Urological Outcomes Research Articles

SUN-223 Impact of Testosterone Replacement Therapy (TRT) on Prostate Specific Antigen (PSA) in Patients with Clinical Evidence of Prostate Hyperplasia

Introduction/ Background Prostate cell growth is androgen dependent, so dogma holds that testosterone replacement therapy (TRT) can lead to the onset, progression, and unmasking of prostate problems. As a result, there continues to be a theoretical concern that TRT-induced proliferation of prostatic epithelial cells could result in benign prostatic hyperplasia (BPH), or prostate cancer. Although the intensity and frequency of monitoring prostate health during TRT remains controversial, a Prostate Specific Antigen (PSA) level >4 ng/ml is widely considered the cut-off at which urological evaluation should be sought. It is noteworthy that, despite a lack of conclusive evidence that TRT causes prostate cancer, Endocrine Society guidelines show an abundance of caution in recommending prostate cancer screening with PSA and DRE 3 to 12 months after treatment initiation followed by race- and age-appropriate monitoring after 1-year in patients who agree to prostate cancer monitoring after shared decision making. One unfortunate consequence of such vigilance is a reported increase in prostate biopsies for patients on TRT with PSA elevations. Although the merits of such vigilance might be debatable, the consensus appears to be that TRT does not cause prostate cancer, as much as unmask pre-existing subclinical prostate cancer, reflecting confirmation bias. An even more vexing issue is whether PSA monitoring might exaggerate the appearance of risk, given that it is more strongly associated with BPH than prostate cancer. Objective To compare the incidence of PSA >4 ng/ml during TRT in veterans with a pre-existing elevation in PSA or with a prior clinical diagnosis of BPH, versus those without elevated PSA or BPH. Design A retrospective cohort study of male veterans prescribed TRT between 2008 and 2014. Results Patients without a clinical diagnosis of BPH prior to initiating TRT were much less likely to develop PSA >4 ng/ml on TRT (16/746 [2.1%]) compared to those with prior BPH (19/222[8.5%], p=0.00007). Similarly, only 3% (22/879) of patients with PSA <4 ng/ml prior to TRT initiation developed a PSA >4 ng/ml on TRT, whereas ten of the fourteen patients (71.4%) who were prescribed TRT despite PSA >4 ng/ml continued to have a persistent elevation in PSA on TRT (P<0.00001). Surprisingly, PSA in four of the fourteen patients (28.6%) with PSA >4 ng/ml prior to TRT initiation declined to <4 ng/ml on TRT. Conclusions: Patients with PSA <4 ng/ml and no prior BPH are very unlikely to develop PSA >4 ng/ml on TRT. Even in patients with a prior PSA >4 ng/ml, further elevations were not seen on TRT, with a few even experiencing a decline in PSA to <4 ng/ml. We conclude, therefore, that the risk of developing PSA >4 ng/ml on TRT is small in the absence of either a prior diagnosis of BPH or PSA >4ng/ml. Urological outcomes remain uncertain, but need to be determined to better inform monitoring guidelines.

699 - Surgical interventions in an adult population of posterior urethral valves: Long term urological outcomes

699 - Surgical interventions in an adult population of posterior urethral valves: Long term urological outcomes

Cribriform pattern, Genomic Prostate Score, and adverse pathology at radical prostatectomy in a cohort of prostate cancer patients initially on active surveillance.

