Urological Intervention Research Articles

MP46-16 POST-OPERATIVE TRANSOBTURATOR MALE SLING URINARY RETENTION RESOLVES SPONTANEOUSLY WITH TIME AND MAY BE ASSOCIATED WITH HIGHER LONG-TERM SUCCESS

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy1 Apr 2017MP46-16 POST-OPERATIVE TRANSOBTURATOR MALE SLING URINARY RETENTION RESOLVES SPONTANEOUSLY WITH TIME AND MAY BE ASSOCIATED WITH HIGHER LONG-TERM SUCCESS Divya Ajay, Bryce Allio, Ramiro Madden-Fuentes, and Andrew Peterson Divya AjayDivya Ajay More articles by this author , Bryce AllioBryce Allio More articles by this author , Ramiro Madden-FuentesRamiro Madden-Fuentes More articles by this author , and Andrew PetersonAndrew Peterson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1455AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Post-operative urinary retention (POUR) has been reported in 3-21% of patients undergoing a male transobturator sling (TOS) for post-prostatectomy urinary incontinence (PPUI). Our objective was to examine the natural history of POUR in men undergoing TOS, and review the treatment options and resolution rates to propose an algorithm for management. METHODS We reviewed men undergoing a TOS at our institution from 2006 to 2012. Demographic data, post-operative complications and outcomes were extracted by chart review. Post-operative TOS success was defined as the use of 0 or 1 security pads/day, negative stress test on exam or pad weight less than 8 g/day. POUR was defined as patient reported inability to void requiring urological intervention. T-test, fisher′s exact test, cox regression model and Kaplan-Meier survival analysis were performed. RESULTS 290 men with PPSUI that underwent a TOS were identified. POUR was reported in 11.7% (34/290). 33 of these 34 patients had a radical prostatectomy and 1 had a radical cystoprostatectomy with an orthotopic neobladder. POUR was associated with a lower average BMI (25± 2 versus 28± 3, p<0.01). Age, diabetes, pelvic radiation, a prior or concurrent bladder neck contracture had no correlation with POUR. We identified no urodynamic parameters that could distinguish patients that develop POUR during preoperative evaluation. 67.6% (23/34) patients were taught and performed temporary clean intermittent catheterization (CIC), 29% (10/34) had a temporary indwelling foley placed. All patients resolved spontaneously with 85% (29/33) lasting 1-7 days and 12% (4/33) for 7-30 days. Figure 1 shows survival estimates of TOS failure in men who experienced short-term POUR versus those who did not (p=0.04). Those with POUR had better long term outcomes with a hazard ratio of 0.47 (95%CI 0.2- 1.0). None had permanent retention nor required surgical intervention such a sling release. CONCLUSIONS We feel that this information is valuable in that all cases resolved spontaneously thus allowing us to avoid surgical intervention in these cases. We propose the following algorithm outlined in Figure 2 for the management of POUR. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e625-e626 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Divya Ajay More articles by this author Bryce Allio More articles by this author Ramiro Madden-Fuentes More articles by this author Andrew Peterson More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Sedoanalgesia Administration with Propofol and Ketamine for Minor Urologic Interventions

Sedoanalgesia Administration with Propofol and Ketamine for Minor Urologic Interventions

Impact of prolonged oocyte incubation time before vitrification on oocyte survival, embryo formation, and embryo quality in mice.

