1
|
Emrich Accioly JP, Bena J, Xiao H, Jeong S, Khouri RK, Angermeier KW, Dewitt-Foy M, Nemunaitis G, Wood HM. Decisional regret and impacts on quality of life following genitourinary reconstruction for neurogenic bladder: A comparison between acquired and congenital spinal cord injury. PM R 2024. [PMID: 38676469 DOI: 10.1002/pmrj.13157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 11/06/2023] [Accepted: 11/14/2023] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Patient expectations and baseline health are important drivers of outcomes following major genitourinary reconstructive surgery for neurogenic bladder (NGB). Differences in expectations and quality of life (QoL) improvements among different populations with NGB remain insufficiently explored in the literature. OBJECTIVE To compare decisional regret (DR) and urinary-related QoL (UrQoL) in patients undergoing urinary diversion for NGB arising from spinal cord injury of acquired (A-SCI) and congenital (C-SCI) etiologies. We hypothesize that patients with A-SCI have higher expectations of improvement in QoL following surgery when compared with C-SCI, which may lead to higher DR and decreased UrQoL, postoperatively. DESIGN In this cross-sectional survey study, we compared A-SCI to C-SCI in terms of DR, UrQoL, and postoperative changes in self-reported physical health, mental health, and pain using validated patient-reported outcome measures. SETTING Participants were enrolled from a quaternary care institution via mail and MyChart. PARTICIPANTS The A-SCI group consistied of 17 patients with traumatic spinal cord injury the C-SCI group was composed of 20 patients with spina bifida. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The Decisional Regret Scale, Short form- Qualiveen (SF-Qualiveen), and Patient-reported outcomes measurement Information system-10 (PROMIS-10) Global Health surveys. RESULTS The A-SCI group displayed poorer preoperative physical health than the C-SCI cohort, but absolute postoperative changes in this score, along with mental health score and pain level, were not significant after adjusting for baseline scores and follow-up time. SF-Qualiveen scores revealed significantly worse impact of NGB in UrQoL for A-SCI than for C-SCI when adjusted for other factors. No differences in DR were seen between the groups. CONCLUSIONS Patients with A-SCI demonstrate lower self-reported baseline physical health compared with patients with C-SCI, which may have implications in setting patient expectations when undergoing urinary diversion. In this small cohort, we found a milder self-reported postoperative impact of NGB in UrQoL in patients with C-SCI.
Collapse
Affiliation(s)
- João Pedro Emrich Accioly
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - James Bena
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Huijun Xiao
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Stacy Jeong
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Roger K Khouri
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Kenneth W Angermeier
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Molly Dewitt-Foy
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gregory Nemunaitis
- Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hadley M Wood
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| |
Collapse
|
2
|
Khouri RK, Accioly JPE, DeWitt-Foy ME, Wood HM, Angermeier KW. Posterior Urethral Reconstruction at the Time of Rectourethral Fistula Repair: Technique and Outcomes. Urology 2024; 186:36-40. [PMID: 38403139 DOI: 10.1016/j.urology.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/11/2024] [Accepted: 02/19/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE To assess the impact of posterior urethral stenosis or defect on outcomes following rectourethral fistula (RUF) repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair. METHODS We identified 130 men who underwent RUF repair at our institution between 2003 and 2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months preoperatively), and 20 men suprapubic catheter placement (median, 5.5 months preoperatively). RESULTS RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intraoperatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%). At a median follow-up of 55.7 months (interquartile range (IQR), 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation. CONCLUSION Posterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis or defect.
Collapse
Affiliation(s)
- Roger K Khouri
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Northwell Health, The Smith Institute for Urology, New Hyde Park, NY
| | - João Pedro Emrich Accioly
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Molly E DeWitt-Foy
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Hadley M Wood
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Kenneth W Angermeier
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
| |
Collapse
|
3
|
Werneburg GT, Adler A, Khooblall P, Wood HM, Gill BC, Vij SC, Angermeier KW, Lundy SD, Miller AW, Bajic P. Penile prostheses harbor biofilms driven by individual variability and manufacturer even in the absence of clinical infection. J Sex Med 2023; 20:1431-1439. [PMID: 37837552 DOI: 10.1093/jsxmed/qdad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Culture-based studies have shown that penile prostheses harbor biofilms in the presence and absence of infection, but these findings have not been adequately validated using contemporary microbiome analytic techniques. AIM The study sought to characterize microbial biofilms of indwelling penile prosthesis devices according to patient factors, device components, manufacturer, and infection status. METHODS Upon penile prostheses surgical explantation, device biofilms were extracted, sonicated, and characterized using shotgun metagenomics and culture-based approaches. Device components were also analyzed using scanning electron microscopy. OUTCOMES Outcomes included the presence or absence of biofilms, alpha and beta diversity, specific microbes identified and the presence of biofilm, and antibiotic resistance genes on each prosthesis component. RESULTS The average age of participants from whom devices were explanted was 61 ± 11 years, and 9 (45%) of 20 had a diagnosis of diabetes mellitus. Seventeen devices were noninfected, and 3 were associated with clinical infection. Mean device indwelling time prior to explant was 5.1 ± 5.1 years. All analyzed components from 20 devices had detectable microbial biofilms, both in the presence and absence of infection. Scanning electron microscopy corroborated the presence of biofilms across device components. Significant differences between viruses, prokaryotes, and metabolic pathways were identified between individual patients, device manufacturers, and infection status. Mobiluncus curtisii was enriched in manufacturer A device biofilms relative to manufacturer B device biofilms. Bordetella bronchialis, Methylomicrobium alcaliphilum, Pseudoxanthomonas suwonensis, and Porphyrobacter sp. were enriched in manufacturer B devices relative to manufacturer A devices. The most abundant bacterial phyla were the Proteobacteria, Actinobacteria, and Firmicutes. Glycogenesis, the process of glycogen synthesis, was among the predominant metabolic pathways detected across device components. Beta diversity of bacteria, viruses, protozoa, and pathways did not differ among device components. CLINICAL IMPLICATIONS All components of all penile prostheses removed from infected and noninfected patients have biofilms. The significance of biofilms on noninfected devices remains unknown and merits further investigation. STRENGTHS AND LIMITATIONS Strengths include the multipronged approach to characterize biofilms and being the first study to include all components of penile prostheses in tandem. Limitations include the relatively few number of infected devices in the series, a relatively small subset of devices included in shotgun metagenomics analysis, and the lack of anaerobic and other expanded conditions for culture. CONCLUSION Penile prosthesis biofilms are apparent in the presence and absence of infection, and the composition of biofilms was driven primarily by device manufacturer, individual variability, and infection, while being less impacted by device component.
