31 May 2017, data on men presenting with urethral pathologies requiring reconstruction were entered onto a secure online data platform. Surgeon‐entered information was collected in 95 fields regarding the stricture aetiology, prior management, mode of presentation, type of surgery and outcomes, with a potential 283 variable responses in the 95 fields. Data were analysed to compare UK practice with that reported in the contemporary literature and with guidelines.ResultsData on 4809 men were entered by 39 centres and 50 surgeons. Field completeness was 70.7%, 74.3% and 53.7% for preoperative, operative and follow‐up data, respectively. Referral for stricture reconstruction frequently followed two prior endoscopic procedures and the stricture was not always assessed anatomically before surgery. Urinary retention was a common symptom in men awaiting reconstruction. Short unifocal strictures of the anterior urethra were the commonest reason for referral, whilst lichen sclerosus and hypospadias generated a significant volume of revisional stricture surgery. Lower numbers of very complex interventions are required for the management of posterior urethral pathology. Although precise criteria for determining success are not clear, management of urethral reconstruction in the UK was found to have a low risk of Clavien–Dindo grade 3 or higher complications, and was associated with outcomes similar to those reported in contemporary series except in the management of posterior urethral fistulae.ConclusionsOnline databases can provide volume data on the management of reconstructive urethral surgery across a multiplicity of centres in one country. They can also indicate compliance with accepted standards of, and expected outcomes from, this tertiary practice.

091 Outpatient Buccal Mucosal Graft Urethroplasty Outcomes Are Comparable To Inpatient Procedures

Recent literature reflects that rates of outpatient urethroplasty (primarily anastomotic) are increasing nationwide. However, due to concerns about imbibition and inoculation, graft urethroplasty remains primarily relegated to the inpatient setting. We sought to compare outcomes between inpatient and outpatient buccal mucosal graft (BMG) urethroplasty among a large tertiary referral center series. A retrospective review of all patients who underwent BMG urethroplasty between 2008 and 2017 was performed, including only first stage and one stage procedures. Patients were divided into inpatient (23 hour stay) and outpatient groups. Demographics and outcomes were collected and analyzed after database review, with success defined as no need for further endoscopic or open re-operative management. Among 149 patients undergoing BMG urethroplasty during the study period, 88 cases (59.1%) were performed on an inpatient basis, and 61 cases (40.9%) on an outpatient basis. Patient characteristics were similar between inpatient and outpatient groups, including mean stricture length (5.1 cm vs. 4.6 cm, p=0.15), mean age (52.1 vs. 48.7 years, p=0.14), ASA classification (2.1 vs. 2.0, p=0.19), BMI (30.9 vs. 31.7 kg/m2, p=0.4), prevalence of CAD (15.9% vs. 13.1%, p=0.4), DM (23.9% vs. 11.5%, p=0.06), and ED (21.2 vs. 13.3, p=0.16) and mean number of prior endoscopic procedures (8.0 vs. 4.6, p=0.1). Success was comparable in the two groups (75% inpatient vs. 79% outpatient, p=0.38), though median follow-up was longer in the inpatient group compared to the outpatient group (73.6 mo vs. 26.2 mo, p<0.001). A greater proportion of 1st stage graft repairs were performed as an outpatient compared to inpatient (69% v 31%, p<0.001). Rates of major, minor, and overall complications were similar between groups (30.7% inpatient, 26.2% outpatient, p=0.34). On multivariate logistic regression analysis, history of pelvic radiation was predictive of stricture recurrence (OR 8.33, CI 1.21-57.3, p=0.03), but outpatient BMG urethroplasty was not predictive.