Oocyte incubation time before freezing is one of the factors affecting oocyte vitrification. In the assisted reproductive technology (ART) clinics, it is sometimes decided to perform oocyte vitrification after a long period of incubation time due to various conditions, such as inability to collect semen samples, unsuccessful urological interventions (PESA, TESE, etc.), or unexpected conditions. A time factor of up to 6h has been studied in the available reports. Therefore, this study was designed to evaluate oocyte incubation time before freezing at 0, 6, 12, 18, and 24h after retrieval. Metaphase II (MII) oocytes were obtained from NMRI female mice after being randomly divided into the five groups of 0, 6, 12, 18, and 24h of freezing via hormonal stimulation following retrieval and entered into the vitrification-warming process. The thawed oocytes were evaluated according to the survival criteria and then inseminated with the sperms of male mice for in vitro fertilization. The next day, the embryo formation rate and embryo quality were assessed. Our results demonstrated that even after 24h of incubation, the survival rate of oocytes was 51.35% with the embryo formation rate of 73.21%. However, the survival and embryo formation rates significantly decreased within 12, 18, and 24h after retrieval compared to the groups vitrified at 0h. The embryo quality was significantly reduced by vitrification at 0 to 24h after retrieval. According to our data, although a prolonged incubation time before freezing reduced the survival rate, there was still a chance for oocytes to stay alive with acceptable embryo formation and quality rates after vitrification warming of oocytes.

Evaluation of financial burden following complications after major surgery in France: Potential return after perioperative goal-directed therapy

ObjectivePerioperative goal-directed therapy (PGDT) has been demonstrated to improve postoperative outcomes and reduce the length of hospital stays. The objective of our analysis was to evaluate the cost of complications, derived from French hospital payments, and calculate the potential cost savings and length of hospital stay reductions. MethodsThe billing of 2388 patients who underwent scheduled high-risk surgery (i.e. major abdominal, gynaecologic, urological, vascular, and orthopaedic interventions) over three years was retrospectively collected from three French hospitals (one public-teaching, one public, and one private hospital). A relationship between mortality, length of hospital stays, cost/patient, and severity scores, based mainly on postoperative complications but also on preoperative clinical status, were analysed. Statistical analysis was performed using Student's t-tests or Wilcoxon tests. ResultsOur analyses determined that a severity score of 3 or 4 was associated with complications in 90% of cases and this represented 36% of patients who, compared with those with a score of 1 or 2, were associated with significantly increased costs (€ 8205±3335 to € 22,081±16,090; P<0.001, delta of € 13,876) and a prolonged length of hospital stay (mean of 10 to 27 days; P<0.001, delta of 17 days). According to estimates for complications avoided by PGDT, there was a projected reduction in average healthcare costs of between € 854 and € 1458 per patient and a reduction in total hospital bed days from 1755 to 4423 over three years. Based on French National data (47,000 high risk surgeries per year), the potential financial savings ranged from € 40M to € 68M, not including the costs of PGDT and its implementation. ConclusionOur analysis demonstrates that patients with complications are significantly more expensive to care for than those without complications. In our model, it was projected that implementing PGDT during high-risk surgery may significantly reduce healthcare costs and the length of hospital stays in France while probably improving patient access to care and reducing waiting times for procedures.

The Diagnosis and Management of Patients with Renal Colic across a Sample of US Hospitals: High CT Utilization Despite Low Rates of Admission and Inpatient Urologic Intervention.

