Mechanism of Action of the Transobturator Sling for Post-Radical Prostatectomy Incontinence: A Multi-institutional Prospective Study Using Dynamic Magnetic Resonance Imaging

OBJECTIVE

To compare the length of the membranous (functional) urethra in male patients who underwent the male transobturator sling (TOS) for postradical prostatectomy urinary incontinence (PPI). The TOS is in established use for treatment of PPI; however, the precise mechanism of action is unknown.

MATERIALS AND METHODS

This is a prospective case-controlled study on men undergoing male TOS surgery from 2008 to 2014. The comparison arm included patients without incontinence after radical prostatectomy. All participants underwent dynamic magnetic resonance imaging (MRI) at baseline and this was repeated after TOS placement for those who underwent the procedure. Three standardized points were measured using MRI and compared in both groups in addition to clinical measures.

RESULTS

Thirty-nine patients were enrolled and 31 patients completed the protocols. The controls (N = 14) had a longer vesicourethral anastomosis to urethra measured at the penile bulb (functional urethral length) distance compared to the pre-TOS group at rest (1.92 cm controls vs 1.27 cm pre-TOS, P = .0018) and at Valsalva (2.13 cm controls vs 1.72 cm pre-TOS, P = .0371). Placement of the sling (N = 17) increased the functional urethral length distance at rest (1.92 cm control vs 1.53 cm post-TOS, P = .09) and at Valsalva (1.94 cm post-TOS vs 2.13 cm control, P = .61), so that the difference was no longer statistically significant.

CONCLUSION

We identified that one possible mechanism in improvement in stress urinary incontinence post-TOS placement is the lengthening of the vesicourethral anastomosis to bulbar-urethra distance. This is the first such study utilizing dynamics MRI in post prostatectomy controls, incontinent pre-TOS, and post-TOS to assess and show these findings.

Caregiver word reading literacy and health outcomes among children treated in a pediatric nephrology practice

BACKGROUND

Caregivers play a major role in the healthcare of pediatric patients, particularly during childhood and adolescence. This study examined the impact of caregivers' functional literacy on the health outcomes of adolescents with chronic kidney disease (CKD) or end-stage kidney disease (ESKD).

METHODS

Caregiver-child dyads in a Southeastern US pediatric nephrology clinic participated in this cross-sectional study. We collected demographic information, data on caregivers' functional literacy skills (Wechsler Individual Achievement Test Word Reading Subtest) and child health outcomes (healthcare utilization and adherence). Negative binomial regression analyses were used to test the relationships.

RESULTS

A total of 98 pediatric patients and their caregivers participated. Caregivers' word reading literacy was associated with their children's healthcare utilization. Patients whose caregivers had lower word reading literacy skills (<7th grade) had greater incidence of emergency room (ER) visits (adjusted incidence rate ratio = 2.05, 95% confidence interval: 1.007, 4.177, P < 0.05) after adjusting for major demographic factors. Patients' hospitalization rates and adherence to medication/diet/appointments were comparable in the two groups.

CONCLUSIONS

Low caregiver functional word reading literacy was negatively related to health outcomes of adolescents with CKD/ESKD as reflected by greater ER visits. Educational materials and teaching strategies (dialysis training protocols, patient education materials) adjusted for low literacy levels may contribute to better outcomes.

The contemporary management of urethral strictures in men resulting from lichen sclerosus

Lichen sclerosus (LS) is a chronic, inflammatory disease primarily involving the genital skin and urethra in males. Historically, the treatment of this common condition was a challenge due to its uncertain etiology, variable response to therapy, and predilection to recur. The etiology of LS is still debated and has been linked to autoimmune disease, infection, trauma, and genetics. Today, topical steroids are a mainstay of therapy for patients, even in the presence of advanced disease, and can induce regression of the disease. In advanced cases, surgery may be required and range from circumcision, meatoplasty, or, in the case of advanced stricture disease, urethroplasty or perineal urethrostomy. When urethroplasty is required, the use of genital skin as a graft or flap is to be avoided due to the predilection for recurrence. Surgical management should be approached only after failure of more conservative measures due to the high risk of recurrence of LS in the repaired site despite the use of buccal grafting. LS may be associated with the development of squamous cell carcinoma and for this reason, patients should undergo biopsy when LS is suspected and long-term surveillance is recommended.

A case of Fournier's gangrene necessitating total penectomy

Fournier's gangrene is an uncommon necrotizing infection affecting the genital and perineal area. Penile involvement in particular is rare owing to its rich vascular supply. In this report, we document a case of Fournier's gangrene involving penile and urethral tissue requiring multiple debridements resulting in significant penile deformity and a non-healing wound. Eventually, the patient underwent penectomy and perineal urethrostomy creation. In this case, penectomy and perineal urethrostomy provide a functional outcome for highly refractory and complex patients with Fournier's gangrene involving penile tissue.