Collapse
Affiliation(s)
- Glenn T Werneburg
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Ava Adler
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Prajit Khooblall
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Hadley M Wood
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Bradley C Gill
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Sarah C Vij
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Kenneth W Angermeier
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Scott D Lundy
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Aaron W Miller
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Petar Bajic
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| |
Collapse
|
4
|
Werneburg GT, Lundy SD, Hettel D, Bajic P, Gill BC, Adler A, Mukherjee SD, Wood HM, Angermeier KW, Shoskes DA, Miller AW. Microbe-metabolite interaction networks, antibiotic resistance, and in vitro reconstitution of the penile prosthesis biofilm support a paradigm shift from infection to colonization. Sci Rep 2023; 13:11522. [PMID: 37460611 PMCID: PMC10352235 DOI: 10.1038/s41598-023-38750-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 07/14/2023] [Indexed: 07/20/2023] Open
Abstract
To understand differences between asymptomatic colonized and infected states of indwelling medical devices, we sought to determine penile prosthesis biofilm composition, microbe-metabolite interaction networks, and association with clinical factors. Patients scheduled for penile prosthesis removal/revision were included. Samples from swabbed devices and controls underwent next-generation sequencing, metabolomics, and culture-based assessments. Biofilm formation from device isolates was reconstituted in a continuous-flow stir tank bioreactor. 93% of 27 analyzed devices harbored demonstrable biofilm. Seven genera including Faecalibaculum and Jeotgalicoccus were more abundant in infected than uninfected device biofilms (p < 0.001). Smokers and those with diabetes mellitus or cardiac disease had lower total normalized microbial counts than those without the conditions (p < 0.001). We identified microbe-metabolite interaction networks enriched in devices explanted for infection and pain. Biofilm formation was recapitulated on medical device materials including silicone, PTFE, polyurethane, and titanium in vitro to facilitate further mechanistic studies. Nearly all penile prosthesis devices harbor biofilms. Staphylococcus and Escherichia, the most common causative organisms of prosthesis infection, had similar abundance irrespective of infection status. A series of other uncommon genera and metabolites were differentially abundant, suggesting a complex microbe-metabolite pattern-rather than a single organism-is responsible for the transition from asymptomatic to infected or painful states.
Collapse
Affiliation(s)
- Glenn T Werneburg
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA.
| | - Scott D Lundy
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA
| | - Daniel Hettel
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA
| | - Petar Bajic
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA
| | - Bradley C Gill
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA
| | - Ava Adler
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA
| | - Sromona D Mukherjee
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA
| | - Hadley M Wood
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA
| | - Kenneth W Angermeier
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA
| | - Daniel A Shoskes
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA
| | - Aaron W Miller
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, 44195, USA
| |
Collapse
|
5
|
DeWitt-Foy ME, Anele UA, Accioly JPE, Sharpe MG, Michael P, Angermeier KW. Cancer risk in bladder diverticula: a large institutional analysis of risk and management. Int Urol Nephrol 2023; 55:541-546. [PMID: 36525224 DOI: 10.1007/s11255-022-03447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Bladder diverticula (BD) are usually asymptomatic, but may increase the risk of infections, stones, or malignancy, likely due to urinary stasis within the BD. We aim to characterize the risk of bladder cancer (BC) within diverticula. METHODS Retrospective review was conducted of patients diagnosed with BD between 1994 and 2021 at a single institution. Cancer risk was characterized using descriptive statistics and multivariable logistic regression as appropriate. RESULTS We identified 764 patients with mean age 68 years, the majority of whom were male (87%) and Caucasian (86%). Of this total, 13.3% (102/764) had a diagnosis of BC and 35.3% of this subset (36/102) had definitive cancer within the BD. Diverticulectomy or partial cystectomy was performed in 13.6% (104/764), 76% of whom were preoperatively presumed to have benign disease. Surgical patients were younger and had larger BD. Of the 79 patients who underwent diverticulectomy without preoperative suspicion for cancer, 5 were incidentally diagnosed with BC on final pathology. On multivariable logistic regression, male gender [odds ratio (OR) = 2.6, p = 0.03] and increasing age (OR = 1.02, p = 0.03) were independent risk factors for BC diagnosis. Indwelling catheter, recurrent urinary tract infections (UTIs), and bladder stones did not affect the risk of BC. CONCLUSIONS The majority of patients with BD are not managed with surgery. BC is identified in a small but considerable proportion of patients with BD, with an even lower rate of incidentally diagnosed cancer among those undergoing BD surgery. Male gender and increasing age increased the risk of BC diagnosis.
Collapse
Affiliation(s)
| | - Uzoma A Anele
- University of Louisville Health, Louisville, KY, USA
| | | | | | | | | |
Collapse
|
6
|
Munoz-Lopez C, Lewis K, Dewitt-Foy M, Lone Z, Montague DK, Angermeier KW, Gill BC. Outcomes of Inflatable Penile Prosthesis following Radical Cystectomy - A matched Cohort Analysis. Urology 2023:S0090-4295(23)00144-9. [PMID: 36796542 DOI: 10.1016/j.urology.2023.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/22/2023] [Accepted: 01/30/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE To evaluate outcomes of inflatable-penile-prosthesis (IPP) implantation after radical-cystectomy compared with other etiologies of erectile dysfunction. MATERIALS AND METHODS All inflatable penile prostheses within the past 20 years in a large regional health system were reviewed, and erectile dysfunction etiology was determined as radical-cystectomy, radical-prostatectomy, or organic/other ED. Cohorts were generated by 1:3 propensity score match using age, body mass index, and diabetes status. Baseline demographics and relevant comorbidities were evaluated. Clavien-Dindo complications, grade, and reoperation were assessed. Multivariable logarithmic regression was used to identify the predictors of 90-day complications following IPP implantation. Log-rank analysis was used to assess the time-to-reoperation after IPP implantation in patients with a history of cystectomy compared with non-cystectomy etiologies. RESULTS Of 2600 patients, 231 subjects were included in the study. Comparing patients undergoing IPP for cystectomy vs. pooled non-cystectomy indications, those who underwent radical-cystectomy had a higher overall complication rate(24% vs. 9%, p=0.02). Clavien-Dindo complication grades did not differ across groups. Reoperation was significantly more common following cystectomy (cystectomy: 21% vs. non-cystectomy: 7%, p=0.01), however time to reoperation did not differ significantly by indication (cystectomy: 8 years vs non-cystectomy: 10 years, p=0.09). Among cystectomy patients, 85% of reoperations were due to mechanical failure. CONCLUSION Compared to other erectile dysfunction etiologies, patients undergoing IPP with a history of cystectomy have an increased risk of complications within 90-days of implantation and need for surgical device revision, but no greater risk for high-grade complications. Overall IPP remains a valid treatment option after cystectomy.
Collapse
Affiliation(s)
- Carlos Munoz-Lopez
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Kevin Lewis
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Molly Dewitt-Foy
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Zaeem Lone
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Drogo K Montague
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | - Bradley C Gill
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
| |
Collapse
|
7
|
Emrich Accioly JP, Maspero M, Zhao H, Khouri RK, Lavryk O, Angermeier KW, Hull T, Wood HM. Management and Outcomes of Ileal Pouch-Urethral Fistulas. Urology 2023; 172:213-219. [PMID: 36476982 DOI: 10.1016/j.urology.2022.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe a single-center experience with the management of ileal pouch-urethral fistulas (IPUF) following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS We retrospectively identified patients with documented IPUF managed at our institution from a urethral fistula cohort and analyzed their cases. RESULTS Thirteen patients who underwent surgeries for IPUF management from 2005-2022 were identified. Median age at IPAA was 29 years (range 11-53). Indications for IPAA included familial adenomatous polyposis (n=3) and ulcerative colitis (n=10). Median time from IPAA to fistula diagnosis was 15 years (range 0.5-38.5). Eleven patients were initially diverted with either loop (n=8) or end ileostomy (n=3). Overall, two patients had resolution of IPUF symptoms with a loop ileostomy alone and eight eventually underwent pouch excision with end ileostomy, one of which subsequently underwent redo IPAA. Seven patients were managed with primary closure of the urethral defect at the time of pouch excision, five of which also underwent gracilis muscle interposition. With a median follow-up of 4 years (range 0.3-13 years), all patients had resolution of their fistulae without any recurrences. CONCLUSION IPUFs are a rare complication after IPAA. In this cohort, all patients had their urinary tract preserved, but most ultimately had permanent fecal diversion. These results can help guide management of this complex issue.
