Urological Procedures Research Articles

The effect of preoperative oral hygiene on postoperative infections after cystectomy and urethroplasty—A quasi‐experimental study

AbstractResearch has demonstrated that systematic preoperative oral hygiene reduces nosocomial infections after elective thoracic surgery. However, the impact of preoperative oral hygiene on patients undergoing urologic procedures is unknown. Therefore, the aim of this study was to investigate the effects of systematic preoperative oral hygiene on prescriptions with antibiotics following cystectomy or urethroplasty. A quasi‐experimental study design included all patients undergoing elective radical cystectomy or urethroplasty from 1 January 2018 to 31 May 2021. Patients undergoing cystectomy or urethroplasty were grouped into a prospective intervention group and a retrospective control group. Patients in the intervention group were admitted from 1 January 2020 to 31 May 2021, and were recommended to brush their teeth and rinse their mouths with chlorhexidine gluconate 0.12% four times a day starting 2 days before surgery and continuing until the morning of the operation. Patients admitted from 1 January 2018 to 31 December 2019 received no oral hygiene recommendations and were used as a retrospective control group. Data on oral hygiene performance were self‐reported and collected at admission and data on prescription of antibiotics were collected through the patients' records. The relative risk was calculated to report the effect of the intervention. In total, 39 patients with cystectomy were in the intervention group, whereas 31 were in the control group. For patients having urethroplasty, 27 were in the intervention group and 98 were in the control group. The effect of oral hygiene on the prescription of antibiotics for patients who completely adhered to the oral hygiene recommendations showed a relative risk of 0.554 (95% CI 0.333–0.921) p = 0.02 for cystectomy and 0.825 (95% 0.308–2.209) p = 0.70 for urethroplasty. This study showed a statistically significant reduction in the prescription of antibiotics following oral hygiene recommendations for patients undergoing cystectomy. However, no statistically significant effect was demonstrated for patients undergoing urethroplasty. Despite this result, it seems important to be aware of oral hygiene in patients undergoing surgery to potentially reduce the number of infections and the use of antibiotics because of the antimicrobial resistance that the healthcare system faces.

Comparing outcomes of single-use vs reusable ureteroscopes: a systematic review and meta analysis.

Flexible ureterolithotripsy is a frequent urological procedure, usually used to remove stones from the kidney and upper ureter. Reusable uretero-scopes were the standard tool for that procedure, but recent concerns related to sterility and maintenance and repair costs created the opportunity to develop new technologies. In 2016, the first single-use digital flexible ureteroscope was introduced. Since then, other single-use ureteroscopes were developed, and studies compared them with the reusable ureteroscopes with conflicting results. The purpose of this study is to describe the literature that compares the performance of single-use and reusable flexible ureteroscopes in retrograde intrarenal surgery for urinary stones. A Systematic Review was performed in October 2022 in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). A search in MEDLINE, EMBASE, Web of Science, Google Scholar and LILACS retrieved 10,039 articles. After screening, 12 articles were selected for the Meta-Analysis. No differences were found in stone-free rate (OR 1.31, CI 95% [0.88, 1.97]), operative time (MD 0.12, CI 95% [-5.52, 5.76]), incidence of post-operative fever (OR 0.64, CI 95% [0.22, 1.89]), or incidence of post-operative urinary tract infection (OR 0.63 CI 95% [0.30, 1.32]). No differences were observed in the studied variables. Hence, the device choice should rely on the availability, cost analysis and surgeons' preference.

Robotic-assisted laparoscopic Malone appendicostomy: a 6-year perspective.

A robotic-assisted laparoscopic approach to appendicostomy offers the benefits of a minimally invasive approach to patients who would typically necessitate an open procedure, those with a larger body habitus, and those requiring combined complex colorectal and urologic reconstructive procedures. We present our experience performing robotic-assisted appendicostomies with a focus on patient selection, perioperative factors, and functional outcomes. A retrospective review of patients who underwent a robotic-assisted appendicostomy/neoappendicostomy at our institution was performed. Twelve patients underwent robotic-assisted appendicostomy (n = 8) and neoappendicostomy (n = 4) at a range of 8.8-25.8years. Five patients had a weight percentile > 50% for their age. Seven patients underwent combined procedures. Median operative time for appendicostomy/neoappendicostomy only was 185.0min. Complications included surgical site infection (n = 3), stricture requiring minor operative revision (n = 2), conversion to an open procedure due to inadequate appendiceal length (prior to developing our technique for robotic neoappendicostomies; n = 1), and granuloma (n = 1). At a median follow-up of 10.8months (range 1.7-74.3months), 91.7% of patients were consistently clean with antegrade enemas. Robotic-assisted laparoscopic appendicostomy and neoappendicostomy with cecal flap is a safe and effective operative approach. A robotic approach can potentially overcome the technical difficulties encountered in obese patients and can aid in patients requiring both a Malone and a Mitrofanoff in a single, combined minimally invasive procedure.