88 Background: A growing body of literature suggests that the presence of cribriform pattern (CP) in prostate biopsy specimens portends worse outcomes. Furthermore, CP tumors have been found to harbor a myriad of genomic alterations associated with more aggressive disease. We sought to examine the association between CP and Genomic Prostate Score (GPS) and how this association helps predict adverse pathology (AP) at radical prostatectomy (RP) in patients initially managed with active surveillance (AS). Methods: Using the UCSF Urologic Outcomes Database (UODB), we identified 180 AS patients who underwent GPS testing and subsequently RP. Biopsy specimens were re-reviewed centrally to confirm Gleason grade. AP was defined as GS ≥ 4+3, pT3/4, or pN1 on surgical pathology. Clinical and demographic characteristics were compared by CP status using t-tests and chi-squared tests. Cox proportional hazards regression was performed to identify factors associated with AP after adjusting for age, PSA density (log), percentage of positive biopsy cores, biopsy source (UCSF versus outside), and year of diagnosis. Additional models included the base covariates plus presence of CP, GPS, and both CP and GPS. Results: For the cohort, mean age was 60.7 years (SD 7.1) with median PSA of 5.3 ng/ml (interquartile range, IQR 4.2-6.9) at diagnosis. Median PSAD was 0.14 (IQR 0.10-0.20). Among 180 patients, 27 (15%) had CP at biopsy. Mean GPS was significantly higher in CP+ compared to CP- patients (35, SD 12.7 versus 27, SD13.7, p &lt; 0.01), and a greater proportion of CP+ patients had AP compared to CP- (59% versus 54%, p &lt; 0.01). On multivariate analysis, CP was associated with AP (HR 1.9, 95% CI 1.1-3.4, p = 0.02), but significance was lost after adjusting for GPS (p = 0.19). Conclusions: The presence of CP at biopsy was statistically significantly associated with higher GPS. While both were associated with AP at RP, CP was not associated with AP independent of GPS, suggesting an interaction or commonality between these factors not previously explored.

Ureteric implantation into the bowel portion of augmented bladders during kidney transplantation: a review of urological complications and outcomes.

In patients with bladder augmentation undergoing kidney transplantation, conventional technique recommends anastomosing the transplanted ureter to the bladder. We report our technique of ureteric implantation into the bowel portion of the enterocystoplasty, and review the urological outcomes of transplantation in these patients. Seven patients (mean age: 26 years (range 24-54 years), two females, five deceased donors) with augmented cystoplasty and subsequent kidney transplantation by a single surgeon from 2011 to 2015 were reviewed. Following standard vascular anastomosis and reperfusion of the transplanted kidney, ureteric implantation involved continuous 5/0 polydiaoxanone anastomosis between the spatulated ureter and full thickness bowel portion of the cystoplasty over a 6-Fr double J stent. A second peri-anastomosis layer of bowel plication was performed to prevent reflux using interrupted 3/0 vicryl sutures. Short-term urological and kidney function outcomes were evaluated. Causes of renal failure included: posterior urethral valve with reflux nephropathy (two patients), bilateral vesicoureteric reflux (two patients), lumbosacral agenesis with neurogenic bladder (one patient), tuberculosis of the urinary tract with post-infective ureteric stricture (one patient), and lupus nephritis (one patient). Bladder reconstruction was performed at median duration of 103 months (35-171 months) before transplantation. Gastrocystoplasty was performed in two patients while colon and/or ileum were used in the remaining six. After transplantation, all reconstructed bladders except one had a Mitrofanoff for clean intermittent self-catheterization, 5-8 times per day. There were no post-operative ureteric/surgical complications. Delayed graft function occurred in three of seven patients. 30-day asymptomatic bacteriuria rate was three out of seven after stent removal. 1-year post-transplantation, patient and graft survival were 100%. Mean serum creatinine was 142.7 (standard deviation: 51.48). Median number of hospital admissions for urinary tract infections was 0.225 (range 0-0.40). Over a median follow-up period of 4 years (2-7 years), one graft failed from acute T-cell-mediated rejection. This patient passed away from cardio-respiratory collapse after a seizure, 35 months post-transplantation. As of June 2018, the other six kidney grafts were functioning. No complications including calculi formation and/or malignancy were reported. In patients with previously augmented bladders now undergoing kidney transplantation, ureteric implantation into the bowel portion of the cystoplasty appears to be safe.

In utero myelomeningocoele repair and urological outcomes: the first 100 cases of a prospective analysis. Is there an improvement in bladder function?