ObjectivesSymptomatic ureterolithiasis (renal colic) is a common Emergency Department (ED) complaint. Variation in practice surrounding the diagnosis and management of suspected renal colic could have substantial implications for both quality and cost of care as well as patient radiation burden. Previous literature has suggested that CT scanning has increased with no improvements in outcome, owing at least partially to the spontaneous passage of kidney stones in the majority of patients. Concerns about the rising medical radiation burden in the US necessitate scrutiny of current practices and viable alternatives. Our objective was to use data from a diverse sample of US EDs to examine rates of and variation in the use of CT scanning, admission, and inpatient procedures for patients with renal colic and analyze the influence of patient and hospital factors on the diagnostic testing and treatment patterns for patients with suspected renal colic.MethodsWe conducted a retrospective cohort study of adult patients who received a diagnosis of renal colic via a visit to an ED at 444 US hospitals participating in the Premier Healthcare Alliance database from 2009–2011. We modeled use of CT, admission, and inpatient urologic intervention as functions of both patient characteristics and hospital characteristics.ResultsOver the 2-year period, 307,612 patient visits met inclusion criteria. Among these patients, 254,211 (82.6%) had an abdominal CT scan, with 91.5% being non-contrast (“renal protocol”) CT scans. Nineteen percent of visits (58,266) resulted in admission or transfer, and 9.8% of visits (30,239) resulted in a urologic procedure as part of the index visit. On multivariable analysis male patients, Hispanic patients, uninsured patients, and privately insured patients were more likely to have a CT scan performed. Older patients and those covered by Medicare were more likely to be admitted, and once admitted, white patients and privately insured patients were more likely to have a urologic intervention. Only hospital region was associated with variation in CT rates, and this variation was minimal. Region and size of the hospital were associated with admission rates, and hospitals with more practicing urologists had higher intervention rates.ConclusionsIn this dataset, the majority of patients did not require admission or immediate intervention. Despite this, the large majority received CT scans, in a cohort representing 15–20% of all US ED visits. The CT rate was minimally variable at the hospital level, but the admission rates varied 2-fold, suggesting that hospital-level factors affect patient management. The high rate of CT usage coupled with the low rate of immediate intervention suggests that further research is warranted to identify patients who are at low risk for an immediate intervention, and could potentially be managed with ultrasound alone, expectant management, or delayed CT.

Prevalence and management status of urologic diseases in geriatric hospitals in South Korea: A field research

PurposeWe aimed to investigate the current management status of urologic diseases in geriatric hospitals in South Korea.Materials and MethodsQuestionnaire surveys and in-depth person-to-person interviews were conducted at 13 hospitals within the Seoul and Incheon areas.ResultsThe study was carried out from July to December 2014; 75.6% of patients (1,858/2,458) and 77.5% (779/1,031) of medical personnel responded to our survey. All surveys and interviews were performed by urology specialists, fellows, residents, or nurses. The hospitals included in the study had an average of 215.2 beds (range, 110–367), 189.1 patients (range, 90–345), and 40.2 nurses (range, 10–83). The average number of physicians was 6.2 (range, 3–11), but none of these were certified urologists. Only 4 hospitals provided consultation services for urological disorders. In total, 64% of patients had urological disorders, although only 20.7% of patients were receiving medication. Most patients were being treated using urological interventions; diapers (49.7%), indwelling catheters (19.5%), clean intermittent catheters (12.2%), and external collection urinary drainage (7.9%). However, most interventions were inadequately implemented, and only 17% of the patients had been examined by a certified urologist. Urological complications were found in 20.2% of patients, and secondary complications occurred in 18.8%. Excluding redundant cases, the total prevalence of urological complications was 39.0%.ConclusionsUrologic diseases are poorly managed, and no certified urologists work in geriatric hospitals. Therefore, more designated urologists are needed in geriatric hospitals.

Chromobacterium violaceum causing community-acquired urinary tract infection

Chromobacterium violaceum is an opportunistic pathogen in humans. Nearly 150 cases have been reported worldwide. The usual presentation is with an initial localized skin lesion and progression to multiple liver and lung abscesses and finally fatal septicemia. Progression is usually seen in immunocompromised individuals or when appropriate antimicrobial therapy was delayed. Mortality ranges up to 60% if not promptly treated. A 73-year-old male presented with febrile urinary tract infection (UTI). His urine culture grew C. violaceum. Neither was he immunocompromised nor was he having any risk factor for this infection. He was not admitted in any hospital in the recent past. He did not have any urological intervention in the past. He was treated successfully with culture sensitive antibiotics. He responded well and he continues to be asymptomatic at 6 months of follow-up. The incidence of UTI by C. violaceum is on the rise. Only three cases of UTI caused by C. violaceum have been reported so far worldwide. This is the second case of symptomatic UTI caused by C. violaceum from the Indian subcontinent. The early recognition of this infection and prompt treatment with appropriate antibiotic go a long way in the prevention of sepsis and its associated morbidity.