Antibiotic prophylaxis with urodynamic studies in spinal cord injury: Assessing practice patterns and outcomes to guide future practice in a single center

Context/Objective Despite urinary tract infections (UTIs) being a common problem in patients with spinal cord injuries (SCIs), and a well-known complication of invasive urologic procedures, little consensus exists regarding the standard of care for peri-procedural antibiotic use for SCI patients undergoing urodynamics studies (UDS). Our research seeks to evaluate local antibiotic prophylaxis pattern in SCI patients undergoing UDS, assess incidence of post-procedural UTI, describe local antibiotic resistance trends, and provide antibiotic stewardship considerations to guide future practice. Design/Setting/Participants Retrospective cohort study of SCI patients undergoing UDS from January 2010 to January 2020 at a Veterans Affairs SCI Center. Data on patient demographics, UTI risk factors, pre-procedural urinalysis and culture, and peri-procedural antibiotics was extracted. Incidence of post-procedural UTI was tabulated. Findings were summarized using descriptive statistics. Results 331 patients were studied. Pre-procedural urine culture was done in 73% of cases, with positive results in 49%. E. coli was the most commonly isolated organism (19%). Antibiotics were used in 86% of cases, 26% of which had a negative culture. A onetime dose of intramuscular gentamicin given immediately pre-procedure was the most common practice (53%; N = 152). No cases of post-procedural UTIs were identified during the study period. Conclusion No post-UDS UTIs occurred under current local practice where most patients received a one-time dose of intramuscular gentamicin as prophylaxis. Though routine gentamicin prophylaxis may play a role in reducing UTI incidence, the low rate of post-UDS UTI in this population, including patients with positive cultures who received no antibiotics, suggests the possibility of refining practice patterns to improve antibiotic stewardship.

Gap analysis between trainees' subjective competencies and the competencies expected by instructors in urology: A need assessment survey in Japan.

According to the rapid progress in surgical techniques, a growing number of procedures should be learned during postgraduate training periods. This study aimed to clarify the current situation regarding urological surgical training and identify the perception gap between trainees' competency and the competency expected by instructors in Japan. Regarding the 40 urological surgical procedures selected via the Delphi method, we collected data on previous caseloads, current subjective autonomy, and confidence for future skill acquisition from trainees (<15 post-graduate years [PGY]), and the competencies when trainees became attending doctors expected by instructors (>15 PGY), according to a 5-point Likert scale. In total, 174 urologists in Hokkaido Prefecture, Japan were enrolled in this study. The response rate was 96% (165/174). In a large proportion of the procedures, caseloads grew with accumulation of years of clinical practice. However, trainees had limited caseloads of robotic and reconstructive surgeries even after 15 PGY. Trainees showed low subjective competencies at present and low confidence for future skill acquisition in several procedures, such as open cystectomy, ureteroureterostomy, and ureterocystostomy, while instructors expected trainees to be able to perform these procedures independently when they became attending doctors. Trainees showed low subjective competencies and low confidence for future skill acquisition in several open and reconstructive procedures, while instructors considered that these procedures should be independently performable by attending doctors. We believe that knowledge of these perception gaps is helpful to develop a practical training program.

Urological Outcomes in Post-Pubertal Patients With Myelomeningocele: A Single-Center Retrospective Study

BackgroundRecent decades have seen changes in the urological treatment of myelomeningocele (MMC). We aimed to evaluate the urological outcomes in post-pubertal patients and to clarify associations with walking status, hydrocephalus, and sex. MethodsA retrospective study of 103 MMC patients at their final pediatric urological control. Urological procedures, the necessity for Clean Intermittent Catheterization (CIC) and anticholinergic medication, the state of continence, renal ultrasound findings, and serum creatinine values were assessed. ResultsThe median age of the patients was 18 years (IQR 16.7–19.6), with 51 (49.5%) being female. Renal function was preserved in all but of one, who presented with mild hydronephrosis. 38 patients walked without assistance, 46 used wheelchairs. Most patients (93%) utilized CIC, and 83% had interventions for overactive or poorly compliant bladder, including anticholinergic medication (47%), Botox treatments (35%), or bladder augmentation (36%). Nearly half (45%) had undergone bladder neck procedures. Continence status revealed 55% fully continent, 18% were rarely incontinent, and 26% were incontinent daily, with most episodes limited to droplet leakage. Incontinence was not associated with the ambulatory status, hydrocephalus, or sex (p = 0.08, >0.99, and 0.07 respectively). ConclusionsRenal function was effectively maintained with our treatment strategy; however, daily incontinence episodes occurred in one out of four patients, with an additional 18% experiencing occasional rare incontinence episodes. Incontinence, when present, was mostly mild. We found no association between patient characteristics, treatment approach, and continence. Emphasizing incontinence treatment becomes a mainstay in future studies. Level of EvidenceIV.

Single Port Modified Partial Nephrectomy: Novel Simultaneous Access to Peritoneal and Retroperitoneal Partial Nephrectomy, Initial Clinical Experience.