Collapse
Affiliation(s)
| | - Mariana Maspero
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland OH
| | - Hanson Zhao
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Roger K Khouri
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Olga Lavryk
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland OH
| | - Kenneth W Angermeier
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland OH
| | - Hadley M Wood
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
8
|
Werneburg GT, Hettel D, Adler A, Mukherjee SD, Lundy SD, Angermeier KW, Wood HM, Gill BC, Vasavada SP, Goldman HB, Rackley RR, Shoskes DA, Miller AW. Biofilms on Indwelling Artificial Urinary Sphincter Devices Harbor Complex Microbe-Metabolite Interaction Networks and Reconstitute Differentially In Vitro by Material Type. Biomedicines 2023; 11:biomedicines11010215. [PMID: 36672723 PMCID: PMC9855829 DOI: 10.3390/biomedicines11010215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
The artificial urinary sphincter (AUS) is an effective treatment option for incontinence due to intrinsic sphincteric deficiency in the context of neurogenic lower urinary tract dysfunction, or stress urinary incontinence following radical prostatectomy. A subset of AUS devices develops infection and requires explant. We sought to characterize biofilm composition of the AUS device to inform prevention and treatment strategies. Indwelling AUS devices were swabbed for biofilm at surgical removal or revision. Samples and controls were subjected to next-generation sequencing and metabolomics. Biofilm formation of microbial strains isolated from AUS devices was reconstituted in a bioreactor mimicking subcutaneous tissue with a medical device present. Mean patient age was 73 (SD 10.2). All eighteen artificial urinary sphincter devices harbored microbial biofilms. Central genera in the overall microbe−metabolite interaction network were Staphylococcus (2620 metabolites), Escherichia/Shigella (2101), and Methylobacterium-Methylorubrum (674). An rpoB mutation associated with rifampin resistance was detected in 8 of 15 (53%) biofilms. Staphylococcus warneri formed greater biofilm on polyurethane than on any other material type (p < 0.01). The results of this investigation, wherein we comprehensively characterized the composition of AUS device biofilms, provide the framework for future identification and rational development of inhibitors and preventive strategies against device-associated infection.
Collapse
|
9
|
Affiliation(s)
- Kenneth W Angermeier
- Professor of Urology, Director, Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
10
|
Anele UA, Wood HM, Angermeier KW. Management of Urosymphyseal Fistula and Pelvic Osteomyelitis: A Comprehensive Institutional Experience and Improvements in Pain Control. Eur Urol Focus 2021; 8:1110-1116. [PMID: 34479839 DOI: 10.1016/j.euf.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/18/2021] [Accepted: 08/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Urosymphyseal fistula (USF) is an uncommon but painful and devastating condition typically occurring after radiotherapy for pelvic malignancy, with a delayed diagnosis and a risk of opioid dependence. OBJECTIVE To characterize our institutional experience and determine the impact of intervention for USF on pain control and opioid use. DESIGN, SETTING, AND PARTICIPANTS We evaluated data for 33 adult patients diagnosed with USF and managed at a quaternary institution between 2009 and 2021. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We assessed chronic opioid use, pain scores, prior therapy for pelvic malignancy, prior endoscopic procedures, microbiology and histology congruence, and postoperative complications. For comparative analyses we used a χ2 test or Fisher's exact test for categorical variables and a Wilcoxon signed-rank test for continuous variables. RESULTS AND LIMITATIONS Nearly 94% of the patients had received prior pelvic radiotherapy and >80% occurred in 2016-2021 but were not diagnosed until a median of 10 mo (interquartile range [IQR] 3.5-19.5) following endoscopic procedure(s). Osteomyelitis was suspected in 78.8% of imaging reports and nearly 70% had a positive preoperative urine culture. Over 90% of patients underwent cystectomy, pubic bone debridement or resection, and a soft-tissue pedicle flap. Preoperative urine cultures were concordant with 60% of intraoperative tissue/bone cultures. Histologic osteomyelitis was identified in 85% and concordant with 80% of preoperative imaging. Clavien-Dindo grade ≥3 complications occurred in 15.6%. The median pain score decreased from 4 (IQR 0-8) preoperatively to 0 (IQR 0) postoperatively (p < 0.001). Chronic opioid use decreased from 39.4% to 21.2% (p = 0.02). CONCLUSIONS Pelvic osteomyelitis may complicate USF and commonly manifests with severe, persistent pain. USF incidence may be increasing or at least increasingly recognized, but diagnosis is delayed. Definitive management results in significant improvements in pain perception and a decrease in chronic opioid use. PATIENT SUMMARY We examined features of urinary fistulas, which are abnormal openings or connections between part of the urinary tract and another structure. Patients with a urinary fistula involving the pelvic bones can present with severe pain, but diagnosis of the condition is often delayed. Removal of some pelvic bone with bladder removal or repair can result in a decrease in long-term pain and in the use of opioid drugs for pain relief.
Collapse
Affiliation(s)
- Uzoma A Anele
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Hadley M Wood
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kenneth W Angermeier
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
11
|
Anele UA, Wood HM, Angermeier KW. Urosymphyseal fistulas in women: identification and characterization of a previously undescribed phenomenon. J Surg Case Rep 2021; 2021:rjab331. [PMID: 34386191 PMCID: PMC8354677 DOI: 10.1093/jscr/rjab331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/10/2021] [Accepted: 07/13/2021] [Indexed: 12/05/2022] Open
Abstract
Urosymphyseal fistula (USF) is a very uncommon but catastrophic condition which typically occurs in the setting of previous radiation treatment for prostate cancer. As a result, USF has only been described in male populations. For the first time, we characterize this phenomenon in a series consisting of four women managed at our quaternary institution. We found that most patients presented with pubic pain and all were diagnosed with USF on CT or MRI. Imaging commonly demonstrated features suggesting osteomyelitis which was confirmed on histology. Patients experienced significant decreases in peri-operative pain scores following extirpative surgery with urinary diversion, bone debridement/resection and tissue interposition. This case series highlights the rarity of USF in women in order to help promote increased recognition and timely management.