To evaluate the first 100 cases of in utero myelomeningocoele (MMC) repair and urological outcomes in a prospective analysis aiming to define possible improvement in bladder function. We used a protocol consisting of a detailed medical history, urinary tract ultrasonography, voiding cystourethrography, and urodynamic evaluation. Patients were categorised into four groups: normal, high risk (overactive bladder with a detrusor leak-point pressure >40cm H2 O and high filling pressures also >40cm H2 O), incontinent, and underactivity (underactive bladder with post-void residual urine), and patients were treated accordingly. We evaluated 100 patients, at a mean age of 5.8months (median 4months), classified as high risk in 52.6%, incontinent in 27.4%, with underactive bladder in 4.2%, and only 14.7% had a normal bladder profile. Clean intermittent catheterisation was initiated in 57.3% of the patients and anticholinergics in 52.6%. Antibiotic prophylaxis was initiated in 19.1% of the patients presenting with vesico-ureteric reflux. The high incidence of abnormal bladder patterns suggests little benefit of in utero MMC surgery concerning the urinary tract.

Prognostic value of the albumin-to-alkaline phosphatase ratio on urologic outcomes in patients with non-metastatic renal cell carcinoma following curative nephrectomy.

Background: Few studies focused on the relationship between the albumin-to-alkaline phosphatase ratio (AAPR) and the urologic outcomes in patients with non-metastatic renal cell carcinoma (RCC) following curative surgery. The aim of this study was to evaluate the prognostic value of preoperative AAPR in non-metastatic RCC patients.Methods: The prognostic value of AAPR was evaluated in a primary cohort with 419 non-metastatic RCC patients following curative radical or partial nephrectomy and then further validated in an independent cohort consisting of 204 patients. A nomogram was developed based on the independent predictors, and its predictive value was assessed.Results: Kaplan-Meier survival analysis demonstrated that patients with low AAPR levels were significantly associated with worse overall survival (OS) and cancer-specific survival (CSS) compared with patients with high AAPR levels both in two cohorts. Univariate and multivariate analyses revealed that low AAPR was an independent risk factor for OS (HR = 2.745; 95%CI, 1.266-5.953; P = 0.011) and CSS (HR = 3.042; 95%CI, 1.278-7.243; P = 0.012). Moreover, subgroup analysis (Fuhrman grade G1+G2 and Fuhrman grade G3+G4; T1+T2 stage and T3+T4 stage) revealed that low AAPR was also related to worse urological outcomes. Although no significant differences between patients with low AAPR and patients with high AAPR can be observed with regard to CSS under Fuhrman grade G1+G2 (P=0.058) and T1+T2 stage (P=0.318), there was a worse CSS trend in low AAPR patients. The established nomograms for OS and CSS were well calibrated and had moderate discriminative ability (concordance index: 0.821 and 0.839, respectively)Conclusions: Preoperative AAPR might be an independent prognostic factor in patients with non-metastatic RCC. The ratio should be applied in RCC patients for risk stratification and clinical decision-making.

Need for urodynamic evaluation as a regular follow-up tool in assessment of long-term urological outcomes in patients with sacrococcygeal teratoma

AimTo assess the long-term urologic outcomes in follow-up of patients of sacrococcygeal teratoma (SCT) using urodynamic study (UDS) in addition to clinical and radiologic evaluation. MethodsA prospective study of clinical, radiological and urodynamic evaluation in patients with SCT who underwent resection between January 2002–June 2015 and were followed up till January 2016 was conducted. ResultsTotal 57 patients, 42 (73.7%) females and 15 (26.3%) males with 35 (62.4%) following treatment for benign and 22 (38.5%) for malignant disease were included. Twenty-eight of 57 (49.12%) had urological problems. Clinical complaints in 21 (36.8%) patients included stress urinary incontinence-14 (66.7%), enuresis-9 (42.9%), and poor stream or dribbling of urine-6 (28.6%). Eight of 51 patients (15.7%) had abnormal ultrasound findings, which included contracted, trabeculated thick walled bladder (3), bilateral hydronephrosis (3) and significant post void residue (PVR) (6). Seven of 57 underwent micturating cystourethrogram (MCU), 5 had an abnormal report[significant PVR (4), small trabeculated bladder (3), reflux (2) and large capacity bladder (1)]. Urodynamic study was done in 27 patients, 18/27 (66.7%) had abnormalities. Six patients without any clinical or ultrasonographic abnormalities had abnormal UDS. Total 28 (49.12%) had urological comorbidities. Three patients had overactive bladder, five dysfunctional voiding, one underactive bladder and one had giggle incontinence. Children were managed by behaviour therapy and pharmacotherapy. ConclusionUrodynamic evaluation could detect abnormalities in patients who had no urinary complaints or abnormality on ultrasound. The abnormalities have a potential for progressive upper tract damage. Urodynamics should be an integral part of urological surveillance in patients operated for SCT. Type of studyPrognostic study. Level of EvidenceLevel II (Prospective cohort study).