Introduction and Objective: Since its Food and Drug Administration (FDA) approval in 2018, Intuitive Surgical DaVinci single port (SP) robotic platform has been an effectively used technology for multiple urologic procedures. The purpose of this study is to share our early intraoperative and perioperative outcomes and potential benefits for performing a lower anterior access (LAA) incision for SP robot-assisted partial nephrectomy (SP-RAPN). The LAA incision enables performing a trans- or retroperitoneal (RP) approach through the same incision and eases the transition to a RP approach. Methods: This study is a prospective review of 78 SP-RAPN cases between March 2021 and January 2023 by an experienced robotic surgeon. A single 2-3 cm oblique incision parallel to the external oblique muscle, one-third of the distance between the iliac crest and umbilicus, was used to insert the multichannel port to perform the RAPN. We extracted intra- and perioperative data of these patients to share the outcomes of this approach. Results: SP-RAPN was effectively completed in 78 patients (38 females and 40 males) without conversion to open or laparoscopic techniques. The mean age was 61.2 ± 12.1 years. The mean tumor size was 3.0 ± 1.2 cm, 43 were right-sided masses, and 35 were left sided. The R.E.N.A.L Nephrometry score ranged from (4-11) with an average of 7.0 ± 1.9. Average operating room time was 90.5 ± 24.6 minutes, estimated blood loss was 88.3 ± 134 mL, and length of stay of 1.07 ± 0.7 days. Of the 78 cases, 40 required clamping of the renal artery with average warm ischemia time of 19.4 ± 6.7 minutes in patients who underwent clamping. No complications in all of 78 patients. Conclusions: This study demonstrates the feasibility and reproducibility of SP-RAPN using a LAA incision. This incision provides a standardized approach for surgeons to transition to the RP approach using the SP platform.

(040) Local Anesthesia Only for Penile and Scrotal Procedures: A Prospective Analysis of Patient Tolerability as an Alternative to Sedation

Abstract Introduction Traditionally, urological procedures utilize general or spinal anesthesia (GA) in an operating room (OR) to achieve adequate periprocedural pain relief. However, this approach presents various obstacles, including high OR related expenses, difficulties in accessing healthcare in rural areas, higher risk of anesthetic related complications and long wait times for patients due to limited OR space. This is particularly evident in penile and scrotal procedures, which often receive non-urgent treatment and result in wait times exceeding six months in Canada. The use of local anesthesia (LA) only is an appealing approach that has been gaining more traction in recent literature – however, no study to date has evaluated patient-reported tolerability to procedures conducted in this manner. Objective To investigate the surgical outcomes and patient-reported tolerability of penile and scrotal urologic procedures performed solely under LA. Additionally, information regarding complications is collected to provide data regarding the safety of this method, offering a viable alternative without the need for sedation. Methods This prospective study is registered as a clinical trial NCT05617261. Adult patients undergoing penile or scrotal surgery under LA only have been enrolled since August 2022, and is ongoing until August 2023. Procedures of interest include hydrocelectomies, spermatocelectomies, epididymectomies, testicular biopsies, circumcisions and frenulectomies. For scrotal procedures LA is administered along the median raphe along with a spermatic cord block, and for penile procedures a subcutaneous ring and dorsal penile block is utilized. Demographics, surgeon- and patient-reported visual analogue pain scores (VAS), and surgical variables are collected. Patient tolerability to the procedure and future anesthetic choice for a hypothetical repeat procedure are assessed at a follow-up appointment as our primary outcome. Complication data is also collected including recurrence (if applicable), emergency room visits, excess pain, hematoma &amp; infection. Statistical tests include analyses to determine associations between demographic or surgical variables and patient-reported outcomes. Results Thus far, 215 patients are enrolled with complete follow-up data and statistical analysis on 72 patients. The mean age ± SD is 42.2 ± 16.4 years and there has been a 100% success rate with no perioperative complications or conversions to sedation or general anesthetic. Table 1 highlights the current patient demographic differences between those who do or do not recommend LA. Table 2 describes VAS at each point in time. On follow-up, 93.1% of patients indicated they would opt for LA for a hypothetical repeat procedure, with Figure 1 illustrating this by procedure type. Of the minority opting for GA, only 2 patients did so due to excess pain – highlighting that patient tolerability is not a limiting factor; instead, a desire to have no memory of the procedure is prevalent in this small cohort. Conclusions LA only is a promising technique for various scrotal and penile urologic procedures with high levels of patient tolerability. As we continue our analysis, we anticipate minimal complication rates similar to existing literature and data highlighting cost savings to our public health care system with a substantial reduction in patient wait times and surgical and recovery times – allowing for increased surgical efficiency and accessibility. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

(048) Synchronous Management of Urethral Stricture Disease and Penile Prosthesis Implantation: A Case Series