A CLINICAL CASE OF ENDOVASCULAR TREATMENT OF POST-TRAUMATIC ANEURYSMS OF RENAL ARTERIES

Introduction. Aneurysm of renal artery is a rare and complex pathology of renal bloodstream. Large percentage of observations show that renal artery aneurysms are iatrogenic and happen due to urological interventions. Traumatic aneurysms are much less frequent. By the nature of the blood supply arterial aneurysms are subdiveded into those, which occur when the injured organ is only artery and arteriovenous aneurysms that occur while an artery is damaged along with the accompanying veins. Aneurysms may be treated only surgically, and the only exception is pregnancy. It is possible to use the open treatment option such as aneurysm resection with prosthetics, reanastomosing or its collateral plastics of the renal artery; exclusion of aneurysm with shunting of renal artery or its branches; resection of aneurysm with anastomosing of artery with azygos splanchnic arteries; complex reconstruction using autovein or internal iliac artery segment; including kidney resection at local infarction or nephrectomy in the case of evident nephrosclerosis. Materials and methods. This paper presents a clinical case of successful minimally invasive surgical treatment of traumatic aneurysm of renal artery. It was carried out through stenting of the right lowpolar renal artery: a coronary sheath was used to transfuse and implant the Explorer-Itgimedical Aneugraft 3.0 * 18.0 mm graft-system; the stent-graft was implanted into the right lowpolar renal artery so that it covers the aneurysm ostium. Results. The above case shows the possibility to successfully apply the endovascular method to treat posttraumatic aneurysms of renal arteries with derivative circulation. Conclusion. This technique can be safely and successfully used as an alternative to the traditional «open» surgery, as it is minimally invasive, and allows performing a complete blockade of the pathological blood flow and to avoid an additional operating trauma and compromenation of distal branches.

Derivation of decision rules to predict clinically important outcomes in acute flank pain patients

ObjectiveRoutine CT for patients with acute flank pain has not been shown to improve patient outcomes, and it may unnecessarily expose patients to radiation and increased costs. As preliminary steps toward the development of a guideline for selective CT, we sought to determine the prevalence of clinically important outcomes in patients with acute flank pain and derive preliminary decision rules. MethodsWe analyzed data from a randomized trial of CT vs. ultrasonography for patients with acute flank pain from 15 EDs between October 2011 and February 2013. Clinically important outcomes were defined as inpatient admission for ureteral stones and alternative diagnoses. Clinically important stones were defined as stones requiring urologic intervention. We sought to derive highly sensitive decision rules for both outcomes. ResultsOf 2759 participants, 236 (8.6%) had a clinically important outcome and 143 (5.2%) had a clinically important stone. A CDR including anemia (hemoglobin <13.2g/dl), WBC count >11000/μl, age>42years, and the absence of CVAT had a sensitivity of 97.9% (95% CI 94.8–99.2%) and specificity of 18.7% (95% 17.2–20.2%) for clinically important outcome. A CDR including hydronephrosis, prior history of stone, and WBC count <8300/μl had a sensitivity of 98.6% (95% CI 94.5–99.7%) and specificity of 26.0% (95% 24.2–27.7%) for clinically important stone. ConclusionsWe determined the prevalence of clinically important outcomes in patients with acute flank pain, and derived preliminary high sensitivity CDRs that predict them. Validation of CDRs with similar test characteristics would require prospective enrollment of 2100 patients.