Collapse
Affiliation(s)
| | - Hadley M Wood
- Center for Genitourinary Reconstruction, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kenneth W Angermeier
- Center for Genitourinary Reconstruction, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
12
|
Angermeier KW. EDITORIAL COMMENT. Urology 2020; 139:196-197. [DOI: 10.1016/j.urology.2019.11.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/04/2019] [Indexed: 11/29/2022]
|
13
|
Mishra K, Hoy NY, Wood HM, Angermeier KW. Rectourethral Fistula—Review of Current Practices, Developments, and Outcomes. Curr Bladder Dysfunct Rep 2019. [DOI: 10.1007/s11884-019-00544-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
14
|
Bryk DJ, Angermeier KW, Klein EA. A Case of Metastatic Prostate Cancer to the Urethra That Resolved After Androgen Deprivation Therapy. Urology 2019; 129:e4-e5. [PMID: 30935936 DOI: 10.1016/j.urology.2019.03.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/03/2019] [Accepted: 03/25/2019] [Indexed: 10/27/2022]
Abstract
An 83 year-old male with Gleason score 4+3 prostatic adenocarcinoma status post brachytherapy developed obstructive voiding symptoms 9 years after brachytherapy. Prostate-specific antigen was 0.67. Cystoscopy noted multiple papillary urethral tumors concerning for primary urethral carcinoma. Immunophenotype of biopsies supported diagnosis of Gleason score 4+4 prostatic adenocarcinoma. Androgen deprivation therapy was started. Cystoscopy performed 4 years later, for microhematuria workup, noted complete resolution of the urethral tumors. We present a patient with little serum Prostate-specific antigen change with urethral prostatic adenocarcinoma metastasis that resolved after androgen deprivation therapy.
Collapse
Affiliation(s)
- Darren J Bryk
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
| | - Kenneth W Angermeier
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Eric A Klein
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
15
|
Lundy SD, Sun AY, Angermeier KW, Fergany AF. Robotic repair of iatrogenic prostatosymphyseal fistula following photoselective vaporization of the prostate. Urology Video Journal 2019. [DOI: 10.1016/j.urolvj.2019.100003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
16
|
Sun AY, Babbar P, Gill BC, Angermeier KW, Montague DK. Penile Prosthesis in Solid Organ Transplant Recipients-A Matched Cohort Study. Urology 2018; 117:86-88. [PMID: 29656065 DOI: 10.1016/j.urology.2018.03.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether patients with solid organ transplant (SOT) are at higher risk of developing complications after inflatable penile prosthesis (IPP) implantation. METHODS We retrospectively reviewed outcomes data for all patients with SOT who underwent IPP placement at our institution. A cohort of age-matched IPP recipients without SOT were used as controls. RESULTS We identified 26 patients who underwent SOT and IPP between 1999 and 2015, and 26 controls. Transplants included heart (3), liver (2), kidney only (17), and kidney and pancreas (4). Mean follow-up time after IPP placement was 29.5 months (SOT group) and 13.5 months (controls). Age at IPP did not significantly differ between groups (53.7 + 8.1 vs 56.4 + 9.0, P = .26), nor did body mass index (30.3 + 5.5 vs 30.2 + 4.7, P = .92), history of prostatectomy (7.7% vs 15.4%, P = .39), rectal surgery (3.9% vs 3.9%, P = 1.00), hyperlipidemia (69.2% vs 69.2%, P = 1.00), hypertension (92.3% vs 76.9%, P = .25), or heart disease (57.7% vs 30.8%, P = .093). Peripheral vascular disease was more common in transplant patients (26.9% vs 3.9%, P = .021), as were stroke (19.2% vs 0.0%, P = .05) and diabetes (84.6% vs 53.6%, P = .016). No significant differences in IPP reoperation rates existed between patients with vs without SOT (11.5% vs 11.5%, P = 1.00), nor did they differ by organ transplanted (P = 1.00). No differences in IPP reoperation rate existed between 2-piece vs 3-piece IPP models (P = .47). CONCLUSION Outcomes of IPP implantation in patients with SOT are similar to those of nontransplant patients. Patients with SOT should be considered suitable candidates for penile prosthesis.
Collapse
Affiliation(s)
- Andrew Y Sun
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH.
| | - Paurush Babbar
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH
| | - Bradley C Gill
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH
| | | | - Drogo K Montague
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH
| |
Collapse
|
17
|
Angermeier KW. Editorial Comment. Urology 2018; 112:179-180. [DOI: 10.1016/j.urology.2016.09.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
18
|
|
19
|
Chertack N, Gill BC, Angermeier KW, Montague DK, Wood HM. Predicting success after artificial urinary sphincter: which preoperative factors drive patient satisfaction postoperatively? Transl Androl Urol 2018; 6:1138-1143. [PMID: 29354501 PMCID: PMC5760395 DOI: 10.21037/tau.2017.10.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background To determine which preoperative factors drive patient-reported quality of life (QoL) after artificial urinary sphincter (AUS) implantation. Methods Men receiving AUS after prostate cancer treatment were identified from a prospectively collected dataset. Preoperative factors were recorded during the initial incontinence consultation. Patients underwent urodynamic testing (UDS) preoperatively at surgeon discretion. Patients were surveyed by telephone postoperatively and given the EPIC Urinary Domain (EPIC-UD) and Urinary Distress Inventory (UDI-6) questionnaires. Differences in postoperative maximum pads per day (MxPPD) and questionnaire scores were compared across preoperative factors, with P¡Ü0.05 indicating statistical significance. Results Telephone survey was completed by 101 of 238 patients (42%). Median age was 69 [63–75] years, BMI was 29 [26–32] kg/m2. MxPPD was 5 [3–9] preoperatively and 2 [1–3] postoperatively (r=0.255, P=0.011). Postoperative median EPIC-UD was 82 [67–89] and UDI-6 was 22 [11–36]. Postoperative MxPPD was lower in patients who reported being able to store urine before AUS {2 [1–2] vs. 2 [1–4], P=0.046}, and lower with urodynamically-proven detrusor overactivity (DO) {1.5 [1–2] with vs. 2 [1–4] without, P=0.050}. Detrusor pressure at maximum flow was negatively associated with QoL as measured by EPIC-UD score (r=−0.346, P=0.013) and UDI-6 score (r=0.413, P=0.003). Although 41 (41%) patients had a history of radiation, postoperative outcomes did not significantly differ with or without a history of radiation. Conclusions Few preoperative factors predict QoL after AUS insertion.
Collapse
Affiliation(s)
- Nathan Chertack
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Bradley C Gill
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kenneth W Angermeier
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Drogo K Montague
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hadley M Wood
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
20
|
Zampini AM, Nelson R, Zhang JH, Reese J, Angermeier KW, Haber GP. Robotic Salvage Pyeloplasty With Buccal Mucosal Onlay Graft: Video Demonstration of Technique and Outcomes. Urology 2017; 110:253-256. [DOI: 10.1016/j.urology.2017.07.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 07/16/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022]
|
21
|
Agrawal S, Lacy JM, Bagga H, Angermeier KW, Ciezki J, Tendulkar RD, Reddy CA, Wood HM. Secondary Urethral Malignancies Following Prostate Brachytherapy. Urology 2017; 110:172-176. [PMID: 28882777 DOI: 10.1016/j.urology.2017.08.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 08/18/2017] [Accepted: 08/23/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To understand urethral secondary malignancies among patients treated with brachytherapy (BRT) for primary prostate cancer. PATIENTS AND METHODS Institutional retrospective review identified 13 patients evaluated from 2003 to 2014 with urethral cancer and history of BRT monotherapy for prostate cancer. All patients were biochemically free of their primary disease and radiation-associated secondary malignancies (RASMs) were confirmed pathologically to be histologically distinct from primary tumor. BRT characteristics, patient age, presentation, staging workup, and clinical course were evaluated. RESULTS The mean time from BRT to presenting symptoms of hematuria, urinary retention, and/or renal failure was 71 months. Symptom onset to RASM diagnosis interval was 24 months. Mean time from BRT to RASM diagnosis was 95 months. Eighty-five percent of patients had an undetectable prostate-specific antigen level (<0.2 ng/mL) at last follow-up. Types of RASM included sarcomatoid carcinoma (6), small cell carcinoma (2), urothelial carcinoma with squamous differentiation (2), squamous cell carcinoma (1), rhabdomyosarcoma (1), and urothelial carcinoma (1). A majority of patients were diagnosed with advanced disease with either distant metastases (54%) or local progression (23%). Ten patients died during this study period with median time to death after RASM diagnosis of 6 months. CONCLUSION RASMs localized to the posterior urethra displayed advanced disease and high mortality rates. Refractory lower urinary tract symptoms, hematuria, and history of prostate BRT should raise suspicion for urethral RASMs. Further studies are warranted to determine patient and disease characteristics that correlate with disease-specific mortality of secondary urethral malignancies.