Abstract Introduction Urethral stricture disease (USD) is found in approximately 0.9% of all men in developed countries; however, the prevalence of USD is expected to increase with time due to an aging population, a rising incidence of prostate cancer, the use of radiotherapy, and increasing utilization of endoscopic procedures in urology. Due to an increasing prevalence of USD, surgeons may encounter an undiagnosed urethral stricture at increasing rates during penile prosthesis (PP) implantation, and there is currently limited data to evaluate the risk of treating the stricture at that time. Objective Our study aims to monitor the outcomes of PP placement in the event of a urethral stricture. Methods A retrospective IRB-approved review (IRB00205900) was performed using the Johns Hopkins EMR for patients that had undergone PP implantation and incidentally found USD at the time of procedure from 2009 to 2023. Patients undergoing PP implantation without incidentally finding USD were excluded. Cases that could proceed as planned were classified as “completed,” while cases that could not proceed were classified as “aborted.” Stricture characteristics (location, size), procedural information, pertinent demographic data, and comorbidities were noted. Successful management was defined as the absence of complications requiring explantation, including device infection, erosion, or failure, within 90 days of the procedure. Recurrence of stricture was defined as the presence or worsening of obstructive lower urinary symptoms at any post-operative follow-up visits. Results Of the 2375 PP implantations performed from 2009 to 2023, twenty-four cases were identified in which an incidental USD was found. Out of the twenty-four patients, eighteen patients (75%) had IPPs implanted, while six patients (25%) had their procedures aborted. Of the eighteen patients, thirteen (13/18, 72.2%) underwent urethral dilation with Amplatz dilators, three patients (3/18, 16.7%) had passive dilation with a 16 F flexible cystoscope, and two patients (2/18, 11.1%) received a direct vision internal urethrotomy (DVIU). Within 90 days after the procedure, only one patient presented with urinary retention four days after the procedure (1/18, 5.6%). No PP infections were reported within 90 days in any patient. Only one patient (1/18, 5.6%) had their device explanted due to extrusion five years after the procedure. One patient had a recurrence of their stricture after four years (1/18, 5.6%). Of the six patients that had their procedures aborted, three patients (3/6, 50.0%) underwent urethroplasty. One patient (1/6, 16.7%) underwent urethral dilation and suprapubic tube placement, and two patients (2/6, 33.3%) underwent a DVIU. Five of these six cases had strictures greater than 2 cm with urethral lumens between 8-10F (5/6, 83.3%), while one patient had an obliterated urethra (1/6, 16.7%). Conclusions This retrospective case study of patients receiving synchronous USD management and PP implantation yielded high success and low complication rates. While a large, multi-institutional study should be performed, our study displays promising results and creates a framework that other surgeons may follow. Disclosure No.

(041) Pre-Operative Bilateral Pudendal Nerve Blocks can Reduce Opioid Utilization for Patients Undergoing Urologic Prosthetic Procedures

Abstract Introduction Opioid related overdoses and deaths have been increasing in recent decades, and recent studies have shown that even short courses of opioids can result in dependence and misuse. Urologic prosthetic procedures can be painful, and historically pain management has been predominantly through opioid-based analgesia. Multimodal pain management plans have been shown to help reduce exposure to opioids, and these include local nerve blockade. Objective Our study aims to assess the efficacy of bilateral pudendal nerve block in post-operative pain management and reduction of opioid use. Methods We conducted a retrospective review of all patients undergoing urologic prosthetic surgeries at a single Canadian institution between September 2020 and June 2023. Prosthetic surgeries included inflatable penile prosthesis (IPP) and artificial urethral sphincter (AUS) implants and explantation/reimplantation, but patients were only included once during the study period. Patients with chronic pain or missing pain data were excluded. Patients received bilateral pudendal nerve blocks at the discretion of the surgeon as a practice change starting in 2021 and compared to a control group (no blocks). Pain was assessed by the nursing care team using an analogue rating scale (out of 10), and all opioid and non-opioid pain medications were blindly recorded by nursing as their part of their usual documentation. Opioid utilization was converted to oral morphine equivalents (OMEs). Primary outcome was OMEs utilization in the post-operative period while in hospital, with a secondary of overall pain scores. Data was analysed using two-sample t-tests, and significance set to a p-value of 0.05. Results Our study included a total of 134 patients, with 59 patients receiving preoperative bilateral pudendal nerve blocks (54 IPP, 5 AUS), and 75 patients receiving the standard protocol (31 IPP, 44 AUS). The median age of patients receiving pudendal nerve blocks was 62.51 compared to the control group median age of 67.81. (p&amp;lt;0.05). There was no difference in ages in sub-analysis of IPP and AUS cohorts. Sub-analysis of the AUS cohort demonstrated a lower median pain score immediately post-op for those receiving blocks compared to control (0.8 vs. 2.73 respectively, p&amp;lt;0.05), with no difference in pain scores otherwise. AUS patients with pudendal nerve blocks consumed significantly less OMEs on day of surgery (median 0 vs. 6.75 OMEs, p&amp;lt;0.05). The IPP cohort with pudendal nerve blocks had no difference in pain scores compared to control, but consumed significantly less OMEs on day of surgery (9.06 vs. 12.56 OMEs respectively, p&amp;lt;0.05) and on post-operative day one (2.99 vs. 7.30 OMEs respectively, p&amp;lt;0.05). Conclusions Preoperative bilateral pudendal nerve blocks appear to reduce post-operative opioid use for patients undergoing urologic prosthetic surgery. Regular use of pudendal nerve blocks for patients undergoing prosthetic and pelvic surgeries may be an efficient means to reduce patient exposure to opioids. Bilateral pudendal nerve blockade for all genital and pelvic surgeries may be an effective opioid harm reduction strategy and warrants further investigation and patient satisfaction outcomes. Disclosure No.