Editorial Comment

No AccessJournal of UrologyNeuropathic Bladder1 Mar 2017Editorial Comment Jonathan C. Routh Jonathan C. RouthJonathan C. Routh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.10.119AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 197(3 Part 2), pp. 869–870 References 1 : Design and methodological considerations of the National Spina Bifida Patient Registry urologic and renal protocol for the newborn and young child. J Urol2016; 196: 1728. Link, Google Scholar 2 Routh JC, Joseph DB, Liu T et al: Variation in bladder continence surgery use among spina bifida centers. Presented at annual meeting of Society for Pediatric Urology, New Orleans, Louisiana, May 15-17, 2015. Google Scholar 3 : Nationwide trends and variations in urological surgical interventions and renal outcome in patients with spina bifida. J Urol2016; 195: 1189. Link, Google Scholar 4 : Bladder augmentation versus urinary diversion in patients with spina bifida in the United States. J Urol2011; 186: 161. Link, Google Scholar © 2017 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 197Issue 3 Part 2March 2017Page: 869-870 Advertisement Copyright & Permissions© 2017 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan C. Routh More articles by this author Expand All Advertisement PDF downloadLoading ...

Management of Patients with Paroxysmal Nocturnal Hemoglobinuria (PNH) - Data from the Spanish PNH Registry

Introduction: Patients with PNH often need surgery due to disease-related complications. However, surgery, anesthesia, and possible surgical complications, including inflammation and acidosis, can trigger complement activation, making surgery an important risk factor for hemolysis (Ando K, et al. Ann Hematol 2012;91:1987-8; van Bijnen ST, et al. Eur J Haematol 2011;87:376-8). Here we report data on the clinical management and treatment results of patients with PNH undergoing surgery.Patients and Methods: We collected data on 14 surgical interventions of 11 patients (8 males; age, 25-76 years). All patients had a high prevalence of PNH clone cells (55-99% in PMN) and were receiving eculizumab (ECU). Types of surgery were: 6 laparoscopic cholecystectomies, a transjugular intrahepatic portosystemic shunt, a distal splenorenal shunt, a laparoscopic Achilles allograft ligamentoplasty, a gastrectomy, an emergency appendectomy, and 3 urologic interventions. Ten patients received ECU 900 mg, while one (patient E, surgery 6) received 1200 mg since he had developed hemolysis at a previous surgical intervention (surgery 5). In two cases (patient G, surgery 8; patient H surgery 11), an additional dose of ECU was administered before surgery. Patient H (surgery 11) had developed hemolysis at previous surgical interventions (surgeries 9 and 10). In most cases, either the date of the ECU dose was taken into account when scheduling surgery or the ECU dose was moved forward to coincide with the date of surgery. The time between the last ECU dose and surgery was normally one day (range, 1-8).Results: In nine cases, transfusions were required due to hemorrhagic complications. Patient I (surgery 12) had a thrombotic event leading to acute myocardial infarction one week after surgery. Increased hemolysis was observed (increased LDH and/or presence of hemoglobinuria) in five cases (patients E, H, I and K; surgeries 5, 9, 10, 12 and 14) during the week following surgery. Two of these patients (patients E and H) later underwent additional surgery (surgery 6, and surgeries 10 and 11, respectively). The pre-surgical ECU dose was increased in surgery 6 (patient E) and an extra dose was administrated in surgery 11 (patient H) and no hemolysis was observed. (See Table.)Discussion: Our findings lead us to recommend that the date of surgery and/or the date of the ECU dose should be adapted to allow as short a time as possible between the last dose of ECU and surgery. Preferably, ECU should be administered just before surgery in order to avoid complications. The normal ECU dose could be increased or an extra dose be administered in order to minimize the risk of hemolysis in high-risk patients or in those with a previous history of surgery-related hemolysis. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Genotype and Phenotype Analysis in Pediatric Patients with Cystinuria