Streamlining risk stratification in infants and young children with spinal dysraphism: Vesicoureteral reflux and/or bladder trabeculations outperforms other urodynamic findings for predicting adverse outcomes

Baseline and interval dimercaptosuccinic acid (DMSA) scans and urodynamic (UD) studies are often obtained in infants and young children with spinal dysraphism (SD). To identify practical UD parameters which accurately stratify urologic risk young children with SD. 130 expectantly managed infants/young children with SD and initial DMSA and UD before age 2 were reviewed. End fill pressure (EFP), bladder trabeculations, vesicoureteral reflux (VUR), initial volume (IV) drained at UD catheter placement, and detrusor pressure at initial volume (DPIV) were evaluated for association with subsequent febrile urinary tract infection (UTI), DMSA abnormalities, and early clean intermittent catheterization (CIC). A combination of factors to accurately stratify risk was sought. Groups were compared by log-rank test. The association of CIC and febrile UTI incidence was evaluated. 31/130 patients developed DMSA abnormalities, 52/130 started early CIC, and 61/130 developed a febrile UTI with median follow-up of 3.8 years. Trabeculations, VUR, EFP ≥40cmH2O, IV ≥50% estimated bladder capacity (EBC), and DPIV >10cmH2O were associated with subsequent abnormal DMSA scan (p<0.001). The best predictor was combination of trabeculation and/or VUR (p<0.001) (Figure). Among patients who maintained a non-trabeculated bladder without VUR during follow-up, 0/51 developed DMSA abnormalities compared with 31/79 who developed one or both (p<0.001). Patients with trabeculations and/or VUR were more likely to start early CIC (8/51 vs. 44/79; p<0.001) and have febrile UTI (11/51 vs. 50/79; p<0.001). In those with trabeculations, CIC was associated with decreased incidence of febrile UTI (incidence rate ratio (IRR) 0.5, 95% CI 0.3-0.9); in those without trabeculations, CIC was associated with increased incidence of febrile UTI (IRR 1.8, 95% CI 1.1-3.1). VUR, bladder trabeculations, EFP ≥40cm H20, IV ≥50% of EBC, and DPIV >10cmH2O were associated with subsequent DMSA abnormalities in young children with SD managed expectantly. Many of these parameters were associated with febrile UTI and early CIC. The combination of trabeculations and/or VUR outperformed other UD parameters in identifying those high and low-risk for adverse urologic outcomes. Routine DMSA scan may have limited utility in patients with a non-trabeculated bladder without VUR, as none developed an abnormal DMSA. Most (71%) abnormal DMSAs were in patients with trabeculations and/or VUR following a febrile UTI. Given these findings and that incidence of febrile UTI may be lower in those with trabeculations while on CIC, patients with trabeculations and/or VUR should be managed aggressively to protect kidneys.

Catheterization for treating neurogenic lower urinary tract dysfunction in patients with multiple sclerosis: A systematic review. A report from the Neuro-Urology Promotion Committee of the International Continence Society (ICS).