Collapse
Affiliation(s)
- Shree Agrawal
- Case Western Reserve University School of Medicine, Cleveland, OH.
| | - John M Lacy
- University of Tennessee Graduate School of Medicine, Knoxville, TN
| | | | | | | | | | | | | |
Collapse
|
22
|
|
23
|
Abstract
Staged buccal mucosa graft urethroplasty has emerged as a reliable procedure for difficult anterior urethral strictures not amenable to one-stage graft or flap reconstruction. It has primarily been used for strictures and/or fistulae occurring after previous surgery for hypospadias or those related to lichen sclerosus (LS). Success rates in these patient populations have improved when compared to earlier techniques. However, prior studies have demonstrated a number of patients requiring more than two procedures to complete the reconstruction, as well as some who have been content with their voiding pattern after the first operation and therefore elected to forego second stage tubularization. In this setting, we have reviewed the surgical technique and summarized previously published work. There may be an opportunity to complete more of these repairs in two operations using additional oral mucosa at the time of tubularization.
Collapse
Affiliation(s)
- Ryan L Mori
- 1 Geisinger Medical Center, Danville, PA 17822, USA ; 2 Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Kenneth W Angermeier
- 1 Geisinger Medical Center, Danville, PA 17822, USA ; 2 Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| |
Collapse
|
24
|
Chertack N, Chaparala H, Angermeier KW, Montague DK, Wood HM. Foley or Fix: A Comparative Analysis of Reparative Procedures at the Time of Explantation of Artificial Urinary Sphincter for Cuff Erosion. Urology 2015; 90:173-8. [PMID: 26743390 DOI: 10.1016/j.urology.2015.11.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/18/2015] [Accepted: 11/24/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine artificial urinary sphincter (AUS) cuff erosion intraoperative management methods: Foley catheter placement, abbreviated urethroplasty (AU), or mobilization with primary urethral anastomosis (PA). We reviewed these options to compare postoperative complications and probability of AUS reimplantation. MATERIALS AND METHODS Medical records of patients treated for AUS cuff erosion from 2005 to 2015 were retrospectively reviewed. We divided patients into 3 groups based on intraoperative management of the urethra: Foley only, AU, or PA. Patient characteristics, operative times, outcomes, complications, and reimplantation factors were recorded and analyzed. RESULTS Seventy-five patients with a median age of 77 years (72-83) were treated for AUS cuff erosion. Fifty-two underwent Foley placement, 8 AU, and 15 PA. Mean follow-up was 13 months (0-106). Severe erosions were more common in the PA group than Foley or AU (100% vs 37%, 100% vs 38%, P <.001, P <.001, respectively). Severe erosions treated with Foley were more likely to develop strictures than mild erosions (38% vs 5%, P = .009). Tandem cuff patients treated with Foley were more likely to develop diverticuli than single cuff patients (33% vs 4%, P = .016). There was no difference in probability of reimplantation between PA and Foley or AU (63% vs 69%, 63% vs 33%, P = .748, P = .438, respectively). CONCLUSIONS Foley catheter placement alone may represent suboptimal management for severe or tandem cuff erosions due to increased risk of urethral complications. Urethral defect management should be determined at the time of explantation by individual patient characteristics and surgeon experience.
Collapse
Affiliation(s)
- Nathan Chertack
- Glickman Urological & Kidney Institute-Cleveland Clinic Foundation, Cleveland, OH; Case Western Reserve University School of Medicine-Cleveland, OH.
| | - Hemant Chaparala
- Glickman Urological & Kidney Institute-Cleveland Clinic Foundation, Cleveland, OH; Case Western Reserve University School of Medicine-Cleveland, OH
| | - Kenneth W Angermeier
- Glickman Urological & Kidney Institute-Cleveland Clinic Foundation, Cleveland, OH
| | - Drogo K Montague
- Glickman Urological & Kidney Institute-Cleveland Clinic Foundation, Cleveland, OH
| | - Hadley M Wood
- Glickman Urological & Kidney Institute-Cleveland Clinic Foundation, Cleveland, OH
| |
Collapse
|
25
|
Montague DK, Angermeier KW. Editorial Comment on "Critical Appraisal and Review of Management Strategies for Severe Fibrosis During Penile Implant Surgery". J Sex Med 2015; 12 Suppl 7:448. [PMID: 26565575 DOI: 10.1111/jsm.13003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Drogo K Montague
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | |
Collapse
|
26
|
Abstract
AIM Squamous cell carcinoma of the penis (PC) has traditionally been treated with partial penectomy with a 2-cm margin. More conservative resection margins have been reported to have no effect on oncologic control, but there is no consensus in the literature regarding functional outcomes after organ-preserving surgery for PC. METHODS Six patients meeting inclusion criteria were retrospectively identified to have received organ-sparing surgery for PC at the Cleveland Clinic from 2003 to 2012. Patient's sexual and urinary quality of life was assessed retrospectively using the International Index of Erectile Function and the patient-reported outcome measure for urethral stricture surgery. RESULTS Three patients (50%) report normal erections but describe intercourse as not very enjoyable and report being dissatisfied with their sex life. The remaining 50% consistently report no sexual activity and denied feeling sexual desire. All report only mild urinary symptoms, including decreased stream (18%) and feelings of incomplete voiding (67%). Eighty-three percent of patients report their sexual symptoms do not interfere with their daily lives. One hundred percent report being satisfied with their procedure. CONCLUSION Our study is the first to use standardized, validated questionnaires to evaluate sexual and urinary function in a North American penile cancer patient population. We report excellent overall urinary function and quality of life following penile-sparing surgery for PC, and our results depict more realistic sexual outcomes than those reported in studies using non-blinded and non-validated methods.
Collapse
Affiliation(s)
- Kyle Scarberry
- Urology Institute, University Hospitals Case Medical Center Cleveland, OH, USA
| | - Kenneth W Angermeier
- Glickman Urological and Kidney Institute, The Cleveland Clinic Cleveland, OH, USA
| | - Drogo Montague
- Glickman Urological and Kidney Institute, The Cleveland Clinic Cleveland, OH, USA
| | - Steven Campbell
- Glickman Urological and Kidney Institute, The Cleveland Clinic Cleveland, OH, USA
| | - Hadley M Wood
- Glickman Urological and Kidney Institute, The Cleveland Clinic Cleveland, OH, USA
| |
Collapse
|
27
|
Warner JN, Malkawi I, Dhradkeh M, Joshi PM, Kulkarni SB, Lazzeri M, Barbagli G, Mori R, Angermeier KW, Storme O, Campos R, Velarde L, Gomez RG, Han JS, Gonzalez CM, Martinho D, Sandul A, Martins FE, Santucci RA. A Multi-institutional Evaluation of the Management and Outcomes of Long-segment Urethral Strictures. Urology 2015; 85:1483-7. [DOI: 10.1016/j.urology.2015.01.041] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 12/28/2014] [Accepted: 01/05/2015] [Indexed: 10/23/2022]
|
28
|
Abstract
The standard of care after a pelvic fracture urethral injury is a repair via a one-stage anastomotic posterior urethroplasty using a step-wise perineal approach. The initial injury, immediate postoperative management, and surgical repair can all affect urinary continence in these patients. Proximal continence mechanisms, particularly the bladder neck, are particularly important in maintaining urinary continence in these patients. Patients with bladder neck dysfunction should be counselled about the greater risk of urinary incontinence.