(273) The Use of In-Office Nitrous Oxide to Aid in Diagnosing Hypertonic Pelvic Floor and Improve Patient Comfort with Pelvic Exams

Abstract Introduction Nitrous oxide is an anesthetic, anxiolytic, and analgesic commonly used for general and dental anesthesia, sedation, and severe pain. Studies show that nitrous oxide is also used in several in-office gynecological and urological procedures as a sedative and anxiolytic agent with a safer drug profile than other anesthetic agents. It is also being trialed as a treatment for mood disorders. Nitrous oxide does not render individuals unconscious, making it a more favorable option for stressful and painful medical procedures than general anesthesia because it allows the patient to feel more in control of their body and aware of the proceedings. Objective To analyze the use of in-office nitrous oxide during medical procedures and evaluate its effectiveness in reducing pain and anxiety levels to predict the utility of it during pelvic exams in patients with vestibulodynia. Methods A literature review was performed through the PubMed database between 2007-2022. The authors independently and thoroughly screened abstracts and full-text articles and assessed the relevant medical literature that acknowledged the use of nitrous oxide in in-office medical procedures. Key terms used to refine the search include [“nitrous oxide in medical procedures”], [“nitrous oxide in gynecology”], [“nitrous oxide in urology”]. Results One study explored the use of nitrous oxide during childbirth in women diagnosed with PTSD, and the results were significant for nitrous oxide reducing PTSD symptom severity. Multiple studies suggest the use of nitrous oxide during dental procedures reduces patient anxiety; one specifically measured sixty anxious patients pre- and post-endodontic procedures and noted a significant reduction in anxiety during the procedure with the use of nitrous oxide. Various studies of gynecological and urological procedures report the successful use of nitrous oxide in reducing peri-procedural pain compared to other analgesic alternatives. A common example is its use during intrauterine device insertion, which is correlated with higher patient satisfaction as it decreases pain. Additionally, a study among patients undergoing extracorporeal shockwave lithotripsy found no significant difference between the use of meperidine, an opioid, and nitrous oxide in post-procedural Visual Analog Scale pain scores with no adverse events reported in the nitrous oxide group. Another study revealed that using local anesthesia in transrectal prostate biopsies resulted in some patients experiencing notable anxiety and pain. At the same time, no such relationship was observed among patients who received nitrous oxide before this procedure. Conclusions Vestibulodynia is a subset of genitopelvic pain isolated to the vulvar vestibule. Vestibulodynia has three proposed etiologies: tissue neural proliferation, musculoskeletal, and hormonally mediated. Discriminating these three etiologies can be difficult, especially when a proper pelvic exam cannot be achieved due to patients’ discomfort. The three etiologies are biologically intertwined, often resulting in vestibulodynia patients experiencing pelvic floor hypertonicity without regard to specific etiology. A painful pelvic exam is stressful and often an anxiety-producing experience for patients with pelvic hypertonicity and vulvodynia. Hence, with the data provided, we suspect that nitrous oxide will be a useful treatment option to mitigate these consequences for the patient, with the added benefit of easing the exam for the provider, leading to a more accurate diagnosis. Disclosure No.

(376) High Capability of ChatGPT to Answer Common Patient Questions on Vasectomy Reviewed by Sexual Medicine Specialists

Abstract Introduction Novel technologies utilizing artificial intelligence (AI) have shown their potential to reduce provider workload and improve task efficiency in certain clinical settings. ChatGPT is an AI-powered chatbot which utilizes natural language processing (NLP) technology to provide human-like responses to open-ended questions posed by users. Recent studies have shown ChatGPT’s ability to provide diabetes counseling in lieu of trained educators, and effectively communicate technical research papers in layman’s terms to patients. Vasectomy is a common urologic clinic procedure that can be a source of anxiety for patients, many of whom desire the opportunity for further pre-operative counseling. Objective The objective of this preliminary study was to evaluate the ability of ChatGPT to respond to common patient questions on vasectomy encountered by sexual medicine specialists. Methods We composed a list of 20 questions commonly asked by patients pertaining to vasectomy. The questions were submitted to ChatGPT Plus with the prompt: “Answer the following questions in 50 words or less”. 3 fellowship-trained sexual medicine specialists then rated the accuracy of ChatGPT’s responses on a scale from 1-5 (1 representing a completely inaccurate response and 5 representing a response in line with what they would recommend to patients). Scores were tabulated and summarized (Table 1). Descriptive statistics were performed. Weighted Cohen’s kappa was calculated to assess for interrater reliability. Results Median score across all 20 responses from 3 raters was 4.1 (IQR 1.3). The most common rating was 5, indicating a high level of agreement between ChatGPT’s responses and those of sexual medicine specialists. The lowest score assigned was 2 (indicating poor accuracy), and was received by 6 responses. Weighted Cohen’s kappa was 0.49, implying moderate agreement amongst raters. Overall, ChatGPT was able to provide relatively accurate and concise responses to these common questions. Conclusions Our results demonstrate the capability of using ChatGPT as a potentially reliable source of information for patients desiring vasectomy counseling. Given the high clinical volume faced by many vasectomy providers, ChatGPT could possibly improve patient satisfaction and reduce provider burden. Further collection of real-world data is needed to better assess the accuracy and reliability of ChatGPT’s responses. Sexual medicine specialists should be aware of the strengths and limitations of emerging AI technologies as a medium for providing accurate health information to patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow, Posterity Health, Coloplast, Hims, Genentech.