To systematically assess all available evidence on efficacy and safety of catheterization for treating neurogenic lower urinary tract dysfunction (NLUTD) in patients with multiple sclerosis (MS). This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified by electronic search of Embase, Medline, Scopus, Cochrane register (last search March 3, 2018) and by screening of reference lists and reviews. After screening 7'015 articles, we included four studies (one prospective and two retrospective cohort studies, one retrospective cross-sectional study), in which a total of 445 patients were enrolled. No randomized controlled trial was available. Catheterization substantially increased quality of life, post void residual, and incontinence episodes in all included studies. Pooling of data for meta-analysis was not possible due to the heterogeneity of reported outcomes. Adverse events were reported in two studies only. Risk of bias and confounding was intermediate. Preliminary data suggests beneficial effects of catheterization on the urological outcome in patients with MS. However, although intermittent and indwelling catheterization is used frequently in daily clinical practice in the MS population, the evidence base is very limited and well-designed, properly sampled, and powered studies are urgently needed.

MP25-20 SURVEY OF UROLOGIC AND ORTHOPEDIC SURGEON VIEWS REGARDING THE MANAGEMENT OF PATIENTS WITH PELVIC FRACTURE URETHRAL INJURIES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) II1 Apr 2018MP25-20 SURVEY OF UROLOGIC AND ORTHOPEDIC SURGEON VIEWS REGARDING THE MANAGEMENT OF PATIENTS WITH PELVIC FRACTURE URETHRAL INJURIES Niels Johnsen, Reza Firoozabadi, and Bryan Voelzke Niels JohnsenNiels Johnsen More articles by this author , Reza FiroozabadiReza Firoozabadi More articles by this author , and Bryan VoelzkeBryan Voelzke More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.857AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Significant controversy exists regarding the management of pelvic fracture urethral injuries (PFUI). While much of the literature focuses on urologic outcomes, the impact of urethral management strategies on orthopedic treatment decisions remains unknown. We surveyed orthopedic and urologic surgeons to assess practice patterns and multi-disciplinary interactions following PFUI. METHODS Anonymous online questionnaires were sent to active clinical members of the Orthopedic Trauma Association (OTA) and the Society of Genitourinary Reconstructive Surgeons (GURS). Participants were queried regarding clinical practice patterns and decision-making in the treatment of PFUI patients. Responses were collected between 9/1/17 and 11/7/17 and aggregated in an online REDCap database. RESULTS 30 OTA and 48 GURS members responded to the survey (response rate of 9% and 17%, respectively). Except for 3 GURS members, all respondents managed PFUI patients annually, with the majority managing between 1 and 10 PFUI per year (69% of GURS respondents vs 93% of OTA respondents). While the preferred management of urethral injuries by GURS respondents was evenly divided (46% suprapubic tube [SPT] and 54% early endoscopic realignment [EER]), 87% of OTA respondents preferred EER. 92% of GURS respondents did not believe that SPT increased the risk of infection following pelvic internal fixation, while 97% of OTA respondents did. 71% of GURS respondents reported that the operative plan of orthopedics was not considered in their choice of EER vs SPT. Conversely, 83% of OTA respondents stated that the presence of a urethral injury affects orthopedic management, with 97% stating that a SPT in particular affects management decision-making. In particular, there was discordance regarding the perceived impact of SPT on choice of internal fixation, with 54% of GURS and 76% of OTA respondents stating that orthopedic surgeons were more inclined to perform external fixation if a SPT was present. Furthermore, 86% of OTA respondents stated that external fixation results in an inferior patient outcome CONCLUSIONS There exists a significant disconnect between urologists and orthopedists regarding the preferred urologic management of PFUI patients and the theoretical risks associated with hardware infection in patients with a SPT. Higher quality data are needed to better elucidate the true infectious risks associated with SPT and improved inter-service dialogue is necessary to maximize patient outcomes. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e334-e335 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Niels Johnsen More articles by this author Reza Firoozabadi More articles by this author Bryan Voelzke More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Detrusor Acontractility after Acute Spinal Cord Injury—Myth or Reality?