Cystinuria is an inherited disorder characterized by defective renal reabsorption of cystine and dibasic amino acids leading to nephrolithiasis. This study was conducted to analyze the genotypes and phenotypes of pediatric patients with cystinuria. Eight children from Seoul National University Hospital and Asan Medical Center presenting with cystinuria from January 2003 to June 2016 were retrospectively analyzed. Mutational studies were performed by direct sequencing. Two of the 8 were male and 6 were female. The median ages at onset and diagnosis were 1.5 (range, 0.3–13.6) and 2.6 (range, 0.7–16.7) years, respectively. The median followed up was 7.7 (range, 3.4–14.0) years. Mutational analyses were performed in 7 patients and revealed biallelic SLC3A1 mutations (AA genotype) in 4 patients, a single heterozygous SLC3A1 mutation (A- genotype) in 1 patient, biallelic SLC7A9 mutations (BB genotype) in 1 patient, and a single heterozygous SLC7A9 mutation (B- genotype) in 1 patient. Two of the mutations were novel. No genotype-phenotype correlations were observed, except for earlier onset age in patients with non-AA genotypes than in patients with the AA genotype. All patients suffered from recurrent attacks of symptomatic nephrolithiasis, which lead to urologic interventions. At the last follow-up, 3 patients had a mild-to-moderate degree of renal dysfunction. This is the first study of genotypic and phenotypic analyses of patients with cystinuria in Korea.

Significance of Urological Surgical Treatment for Viral Hemorrhagic Cystitis after Allogeneic Hematopoietic Stem Cell Transplantation

This study investigated the significance of urological surgical intervention for viral hemorrhagic cystitis (HC) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). A total of 1, 024 patients underwent allo-HSCT at our medical center between January 2006 and July 2014. In the 6 patients (0.58%) who required urological surgical treatment for viral HC, we retrospectively analyzed patient characteristics and outcomes. Two patients underwent nephrostomy for bilateral hydronephrosis due to bladder tamponade. One of these patients showed no improvement in renal function, graft versus host disease worsened and he died on postoperative day (POD) 5. The other patient displayed improved renal function but hematuria did not improve, and total cystectomy was required. To control bleeding, we performed transurethral electrocoagulation (TUC) on 3 patients, and total cystectomy was performed on 2 patients. All 3 patients who underwent TUC had BK virus HC. Two of these patients experienced marked improvement in hematuria from immediately after surgery. Hemostasis was only temporary in the other patient, who eventually died due to septicemia on POD 24. The 2 patients who underwent total cystectomy had adenovirus HC. Both experienced secondary hemorrhage postoperatively and required further surgery. Eventually, one died due to postoperative bleeding on POD 1, and one died due to postoperative pneumonia on POD 57. Urological surgical treatment for HC was effective in some cases, but the ultimate outcome greatly depends on the general condition of the patient and treatment of the underlying hematological disorder. TUC may be considered for HC (particularly BK virus HC), but total cystectomy (especially inaden ovirus HC) should be avoided.

Emergency Department Imaging Modality Effect on Surgical Management of Nephrolithiasis: A Multicenter, Randomized Clinical Trial

In the emergency department ultrasonography is emerging as an alternative to computerized tomography for diagnosing patients with nephrolithiasis. In this multicenter randomized clinical trial we examined rates of urological referral and intervention to elucidate whether the initial diagnostic imaging modality affected the management of nephrolithiasis. Patients 18 to 76 years old who presented to the emergency department with renal colic across 15 diverse treatment centers were randomized to receive abdominal ultrasonography by an emergency department physician or a radiologist, or abdominal computerized tomography. We analyzed the 90-day followup for patients diagnosed with nephrolithiasis to assess subsequent urological evaluation, procedure type and time to intervention. Of 1,666 patients diagnosed with nephrolithiasis in the emergency department 241 (14.5%) had a consultation with urology at initial presentation, 503 (30%) saw a urologist in followup and 192 (12%) underwent at least 1 urological procedure. Median time to outpatient procedure and type of procedure performed did not vary significantly among imaging groups. Most patients (78%) had computerized tomography performed before elective intervention. Patients with ultrasonography performed by an emergency department physician were 2.6 times more likely to undergo computerized tomography before intervention than those who had ultrasonography performed by a radiologist. Patients undergoing a urological intervention who had ultrasonography as initial imaging do not experience a significant delay to intervention or different procedure types, but the majority ultimately undergoes computerized tomography before surgery. Formal ultrasonography by a radiologist may encourage less computerized tomography preoperatively.