(286) Gender Disparities Exist in the Surgical Management of Peyronie's Disease and Urologic Prosthetics: An Evaluation of American Board of Urology (ABU) Surgical Case Logs

Abstract Introduction Urology has been predominantly male-dominated, although recent trends indicate increased female representation among urology residents, physicians and advanced-practitioner providers. While progress has been made, gender disparities persist due to societal perceptions and biases. The goal of this study was to investigate whether a provider gender gap exists in the field of reconstructive urology using American Board of Urology (ABU) case logs. Objective To examine case volume characteristics for provider gender disparities in Peyronie’s disease and urologic prosthetic surgery. Methods Retrospective review of surgical case log data from 2003 to 2023 of certified urologists was performed for 11 Current Procedural Terminology (CPT) codes for the surgical management of Peyronie’s disease (penile plication CPT 54360, plaque excision/incision with grafting CPT 54111, 54112), male urethral sling or artificial urinary sphincter (CPT 53440, 53445), and placement of penile implant (CPT 54400, 54401, 54405). Inclusion criteria included male patients who were 18 years old or older. Data collected included patient and surgeon demographics, surgical procedure, and surgeon fellowship training status. Cases were analyzed using descriptive statistics and regression testing. Results From 2003 to 2023, a total 2,852 urologists performed 15,171 Peyronie’s disease and urologic prosthetic surgical procedures. Among these procedures, 1,910 (13%) Peyronie’s disease, 8,940 (59%) penile implant, and 4,321 (28%) incontinence procedures were identified. Out of the total practicing urologists, 2,626 were male and 226 were female; the distribution of cases revealed 5 cases performed per male surgeon and 4 cases per female surgeon. Over two decades, there was a significant positive trend in the proportion of cases performed by female surgeons (p &amp;lt; 0.001). 169 (6%) surgeons completed fellowships in Andrology or Male Reconstruction, and performed 2,129 (14%) of total procedures. Across surgeons with Andrology or Male Reconstruction fellowship-training, there were 13 cases performed per male surgeon and 7 cases per female surgeon. Conclusions Our study confirms underrepresentation of female surgeons in the field of Peyronie's disease and prosthetic urology. Although there is a trend of increasing female representation over time, further research can be done to identify barriers to gender equality in the field. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast.

(373) Economic Benefits of Patient Care for Prostate Cancer Survivors with Stress Urinary Incontinence and/or Erectile Dysfunction: A Physician Reimbursement Analysis

Abstract Introduction Reconstructive urological procedures play a vital role in enhancing the satisfaction and quality of life of patients with prostate cancer (PCa) following radical prostatectomy (RP). Providing comprehensive postoperative care for common side effects of post-RP, including stress urinary incontinence (SUI) and erectile dysfunction (ED), may result in a greater number of patients with PCa receiving needed consultations and therapies. This analysis sought to explore the potential economic benefits of offering men’s health consultations and reconstructive care for PCa survivors. Objective This study quantified the relative value units (RVUs) generated from providing patient care to PCa survivors covered by Medicare Fee-for-Service who may experience SUI and/or ED due to RP. Methods This physician reimbursement analysis was based on typical patient care pathway scenarios for patients at risk of developing SUI or ED post-RP. Current Procedural Terminology (CPT) codes were utilized to identify and describe the care provided to patients in each scenario, leading to an artificial urinary sphincter (AUS) or male sling for SUI and/or an inflatable penile prosthesis (IPP) for ED. The 2023 CMS Physician and Clinical Laboratory Fee Schedule and Medicare reimbursement rates were used to obtain the most recent RVUs and reimbursement for each CPT. RVUs represent the value assigned to a service or procedure performed by a physician and are used to capture the relative cost values associated with patient care. For each scenario, we reported the total RVUs, which include work, non-facility or facility, and malpractice RVUs, and the total physician reimbursement. The 2023 Physician Conversion Factor was used to calculate the Medicare physician reimbursement. The Medicare physician reimbursement was used as a conservative estimate. Results The four clinical pathway scenarios were patients who did not experience recurrent SUI or ED (no recurrent SUI/ED), patients who only experienced SUI (only SUI), patients who only experienced ED (only ED), and patients who experienced both SUI and ED (SUI + ED). For the no SUI/ED scenario, the total RVUs from providing patient care were 5.26 RVUs, resulting in $205 in physician reimbursement. For the only SUI scenario, the total RVUs were 56.20 RVUs with an average of $1,996 in physician reimbursement for those receiving AUS and 55.54 RVUs with an average of $1,974 in physician reimbursement for those receiving male sling. For the only ED scenario, the total RVUs were 42.51 RVUs, resulting in $1,550 in physician reimbursement. For the SUI + ED scenario, the total RVUs were 98.71 RVUs with an average of $3,547 in physician reimbursement for those receiving AUS and 98.05 RVUs with an average of $3,524 in physician reimbursement for those receiving male sling. Conclusions This study justified the economic benefits of expanding patient care to men who underwent RP for PCa and provided urology practice insight into the potential physician reimbursement when PCa survivors were seen by reconstructive urologists. Disclosure Yes, this is sponsored by industry/sponsor: Boston Scientific. Clarification: Industry initiated, executed and funded study. Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