We assessed urodynamic parameters within the first 40 days after spinal cord injury to investigate whether the detrusor is acontractile during the acute phase of spinal cord injury. We performed a prospective cohort study in 54 patients with neurogenic lower urinary tract dysfunction due to acute spinal cord injury who underwent urodynamic investigation within the first 40 days after injury at a single university spinal cord injury center. Urodynamic investigation revealed an acontractile detrusor in only 20 of the 54 patients (37%) but unfavorable urodynamic parameters in 34 (63%). We found detrusor overactivity in 32 patients, detrusor-sphincter dyssynergia in 25, maximum storage detrusor pressure greater than 40 cm H2O in 17, vesicoureteral reflux in 3 and low bladder compliance (less than 20 ml/cm H2O) in 1. More than 1 unfavorable urodynamic parameter per patient was possible. In contrast to the common notion of an acontractile detrusor during acute spinal cord injury, almost two-thirds of our patients showed unfavorable urodynamic parameters within the first 40 days after spinal cord injury. Considering that early treatment of neurogenic lower urinary tract dysfunction in patients with acute spinal cord injury might improve the long-term urological outcome, urodynamic investigation should be performed timely to optimize patient tailored therapy.

Complications of curative radiation treatment for early prostate cancer.

To report the incidence of urological complications following curative radiation treatment for early prostate cancer, including minimally invasive urological procedures (MUIP), hospital admissions and open surgical procedures. Second malignancies following radiation are also reported and compared with patients undergoing a prostatectomy. Included were patients receiving curative intent external beam radiation treatment for early prostate cancer between January 1, 2002, and December 31, 2009. Medical records were reviewed for baseline characteristics, treatment details and outcomes. Kaplan-Meier methods were used to derive the 5-year cumulative incidence of the urological outcomes and second malignancy. There were 439 patients identified. The median follow-up was 6.96 years. The median age was 69. A total of 56 patients developed a radiation related urological complication, 25 requiring hospital admission. The 5-year cumulative incidence for an MIUP and admission was 3.95% (95% confidence interval (CI), 2.47-6.28) and 2.24% (95% CI, 1.17-4.27), respectively. There were no open surgical procedures. Further malignancy developed in 27 patients during the 5- to 9-year posttreatment period with a cumulative incidence of 10.7% (95% CI, 7.31-15.51). Of the comparator prostatectomy group, of the 265 eligible patients analyzed, 19 patients developed a second malignancy with a cumulative incidence of 9.92% (95% CI, 6.28-15.48). On log-rank testing, there was no difference in the cumulative incidence rates of second malignancy between 5 and 9 years, following respective treatments (P=0.8554). The incidence of MUIP, hospital admissions and open surgical procedures following radiation is reassuringly low. The second malignancy rates are also low and similar to the rates in patients treated with a prostatectomy.

Cystic Cervical Dysraphism: Experience of 12 Cases.

Introduction:Cystic spinal dysraphism of the cervical region is a relatively rare entity, which is more frequently associated with congenital anomalies such as split cord malformation, Chiari malformation, and corpus callosum agenesis, when compared to their lumbosacral counterpart. In our study, we have highlighted the clinical spectrum, associated anomalies (both neural and extra-neural), and surgical nuances of these.Materials and Methods:This study is a retrospective analysis of 225 patients from June 2010 to April 2017. Twelve patients who were between the age of 1 month and 16 years were included in our study. Average age was 32.6 months, and there were five female patients and seven male patients. All patients underwent neurological and radiological examinations followed by surgical excision of the sac and exploration of the intradural sac using the standard microsurgical technique. Neurological, Orthopedic and urological outcomes were studied in our description.Results:Of the 12 cases, 9 patients (75%) had some associated anomaly. Four of the 12 patients (25%) had split cord malformation, 3 had corpus callosum agenesis, and 5 had Chiari malformation. Patients with cervical spina bifida cystica (SBC) present with less neurologic deficits and greater association with CCA.Conclusion:The management strategy and association with other congenital anomalies separates cervical dysraphism as a different clinical entity rather than just group. These patients rather show favorable outcome with regard to neurologic, orthopedic, and urologic problems as compared to their caudal counterpart. Early surgical intervention even before the onset of symptoms is recommended. A proper radiological and urological evaluation is warranted.