A Comparison of UK versus European guidelines in neuro-urology

Two primary guidelines, written by the European Association of Urology (EAU) and National Institute of Clinical Excellence (NICE), have been designed to aid British urologists with managing neuro-urological patients. The EAU guidelines are updated annually, and cover incontinence, sexual function and infertility in the adult neuropathic population. The NICE guidelines, applicable to England, are periodically updated, with the last update being in 2012. The NICE guideline covers adults and children with neurological incontinence. There are fundamental differences in the recommendations of the panels. EAU advocate upfront urodynamics and ultrasound assessment in all patients and treatment recommendations are based on urodynamic findings rather than patient symptoms on which the NICE guidelines are based. The patient group covered comprises a heterogeneous population, including patients at high risk of renal deterioration without urological intervention. Due to this, both guidelines recommend initial risk stratification to determine assessment and follow-up regimens. The reason for variation may be due to the NICE guidelines having an added dimension, in that they ensure all interventions are cost effective for a publicly funded national health service. Both guideline panels acknowledge the paucity of scientific research in the field of neuro-urology and consequently both guidelines are based upon expert opinion and limited retrospective evidence. There is an urgent need to undertake prospective research in this field. A first step can be an establishment of prospective registries among various neuro-urological units.

A Nationwide Assessment of the Emergency Department Management of Acute Urinary Retention Due to Urethral Stricture

To evaluate the nationwide practice patterns of the management of acute urinary retention (AUR) secondary to urethral stricture (US) in an emergency department (ED) setting. We used the 2006-2010 Nationwide Emergency Department Sample to identify men with US who received treatment for AUR. We excluded patients with benign prostatic hyperplasia, vesicourethral anastomotic stenosis, neurogenic bladder, and bladder cancer. Primary outcome was urethral dilation or suprapubic tube (SPT) placement as initial AUR management. Patient demographics and hospital factors were also examined. Multivariate logistic regression was performed to examine factors associated with initial AUR management. We identified 4794 weighted ED encounters of men with US who underwent urethral dilation or SPT placement for AUR. Mean age was 58.6 ± 0.8 years. A total of 4084 (85%) men received urethral dilation, whereas 710 had SPT (15%) placement. In bivariate analysis, patients who received SPT were likely to be younger (P <.001), treated in recent years (P = .002), and in hospitals in the West region (P = .003). In multivariate analysis, SPT placement was significantly associated with younger age (P = .004), public insurance (P = .03), recent treatment years (P = .02), and hospitals in the West region (P = .02). Income and hospital teaching status did not have significant association with initial treatment choice. Urethral dilation remains the most common urologic intervention in the ED for AUR due to US; however, there is an increasing trend toward SPT placement. Patients who are younger, publicly insured, or who receive care in the West region are more likely to receive a SPT for initial treatment of AUR due to US.

Management and outcomes of patients with acute external genital trauma: a 12-year combined institution experience

External genital trauma (EGT) often requires emergent urologic (GU) intervention. Reproductive and sexual outcomes in this population are poorly studied. We aim to characterize the presentation, management, and GU follow-up of patients with EGT. We hypothesize that patients with EGT have poor GU follow-up and that reproductive and sexual dysfunction in this group are poorly characterized.

Fractures in spina bifida from childhood to young adulthood.