Collapse
Affiliation(s)
- Herman S. Bagga
- Corresponding author at: Cleveland Clinic, 9500 Euclid Avenue, Q10, Cleveland, OH 44195, USA.
| | | |
Collapse
|
29
|
Angermeier KW, Rourke KF, Dubey D, Forsyth RJ, Gonzalez CM. SIU/ICUD Consultation on Urethral Strictures: Evaluation and follow-up. Urology 2013; 83:S8-17. [PMID: 24275285 DOI: 10.1016/j.urology.2013.09.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/22/2013] [Accepted: 09/13/2013] [Indexed: 10/26/2022]
Abstract
For the 2010 International Consultation on Urethral Strictures, all available published data relating to the evaluation and follow-up of patients with anterior urethral stricture or posterior urethral stenosis were reviewed and evaluated. Selected manuscripts were classified by Level of Evidence using previously established criteria. Consensus was achieved through group discussion, and formal recommendations were established and graded on the basis of levels of evidence and expert opinion. Retrograde urethrography remains the de facto standard for the evaluation of patients with urethral stricture. It can readily be combined with voiding cystourethrography to achieve a synergistic evaluation of the entire urethra, and this approach is currently recommended as the optimal method for pretreatment staging. Cystoscopy is recommended as the most specific procedure for the diagnosis of urethral stricture and is a useful adjunct in the staging of anterior urethral stricture, particularly to confirm abnormal or equivocal findings on imaging studies. Cystoscopy is also an important modality for assessing the bladder neck and posterior urethra in the setting of a pelvic fracture-related urethral injury. Although urethrography and cystoscopy remain the principle forms of assessment of the patient with urethral stricture, additional adjuncts include uroflowmetry, symptom scores, quality of life assessments, ultrasonography, computed tomography, and magnetic resonance imaging. These modalities might be helpful to further evaluate patients in select circumstances or provide a less invasive approach to monitoring outcomes after surgical treatment. Further research is needed to establish consensus opinion as to the definition of success after urethroplasty and to develop standardized patient outcome measures.
Collapse
Affiliation(s)
- Kenneth W Angermeier
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
| | - Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Alberta, Canada.
| | - Deepak Dubey
- Manipal Institute of Urology and Nephrology, Manipal Hospital, Bangalore, India
| | - Robert J Forsyth
- Ballarat Urology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Christopher M Gonzalez
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| |
Collapse
|
30
|
|
31
|
Li H, Gill BC, Nowacki AS, Montague DK, Angermeier KW, Wood HM, Vasavada SP. Therapeutic durability of the male transobturator sling: midterm patient reported outcomes. J Urol 2012; 187:1331-5. [PMID: 22341294 DOI: 10.1016/j.juro.2011.11.091] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE The male transobturator AdVance™ sling is a viable option for mild to moderate post-prostatectomy incontinence. As this treatment is relatively new, our study provides an analysis of efficacy through patient reported outcomes and pad use. MATERIALS AND METHODS A telephone survey and chart review were conducted on all patients receiving a sling before 2010 by either of 2 surgeons at a large academic institution. The survey included the Patient Global Impression of Improvement and Severity instruments, pad use characteristics before and after sling surgery, and items assessing durability of efficacy. Patient determined (subjective) success was very much or much better on the Patient Global Impression of Improvement without subsequent incontinence therapy. Quantitative success was defined as a decrease to 2 or fewer pads per day. We assessed therapeutic durability in a subanalysis of patients interviewed twice, first in a prior study. RESULTS From initial office followup to 2 years, quantitative success decreased from 87.3% to 62.5% and pad use doubled from a mean±SD of 0.8±1.7 to 1.7±2.5 pads per day. Patient determined success was 53.6% at 2 years. A subgroup of 25 patients interviewed at 7 and 29 months after sling surgery had quantitative success significantly decrease by 20% (p=0.03), subjective success decrease by 4% (p=0.56) and pad use significantly increase (p=0.01) from 1.4±2.2 to 2.3±3.2 pads per day. CONCLUSIONS Most patients receiving the AdVance sling did see improvement in post-prostatectomy incontinence and a decrease in pad use, but in 20% of patients this benefit decreased with time. Nevertheless, patients remained satisfied and perceived the treatment as successful.
Collapse
Affiliation(s)
- Hanhan Li
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio 44195, USA
| | | | | | | | | | | | | |
Collapse
|
32
|
Ching CB, Wood HM, Ross JH, Gao T, Angermeier KW. The Cleveland Clinic experience with adult hypospadias patients undergoing repair: their presentation and a new classification system. Int Braz J Urol 2011. [DOI: 10.1590/s1677-55382011000300024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- CB Ching
- Glickman Urological and Kidney Institute, USA
| | | | | | | | | |
Collapse
|
33
|
Samplaski MK, Wood HM, Lane BR, Remzi FH, Lucas A, Angermeier KW. Functional and quality-of-life outcomes in patients undergoing transperineal repair with gracilis muscle interposition for complex rectourethral fistula. Urology 2011; 77:736-41. [PMID: 21377021 DOI: 10.1016/j.urology.2010.08.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Revised: 08/05/2010] [Accepted: 08/07/2010] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the results and quality of life outcomes of transperineal repair using gracilis muscle interposition in patients who were candidates for attempted preservation of bowel and bladder function. There is currently no widely accepted procedure for the treatment of complex RUF, such as those complicated by radiotherapy, previous attempts at repair, or large in size. METHODS Thirteen patients who underwent transperineal repair with gracilis muscle interposition for complex RUF were identified. Records were reviewed for fistula etiology, prior repair, intraoperative findings, hospital course, complications, diversion reversal, and outcome. Follow-up data were gathered from clinic visits and questionnaires. RESULTS Preoperative diagnoses included: prostate cancer (PCA) (12) and imperforate anus (1). Treatment for PCA included radical prostatectomy (4); brachytherapy (BT) (3); external beam radiation therapy (EBRT) + BT (3); cryoablation (1); and EBRT + cryoablation (1). Five patients underwent prior unsuccessful repair. There were no intraoperative complications. Postoperative complications included fecal incontinence (3) and bladder neck contracture (1). Nine patients (75%) reported some degree of urinary incontinence, with 2 patients reporting this as significant, defined as incontinence "most of the time." Suprapubic catheters were removed after 6 weeks, and median stomal reversal was at 17.5 weeks (12-28). One patient developed a recurrent RUF. All patients completed quality-of-life questionnaires assessing urinary and fecal outcome. Fecal outcome measures were generally better than urinary, but both were reasonable given the complexity of the situation. CONCLUSIONS Transperineal repair with gracilis muscle interposition is an effective treatment for selected patients with complex RUF. Our experience demonstrates low morbidity, high success rates, and reasonable bowel and bladder function postoperatively.