Surgery for tethered cord syndrome: when and how?

Tethered cord syndrome (TCS) is a clinical condition presented with neurological and/or urological signs and findings. Increased hypoxic stress in the spinal cord secondary to traction or stretching is the pathophysiological mechanism of TCS. It is usually observed in childhood but adult cases were also reported. Its diagnosis and treatment are always challenging. Magnetic resonance imaging, electrophysiological and urodynamic studies are the main diagnostic tools for TCS. This syndrome may be primary or secondary to previous surgeries such as myelomeningocele. Asymptomatic patients with low conus medullaris and thick filum terminale are always questionable for surgical treatment. On the other hand, symptomatic patients with normal radiological imaging are critical for surgical decision. Surgical treatment involves correction of the spinal pathologies and release of the spinal cord by cutting the filum terminale. Time of surgery and technical nuances are still in debate among neurosurgeons. Neurological and urological outcomes of the patients usually depend on these factors. Timing of surgery and surgical technique need to be clarified based on the recent clinical studies. This review will focus on the time and technique of TCS surgery. Firstly, a brief description of is e provided, then an extensive view on the surgical treatment of TCS will be performed.

Expectant use of CIC in newborns with spinal dysraphism: Report of clinical outcomes.

Report urologic outcomes among newborns with spinal dysraphism managed within an expectant clean intermittent catheterization (CIC) program. Newborns were followed clinically and with serial ultrasound (US). Urodynamics (UD) and dimercaptosuccinic acid (DMSA) renal scan were obtained at 3-6months, 1 year, 3 years, then as needed. Patients with initial evaluation after 6months were excluded. Median follow-up was 3.2 years. 11/102 began catheterization for continence (median 4.0 years) and 47/102 did not start CIC. Of these, 2/58 developed a DMSA abnormality. 44/102 began CIC early, often for elevated storage pressures and febrile urinary tract infection (UTI). Of these, 20/44 developed a DMSA abnormality including 9 who had abnormality detected prior to starting CIC. Being on CIC or starting immediately upon recognition of new hydronephrosis, reflux, elevated filling pressures, or febrile UTI was associated with lower chance of DMSA abnormalities (4/17, 24%) compared to delaying CIC (16/27, 60%) (p= 0.03). CIC can be deferred until continence in select infants with a low risk of significant DMSA abnormality. However, immediate initiation of CIC upon recognition of risk factors is recommended as this was associated with fewer DMSA abnormalities than delaying CIC. Recommendations for expectantly-managed patients include close follow-up, serial US and UD, and prompt initiation of CIC upon recognition of new hydronephrosis, reflux, elevated storage pressures, or febrile UTIs.

The emerging role of patient-reported outcomes in urology.

The emerging role of patient-reported outcomes in urology.

Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning

BackgroundCloacal malformations represent a uniquely complex challenge for surgeons. The surgical approach to date has been based on the common channel (CC) length with two patient groups considered: less than or greater than 3cm, which we believe is an oversimplification. We reviewed 19 patients, referred after surgery done elsewhere. Eight had postoperative urinary complications, 3 had constant urinary leakage and had been left after surgery with a urethra <1cm, .5 with an original 3 to 5cm common channel, who had undergone total urogenital mobilization (TUM), experienced peri-operative urethral loss needing a vesicostomy, and later, a Mitrofanoff. These patients together with a review of the cloacal and urological literature led us to design a new algorithm where urethral length is a key determinant for care. MethodsWe prospectively collected data on 31 consecutive cloaca patients referred to our team (2014 to 2016) and managed according to this new protocol. The CC length, urethral length, surgical technique employed, and initial outcomes were recorded. ResultsOf 31 primary cases, CC length was 1 to 3cm in 20, 3 to 5cm in 9, and greater than 5cm in 2. In the 1 to 3cm and the 3 to 5cm groups, a urethra less than 1.5cm led us to perform an urogenital separation. We only performed a TUM if the urethra was greater than 1.5cm. Using this protocol, we performed a urogenital separation in 1 of 20 in the 1 to 3cm CC group, 6 of 9 in the 3 to 5cm CC group, and 2 of 2 in the greater than 5cm CC group. Seven patients underwent separation, who with the previous approach, would have had a TUM. Thus far, no urinary leakage or urethral loss has occurred in any patient, but follow-up is less than 3years. ConclusionUrethral length appears to be a vitally important component in cloacal reconstruction. A short urethra left after repair can lead to urinary leakage. A TUM done under the wrong circumstances can lead to urethral loss. We describe a new technical approach to cloacal repair which considers urethral length but recognize that long term urological outcomes will need to be carefully documented. Type of studyClinical cohort study with no comparative group. Level of evidenceLevel 4.