The aims of this study are to study the prevalence and types of fractures according to age group in spina bifida and examine risk factors associated with fracture. This is a retrospective cohort study of 146 individuals with spina bifida aged 2years or older who attended the paediatric or adult spina bifida multidisciplinary clinic at a single tertiary hospital. Median age at which first fracture occurred was 7years (interquartile range 4-13years). Fracture rates in children (ages 2-10), adolescents (ages 11-18) and adults (age>18) were 10.9/1000 (95% confidence interval 5.9-18.3), 5.4/1000 (95% CI 1.5-13.8) and 2.9/1000 (95% CI 0.6-8.1) patient years respectively. Childhood fractures predominantly involved the distal femur and femoral shaft; these fractures were rarely seen in adulthood. Non-ambulatory status was associated with a 9.8 times higher risk of fracture compared with ambulatory patients (odds ratio 9.8, p=0.016, 95% CI 1.5-63.0). Relative risk of re-fracture was 3.1 (95% CI 1.4-6.8). Urological intervention with intestinal segments was associated with renal calculi (p=0.037) but neither was associated with fracture. The risk of fracture is lower in adults compared with children with spina bifida. The predominant childhood fracture affects the distal femur, and immobility is the most significant risk factor for fracture. Clinical factors contributing to fracture risk need to be elucidated to enable selection of patients who require investigation and treatment of osteoporosis.

Ureteral Endometriosis: Preoperative Risk Factors Predicting Extensive Urologic Surgical Intervention

To identify risk factors for urologic reconstruction during surgery for endometriosis. We retrospectively identified patients in a surgical pathology database undergoing surgery for endometriosis at our institution from 2010 to 2015 and subsequently identified those patients with ureteral involvement. Patients were categorized as requiring minimal urologic surgery (eg, ureterolysis only) or more extensive urologic surgery (eg, ureteral reimplant). All patients were undergoing surgery for endometriosis, and preoperative risk factors were then identified to predict the need for intraoperative extensive urologic surgery. Of 386 women undergoing surgery for endometriosis, 82 (21%) women required a surgical procedure on the ureter. Fifteen of these 82 patients (18.3%) with ureteral involvement required urologic surgical expertise in the form of either ureteral reimplantation with or without psoas hitch, or ureterolysis with ureteral stenting or omental wrap. The remaining 67 underwent ureterolysis alone or no intervention. The presence of flank pain, any urinary symptom, or hydronephrosis on preoperative imaging was a significant predictor of the need for major urologic intervention. In patients with endometriosis undergoing surgery who complain of flank pain, any urinary symptom, or have hydronephrosis on preoperative imaging, one should have a high suspicion for needing to perform urologic reconstruction during surgery. Planning for this additional operation can afford the opportunity for appropriate urologic consultation and patient counseling.

Urological injuries following obstetrical and gynecological surgeries

Background: Gynaecological operations have been reported to be associated with injuries to the ureter. This study was aimed at reviewing the urological complications resulting from obstetric and gynaecological surgeries in respect to frequency, clinical presentations, and time of diagnosis. The study was undertaken at Departments of Obstetrics, Gynecology and Urology at Kilimanjaro Christian Medical Centre Tanzania from January 2009 to December 2014.Methods: In this 6-year retrospective study, 11219 obstetrical and gynecological surgeries were performed. All patients who sustained urological injuries were reviewed and entered into a data sheet before analyzing their frequency, clinical presentation and the time of presentation.Results: Of the 9221 obstetrical and 1998 gynecological surgeries performed, 105 (0.94%) were sustained urological injuries. A total of 82 patients had VVF (78%), 18 (17.2%) had ureteral injury, 4 (3.8%) patients had bladder injury only, and 1 patient (1%) had both VVF and Ureteral Injury. With respect to injury rate by specific procedure, caesarean section in obstetric surgeries contributed to 36 patients (34.3%) with urological injuries, whereas TAH was the leading gynecological procedure which contributed to 18 patients (17.1%) with urological injuries. All patients with VVF had history prolonged labor and presented with persistent urine leakage per vagina (urine incontinence). The time of diagnosis to most of the patients was more than 48 hours especially to patients with VVF. There were no patients with urethral injury.Conclusion: Obstetric surgeries have shown to contribute to a higher number of urological injuries as compared to gynecological surgeries. Both VVF and ureteric injuries being the most common in obstetrics and gynecologic surgeries respectively have great economic and social impacts not only to the patients, but also the surrounding community and the country as a whole. Late presentation and diagnosis increases the risks of further complications. Early presentation, diagnosis and urologic intervention is important for the better outcomes.