Effect of core preventative screening on kidney stone surgical patterns.

In the surgical treatment of kidney stones, decreased access to healthcare has been shown to exacerbate stone burden, often requiring more invasive and extensive procedures. The objective of this study is to evaluate the effects of preventative health screening on kidney stone surgical treatment patterns. We performed a retrospective analysis of data from the Healthcare Cost and Utilization Project (HCUP) Florida state-wide dataset and the PLACES Local Data for Better Health dataset from the Centers of Disease Control and Prevention (CDC). ZIP Code Tabulation Areas (ZCTAs) identified from the PLACES data were merged with the HCUP dataset to create a single dataset of community-level stone outcomes and community health measures. We included adult patients 18years or older who underwent at least one urologic stone procedure from 2016 to 2020. 128,038 patients from 885 communities were included in the study. Patients underwent an average of 1.42 surgeries (Median = 1.39, SD = 0.16). Increased core preventative screening was associated with increased surgical frequency (Estimate: 0.51, P < 0.001). The low core preventative screening group had a higher prevalence of PNL than SWL while the high core preventative screening group had a low PNL prevalence compared to SWL. Increased core preventative screenings are associated with less invasive kidney stone surgeries, suggesting that preventative screenings detect stones at an earlier stage.

Displacement of a Ureteral Single J Stent into the Heart: A Case Report and Literature Review

The placement of urethral stents is a commonly performed procedure in urology, typically without complications. However, as illustrated in the present case, major complications can arise. It is crucial to be vigilant about the risk of intravascular or intracardiac malpositioning of the ureteral device, especially when there is an unfavorable evolution or the presence of hematuria. We present the case of a 68-year-old patient undergoing treatment for locally advanced cervical cancer with concomitant radiotherapy and chemotherapy. In the course of her follow-up, the patient developed obstructive renal failure due to extrinsic compression of the ureters. Despite attempts with JJ stent placement, emergency renal drainage became necessary, leading to bilateral nephrostomy. In order to alleviate the patient from nephrostomy tubes and enhance her quality of life, bilateral direct cutaneous ureterostomy was performed, with Single-J probes placed in both ureters. However, during the 4th tube change, conducted without scopic control, the patient experienced thoracic and low back pain at 8 days post-operatively. The CT scan revealed that the left Single-J probe bypassed the renal pelvis without penetrating it. Instead, it ascended the IVC, entering the right atrium, and subsequently reached the right ventricle, accompanied by left pyelocaliectasis. The resolution of the issue was achieved through the implementation of a multidisciplinary approach, engaging the expertise of both urologists and vascular surgeons. The removal procedure involved extracting the distal end of the catheter using a ureteroscope, with simultaneous collaboration from the vascular surgery team. The vascular surgeons performed femoral access and phlebography both during and after catheter removal to mitigate the risk of potential bleeding from the inferior vena cava (IVC). Abdominal access for laparotomy was prepared in anticipation of potential bleeding." The patient underwent placement of a left Single-

Analysis of pathogen distribution and associated risk factors for surgical site infections following laparoscopic urological surgeries

AbstractSurgical site infections (SSIs) pose a significant complication following laparoscopic urological surgeries, impacting patient recovery and healthcare resources. Understanding the pathogen distribution and identifying associated risk factors for SSIs is critical for improving surgical outcomes. A retrospective analysis was performed on 90 patients, from March 2020 to June 2023, to investigate the risk factors and pathogen profiles in SSIs post‐laparoscopic urological procedures. Patients with documented infections were compared to a control group without SSIs. Data on demographics, comorbidities and perioperative variables were collected. Pathogens were identified using the VITEK‐2 Compact system. Statistical analyses included univariate and multivariate logistic regression models. Upon evaluation, demographic and clinical characteristics showed no significant variance in patients with SSIs compared to those without such infections. The predominant pathogen identified was Escherichia coli. Administration of prophylactic antibiotics correlated with a reduced incidence of SSIs, whereas an array of risk factors including surgery duration of 2 h or more, anaemia, white blood cell counts exceeding 10 × 109/L, a history of urinary tract infections, the presence of diabetes mellitus and incidences of urinary leakage post‐surgery were identified as contributors to a heightened risk of SSIs. Prophylactic antibiotics serve as a protective factor against SSIs, whereas several modifiable risk factors, including operation duration, anaemia, elevated leukocytes, history of urinary infections, diabetes and urinary leakage, contribute to the increased risk.