Collapse
Affiliation(s)
- Mary K Samplaski
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | | | | | | | | | | |
Collapse
|
34
|
Shen B, Angermeier KW, Remzi FH, Katz S. Screening and diagnosis of prostate cancer in patients with ileal pouch-anal anastomosis: consensus from an expert panel. Am J Gastroenterol 2011; 106:186-9. [PMID: 21301448 DOI: 10.1038/ajg.2010.300] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Screening for prostate cancer after restorative proctocolectomy with ileal pouch-anal anastomosis can be challenging. Diagnostic biopsy for an elevated level of prostate-specific antigen may present difficulties as well. No guidelines have been issued regarding the value and accuracy of digital examination and the best route to obtain prostate biopsy specimens. A screening and diagnostic algorithm for prostate cancer was developed by an expert consensus panel.
Collapse
Affiliation(s)
- Bo Shen
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | | |
Collapse
|
35
|
Ching CB, Wood HM, Ross JH, Gao T, Angermeier KW. The Cleveland Clinic experience with adult hypospadias patients undergoing repair: their presentation and a new classification system. BJU Int 2010; 107:1142-6. [PMID: 21438977 DOI: 10.1111/j.1464-410x.2010.09693.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE • To characterize and categorize adults with hypospadias who presented to our clinic with urethral stricture and fistula to better clarify the presentation, history and intraoperative findings in this heterogeneous group and to better describe the natural history of this anomaly in adulthood. PATIENT AND METHODS • A retrospective chart review was performed on adults with hypospadias who underwent urethroplasty for urethral stricture, urethrocutaneous fistula, and/or hypospadias repair at Cleveland Clinic between 1993 and 2009. All procedures were performed by a single staff surgeon (K.W.A.). • The charts were reviewed for site of hypospadias, presenting complaint, overall symptoms, history of repair and type of surgery performed. RESULTS • Fifty-five adult patients were identified. Median age was 37 years (range: 18-72). About half of the patients had distal (glanular/subcoronal or pendulous) hypospadias (56.4%) and the others had more proximal (bulbar) hypospadias (43.6%). • Voiding symptoms (such as dysuria, weak stream, spraying, urgency, frequency) were the most common presenting complaint (50.9%) and overall symptom (81.8%). About half of patients underwent a two-stage urethroplasty (52.7%). • Based on their history of repair, patients were divided into three categories: I, patients who have undergone continuous multiple surgeries for repair with significant scarring and tissue loss; II, delayed complications after an initially successful childhood repair; and III, no previous repair. Most patients were category I (58.2%); however, seven patients (12.7%) were category III. Balanitis xerotica obliterans (BXO) was more common in this subgroup compared with other categories (42.9% vs 8.3%, respectively, P= 0.037). In two of the three patients in category III with BXO, the stricture length was longer than 7 cm. CONCLUSIONS • Adults with hypospadias represent a heterogeneous group. More than half of adults with complications related to hypospadias have had multiple operations (category I) representing one of the most difficult challenges to the reconstructive urologist. • Roughly 30% of patients undergo an initially successful repair in childhood with recurrent problems in adulthood (category II), suggesting that the outcomes of repair may not be as durable as estimated by studies with shorter-term follow-up. • Finally, BXO is over-represented in men with hypospadias who have not previously undergone repair, which contradicts the previous suggestion that the risk of BXO is related to the use of skin grafts/flaps from previous repairs and suggests that there may be an increased risk of severe stricture disease in patients who have never undergone corrective surgery for this anomaly.
Collapse
Affiliation(s)
- Christina B Ching
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, USA
| | | | | | | | | |
Collapse
|
36
|
Altunrende F, White MA, Autorino R, Angermeier KW, Wood HM. Large symptomatic periurethral cystic lesion in a male. Urology 2010; 78:56-7. [PMID: 20728922 DOI: 10.1016/j.urology.2010.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 05/11/2010] [Accepted: 05/18/2010] [Indexed: 10/19/2022]
Abstract
We report an unusual case of a periurethral cystic mass in a 43-year-old man who presented with perineal pain, dysuria, painful ejaculation, and post-ejaculatory lower urinary tract symptoms. Computed tomography and magnetic resonance imaging demonstrated a multiocular periurethral cystic structure. On surgical exploration of the urethra, a cystic lesion was identified and removed. The mass was classified as a complex periurethral cyst from the histopathologic findings.
Collapse
Affiliation(s)
- Fatih Altunrende
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | | | | | | | | |
Collapse
|
37
|
|
38
|
|
39
|
Vassil AD, Murphy ES, Reddy CA, Angermeier KW, Altman A, Chehade N, Ulchaker J, Klein EA, Ciezki JP. Five year biochemical recurrence free survival for intermediate risk prostate cancer after radical prostatectomy, external beam radiation therapy or permanent seed implantation. Urology 2010; 76:1251-7. [PMID: 20378156 DOI: 10.1016/j.urology.2010.01.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 12/12/2009] [Accepted: 01/04/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare biochemical recurrence-free survival (bRFS) for patients with intermediate-risk prostate cancer treated by retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), external beam radiation therapy (RT), or permanent seed implantation (PI). METHODS Patients treated for intermediate-risk prostate cancer per National Comprehensive Cancer Network guidelines from 1996 to 2005 were studied. Variables potentially affecting bRFS were examined using univariate and multivariate Cox regression analysis. Five-year bRFS rates were calculated by actuarial methods; bRFS was calculated using Kaplan-Meier analysis. Nadir +2 definition of biochemical failure was used for RT and PI patients; a PSA ≥ 0.4 ng/mL was used for radical prostatectomy (RP) patients. Time to initiation of salvage therapy was compared for each treatment group using the Kruskal-Wallis test. RESULTS Nine-hundred seventy-nine patients were analyzed with a median follow-up of 65 months. Five years bRFS rate was 82.8% for all patients (89.5% PI, 85.7% RT, 79.9% RRP, and 60.2% LRP). Patients treated by LRP had significantly worse bRFS than RT (P < .0001), PI (P < .0001), or RRP patients (P = .0038). Treatment modality (P < .0001) and average number of PSA tests per year (P < .0001) were the only independent predictors of bRFS on multivariate analysis. Median time to initiation of salvage therapy from time of treatment was 28.6 months for all patients (26.1 RP, 21.0 LRP, 47.4 PI, 47.8 RT; P < .0001). CONCLUSIONS Patients with intermediate-risk prostate cancer choosing PI, RT, or RRP appear to have improved 5-year bRFS and delayed salvage therapy compared with LRP.