Re: Patient-Reported Social, Psychological, and Urologic Outcomes after Adult Buried Penis Repair.

Re: Patient-Reported Social, Psychological, and Urologic Outcomes after Adult Buried Penis Repair.

Scientific background of telemedicine-based approaches for medical care organization in urology

The paper includes organizational issues of telemedicine usage in field of urology. Negative outcomes of an urological care had been described and classified. Proposed complex telemedicine system allows to decrease influence of a set of negative factors linked with bad outcomes in urology. (For citation: Apolihin OI, Shadjorkin IA, Perhov VI, et al. Scientific background of telemedicine-based approaches for medical care organization in urology. Urologicheskie vedomosti. 2017;7(3):14-21. doi: 10.17816/uroved7314-21).

Clinical and urodynamic outcomes in children with anorectal malformation subtype of recto-bladder neck fistula

Patients with anorectal malformations (ARMs) have a high incidence of genitourinary anomalies. Those with a recto-bladder neck fistula may represent a high-risk group, but their long-term urologic outcomes are poorly described. To evaluate the clinical and urodynamic outcomes in a large cohort of patients with an ARM subtype of recto-bladder neck fistula. A retrospective cohort study was performed of patients who had been treated for a recto-bladder neck fistula at the present institution since 2007. The primary outcomes were the ability to achieve urinary continence after 4 years of age, and development of a mildly decreased glomerular filtration rate (GFR) or worse (<89ml/min/1.73m2). Continence was defined as the ability to store urine for 3-4h during the day and 8h overnight without leakage. Demographic and clinical data are provided in the Summary Table. The most recent urodynamic findings included the presence of detrusor overactivity in 30 (75%) patients, median leak point pressure of 56.0cmH2O (range, 14-140), median functional cystometric capacity at 40cmH2O of 125.5% age-expected capacity (range, 36-473%), and median maximum cystometric capacity of 131.0% age-expected capacity (range, 44-473%). A mildly decreased GFR or worse developed in 13 (24%) patients. Of the 52 (78%) patients who were followed by pediatric urology at the present institution with a median follow-up of 30.9 months (range, 0.0-86.8), 35 (67%) were at least 4 years of age and could be assessed for continence. Continence was achieved in five (14%) patients voiding spontaneously and 15 (43%) performing CIC. Recurrent urinary tract infections (UTI) (OR 0.70, P=0.006) were an independent predictor of incontinence, while urethral anomalies (OR 1.40, P=0.03) were an independent predictor of chronic kidney disease (CKD) on multiple logistic regression analysis. The findings favorably compared with other studies, but were more robust due to the size of the cohort and breadth of urologic evaluation. Limitations included the retrospective design at a single institution. Incomplete clinical data and misclassification of continence may have lead to bias. This large cohort of patients with an ARM subtype of recto-bladder neck fistula had a high incidence of genitourinary anomalies. They were rarely able to achieve continence with spontaneous voiding alone and were at risk of developing CKD, both of which were likely multifocal in origin. Long-term urologic follow-up is warranted for patients with a recto-bladder neck fistula.