Urology never events in the United Kingdom: A retrospective 10‐year review

AbstractObjectivesThe aim was to assess the prevalence of never events (NEs) specific to urology in the United Kingdom and identify commonly occurring themes.MethodsData from the National Health Service (NHS) NEs website were obtained and all NEs from 2012 to 2022 were reviewed. Urology‐specific NEs were identified and further analysed in their respective categories. Data regarding the total number of surgical procedures performed in the NHS specific to each specialty were obtained via the NHS Hospital Episode Statistics website.ResultsThere were 3972 NEs recorded over the 10‐year period with 95 (2.4%) of these as a result of urology surgery. The most common surgical intervention associated with a urological NE was ureteric stenting, which comprised 45/95 (47.4%) of all analysed NEs. These consisted of wrong site ureteric stent insertion (n = 29), wrong site ureteric stent removal (n = 9), wrong stent type (n = 5) and retained guidewires (n = 2). There were 7.14 million urology surgeries performed in the 10‐year period, and prevalence was 0.0013%.ConclusionNEs are fully preventable serious incidents in the NHS. This is the first study to investigate the prevalence of NEs in urology in the United Kingdom. This study demonstrates that in the last 10 years the prevalence of urology NEs is low at 0.0013%, with ureteric stent procedures accounting for more than half of the NEs. Urologists should be mindful of the potential for wrong site surgery in urologic stenting procedures.

Single-Port Transvesical Vesico-Vaginal Fistula Repair: An Initial Experience.

Vesicovaginal fistula (VVF) is the most common urogenital fistula due to iatrogenic cause, primarily associated with gynecologic surgery (1). Although both conservative and surgical management may be considered, the optimal treatment is still uncertain and several studies were published using different techniques (open, laparoscopic or robotic) and approaches (extravesical, transvesical or transvaginal) (2-5). In this context, we aim to report our initial experience repairing VVF with Single-Port (SP) Transvesical (TV) access. Four patients with a diagnosis of VVF underwent SP-TV VVF repair between May 2022 and December 2023. Diagnosis was confirmed by cystoscopy, cystogram and in two cases by CT Urogram. Under general anesthesia, before robotic time, patients were placed in lithotomy position and a preliminary cystoscopy was performed. Fistula was noted and a 5fr stent was placed through the fistulous tract. Two ureteral stents were placed. Then, with patient supine, a transverse suprapubic 3cm incision and 2cm cystotomy were made for SP access. First step was to mark and remove fistula tract to the vagina. The edges of the vagina and bladder were dissected in order to have a closure free of tension and to create three different layers to close: vagina, muscularis layer of the bladder and mucosal layer of the bladder. A bladder catheter was placed, and the two ureteral stents were removed at the end of procedure. Mean age was 53 years old and three out of 4 patients developed VVF after gynecologic surgery. Two patients underwent VVF repair 6 and 8 months after total hysterectomy. One patient developed VVF after total hysterectomy and oophorectomy followed by radiation therapy. Last patient developed VVF after previous urological procedure. Fistula diameter was between 11 and 15mm. Operative time was 211 min, including preliminary cystoscopy, stents placement and SP-access. All patients were discharged on the same day with a bladder catheter, successfully removed between post-operative day 14-18 after negative cystogram. Only in one case a ureteral stent was left because the fistula was closed to the ureteral orifice and we reported one case of UTI twelve days after surgery, treated with outpatient antibiotics. Mean follow-up was 8 months, patients were scheduled for regular follow-up visits and no recurrence was reported. All patients have at least 3 months of post-operative follow-up. Our experience suggests that SP Transvesical VVF repair may be considered as a safe and feasible minimally invasive treatment for small/medium fistulae (10-15mm).

Robot-Assisted Urological Oncology Procedures, Outcomes, and Safety in Frail Patients: A Narrative Review of Available Studies.

In this study, we assess the impact of frailty on the success rate and risk of complications of robot-assisted urological procedures and introduce effective preoperative screening tools to evaluate frail patients' fitness to tolerate robot-assisted urological surgery. We performed a search of electronic databases for available studies, published up to August 2023, investigating the outcomes of robot-assisted urological oncology procedures and their safety in frail patients. Sixteen studies were ultimately selected, investigating the implications of frailty in robot-assisted radical cystectomy, robotassisted partial nephrectomy, and robot-assisted radical prostatectomy. All the studies used the Clavien-Dindo classification of complications with serious complications considered as Clavien-Dindo 3. Frail patients significantly benefit from robot-assisted urological procedures in comparison to open surgery, with lower rates of blood transfusion and a shorter length of stay. However, they also have a higher risk of postoperative complications than non-frail patients, as well as increased rates of conversion to open, total hospital costs, and in-hospital mortality after robot-assisted procedures. Robot-assisted urological procedures can improve the postoperative recovery of frail patients in comparison to open surgery. Reliable frailty indexes such as the Johns Hopkins indicator and simplified frailty index, as well as the Geriatric 8 screening tool, should be routinely used in the preoperative assessment of frail patients to optimize surgical decision-making.