Collapse
Affiliation(s)
- Andrew D Vassil
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Ciezki JP, Reddy CA, Robinson C, Angermeier KW, Ulchaker J, Chehade N, Altman A, Magi-Galluzzi C, Klein EA. A Comparison of Cause-Specific Mortality among Patients with Low- or Intermediate-Risk Prostate Cancer. Brachytherapy 2010. [DOI: 10.1016/j.brachy.2010.02.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
41
|
Wood HM, Gao T, Phull H, Kay R, Ross JH, Angermeier KW. A COMPARISON OF URINARY FUNCTIONAL OUTCOMES IN ADULT HYPOSPADIACS WITH AND WITHOUT ONGOING PROBLEMS IN ADULTHOOD. J Urol 2009. [DOI: 10.1016/s0022-5347(09)60326-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
42
|
Abstract
Penile prosthesis implantation is suitable treatment for men with erectile dysfunction when nonsurgical treatment options fail or are otherwise unsatisfactory. Three-piece inflatable penile prostheses closely approach the ideal of producing normal penile flaccidity and erection. Nevertheless, even in men with normal corpora cavernosa, many report their prosthetic erection is shorter than their former natural erection. This is due to the lack of glans tumescence and the use of penile cylinders, which only expand in girth. Using girth- and length-expanding cylinders can decrease the loss of penile length frequently seen with prosthesis implantation. Some penile prosthesis recipients have abnormal corpora following radical prostatectomy or after removal of an infected penile prosthesis, or as the result of Peyronie's disease, obesity, or ischemic priapism. In these men with abnormal corpora, associated penile-lengthening procedures can be combined with penile prosthesis implantation. However, experience is limited with these combined procedures.
Collapse
Affiliation(s)
- Drogo K Montague
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, The Cleveland Clinic, Cleveland, OH 44195, USA.
| | | |
Collapse
|
43
|
|
44
|
Samplaski MK, Wood HM, Lane BR, Remzi FH, Angermeier KW. TRANSPERINEAL REPAIR WITH GRACILIS MUSCLE INTERPOSITION FOR COMPLEX RECTOURETHRAL FISTULAS. J Urol 2008. [DOI: 10.1016/s0022-5347(08)60030-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
45
|
Smith AK, Angermeier KW. SECOND STAGE URETHROPLASTY AUGMENTED BY ORAL MUCOSA: AN ALTERNATIVE TO REVISION OF THE FIRST STAGE. J Urol 2008. [DOI: 10.1016/s0022-5347(08)60042-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
46
|
Abstract
PURPOSE During substitution urethroplasty, if the stricture contains a 1 to 2 cm region that is particularly narrow and/or fibrotic, that portion may be excised with subsequent anastomosis of the dorsal or ventral aspect of the urethra to shorten, widen and optimize the urethral wall onto which an onlay graft is to be placed. This procedure is termed augmented anastomotic urethroplasty. To determine the effectiveness of this approach we reviewed our experience with augmented anastomotic urethroplasty in an 8-year period. MATERIALS AND METHODS We reviewed the records of patients who underwent augmented anastomotic urethroplasty between October 1997 and April 2005. Perioperative characteristics were compared between successes and failures using the Wilcoxon/Kruskal-Wallis and Fisher exact tests. RESULTS Of 69 patients who underwent augmented anastomotic urethroplasty for recurrent urethral strictures 5 had undergone previous urethroplasty using a genital skin flap or graft. At a median followup of 34 months (range 13 to 103) 62 patients had no evidence of stricture recurrence and required no further intervention for an overall success rate of 90%. Stricture recurrence, defined as the inability to easily pass a standard flexible cystoscope through the area of repair, occurred in 7 patients (10%). Patients with stricture recurrence were significantly older (mean age 52 vs 39 years, p = 0.02) and more likely to experience postoperative urinary tract infection (28% vs 3.2%, p = 0.05) than patients without repeat stricture. CONCLUSIONS Augmented anastomotic urethroplasty is an effective technique that allows the use of a shorter onlay graft. It may optimize overall results due to improvement in the urethral wall and the associated corpus spongiosum.
Collapse
Affiliation(s)
- Robert Abouassaly
- Section of Presthetic Surgery and Genitourethral Reconstruction, Glickman Urological Institute A/100, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | | |
Collapse
|
47
|
|
48
|
Patel AR, Angermeier KW. 841: Durability of Buccal Mucosa Graft Urethroplasty - 5 Year Outcomes. J Urol 2007. [DOI: 10.1016/s0022-5347(18)31081-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
49
|
Albani JM, Ciaschini MW, Streem SB, Herts BR, Angermeier KW. The role of computerized tomographic urography in the initial evaluation of hematuria. J Urol 2007; 177:644-8. [PMID: 17222650 DOI: 10.1016/j.juro.2006.09.065] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Indexed: 11/26/2022]
Abstract
PURPOSE We determined the usefulness of computerized tomographic urography for the initial evaluation of patients with hematuria as an alternative to excretory urography. MATERIALS AND METHODS A total of 259 patients (140 men and 119 women), age range 20 to 100 (mean 59.4) years, underwent computerized tomographic urography for the evaluation of hematuria and were available for followup. A cohort of 253 patients (153 men, 100 women), age range 21 to 92 (mean 57.6) years, underwent conventional excretory urography and were evaluated for comparison. RESULTS A source of hematuria was identified in 107 patients (41.3%) in the computerized tomographic urography cohort and in 103 patients (40.7%) in the excretory urography cohort. Computerized tomographic urography alone identified a source of hematuria in 25.5% of these patients with the most commonly diagnosed lesions being renal calculi (18.9%), ureteral calculi (2.7%) and renal pelvic masses (2.3%) in the upper tract (0.94 sensitivity), and bladder masses (8.1%), prostatic abnormalities (5.4%) and inflammatory disorders (3.5%) in the lower tract (0.40 sensitivity, 0.99 specificity). The overall detection rate (19.5%), most commonly diagnosed lesions, and lower urinary tract sensitivity and specificity were similar in the excretory urography cohort. However, excretory urography exhibited a markedly lower sensitivity in detecting upper tract lesions (0.50). CONCLUSIONS Computerized tomographic urography exhibited a significantly higher sensitivity than conventional excretory urography in detecting upper tract pathology (94.1% vs 50%). However, sensitivity for detecting lower tract lesions was low (40% or less), suggesting that computerized tomographic urography offers a comprehensive alternative to excretory urography but does not obviate the need for adjunctive cystourethroscopy for accurate evaluation of the lower urinary tract.
Collapse
Affiliation(s)
- Justin M Albani
- Department of Radiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
| | | | | | | | | |
Collapse
|
50
|
Dhar NB, Angermeier KW, Montague DK. Long-term mechanical reliability of AMS 700CX/CXM inflatable penile prosthesis. J Urol 2006; 176:2599-601; discussion 2601. [PMID: 17085168 DOI: 10.1016/j.juro.2006.08.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Indexed: 11/19/2022]
Abstract
PURPOSE We determined the long-term mechanical reliability of the AMS 700CX/CXM inflatable penile prosthesis in men with organic erectile dysfunction. MATERIALS AND METHODS A total of 455 consecutive patients underwent implantation of an AMS 700CX/CXM inflatable penile prosthesis between April 1986 and July 2004. Using telephone interviews and mailed questionnaires we obtained followup on 380 of 455 patients (83%). Data were obtained with regard to 2 end points, including overall failure and mechanical failure caused by any malfunctioning component. RESULTS Followup was 0.49 to 231 months (median 91.5). Ten-year Kaplan-Meier estimates of overall and mechanical survival were 74.9% (95% CI 69.2 to 81.1) and 81.3% (95% CI 75.7 to 87.3), respectively. CONCLUSIONS To our knowledge this is the longest followup of any inflatable penile prosthesis showing overall and mechanical survival by Kaplan-Meier estimates.
Collapse
Affiliation(s)
- Nivedita Bhatta Dhar
- Glickman Urological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | | | | |
Collapse
|