The Artificial Urinary Sphincter is Superior to a Secondary Transobturator Male Sling in Cases of a Primary Sling Failure

PURPOSE

We compared continence outcomes in patients with post-prostatectomy stress urinary incontinence treated with a salvage artificial urinary sphincter vs a secondary transobturator sling.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients undergoing salvage procedures after sling failure from 2006 to 2012. Postoperative success was defined as the use of 0 or 1 pad, a negative stress test and pad weight less than 8 gm per day. We performed the Wilcoxon test and used a Cox regression model and Kaplan-Meier survival analysis.

RESULTS

A total of 61 men presenting with sling failure were included in study, of whom 32 went directly to an artificial urinary sphincter and 29 received a secondary sling. Of the artificial urinary sphincter cohort 47% underwent prior external beam radiation therapy vs 17% of the secondary sling cohort (p = 0.01). Average preoperative 24 hour pad weight and pad number were higher in the artificial urinary sphincter cohort. Median followup in artificial urinary sphincter and secondary sling cases was 4.5 (IQR 4-12) and 4 months (IQR 1-5), respectively. Overall treatment failure was seen in 55% of patients (16 of 29) with a secondary sling vs 6% (2 of 32) with an artificial urinary sphincter (unadjusted HR 7, 95% CI 2-32 and adjusted HR 6, 95% CI 1-31).

CONCLUSION

In this cohort of patients with post-prostatectomy stress urinary incontinence and a failed primary sling those who underwent a secondary sling procedure were up to 6 times more likely to have persistent incontinence vs those who underwent artificial urinary sphincter placement. These data are useful for counseling patients and planning surgery. We currently recommend placement of an artificial urinary sphincter for patients in whom an initial sling has failed.

Malleable penile prosthesis is a cost-effective treatment for refractory ischemic priapism

INTRODUCTION

Refractory ischemic priapism (RIP) can be difficult to treat, consuming significant healthcare-related resources. Acute insertion of a malleable penile prosthesis (MPP) has been reported as an effective therapy that treats the priapism and restores sexual function.

AIM

We report our 6-year, urban public hospital experience with acute insertion of MPP in patients with RIP.

METHODS

We retrospectively reviewed the records of patients receiving MPPs for RIP from 2007 to 2013. Data analyzed included duration of erection, number of emergency room (ER) visits, hospital admissions, days of hospitalization, and postoperative course. Costs were estimated using standard Medicare reimbursement rates.

MAIN OUTCOME MEASURE

Healthcare-related costs of treatment of RIP episodes in men presenting to our institution.

RESULTS

During the study period, 14 men underwent MPP placement acutely for refractory priapism. Thirteen presented with RIP, and one had stuttering priapism over a 14-day hospitalization. Etiologies included sickle cell anemia (4/13, 29%), medication-induced (3/14, 21%), and idiopathic (7/14, 50%). Average preoperative duration of RIP was 82 hours with considerable consumption of health-care resources (average US $83,818 estimated cost, 4 ER visits [range 1-27], 2 hospital admissions [range 1-5], 1.5 shunt procedures [range 1-3], 5 irrigation and drainage procedures using phenylephrine injection [range 2-20], and 5 hospital admission days [range 2-14]). All patients were discharged within 24 hours of MPP surgery.

CONCLUSIONS

The management of RIP is associated with multiple ER visits, prolonged hospital admissions, and significant resource utilization. MPP insertion is efficacious for the immediate resolution of refractory priapism, with potential cost and resource benefits.

Cost-effectiveness of risk stratified followup after urethral reconstruction: a decision analysis

PURPOSE

We propose a novel risk stratified followup protocol for use after urethroplasty and explore potential cost savings.

MATERIALS AND METHODS

Decision analysis was performed comparing a symptom based, risk stratified protocol for patients undergoing excision and primary anastomosis urethroplasty vs a standard regimen of close followup for urethroplasty. Model assumptions included that excision and primary anastomosis has a 94% success rate, 11% of patients with successful urethroplasty had persistent lower urinary tract symptoms requiring cystoscopic evaluation, patients in whom treatment failed undergo urethrotomy and patients with recurrence on symptom based surveillance have a delayed diagnosis requiring suprapubic tube drainage. The Nationwide Inpatient Sample from 2010 was queried to identify the number of urethroplasties performed per year in the United States. Costs were obtained based on Medicare reimbursement rates.

RESULTS

The 5-year cost of a symptom based, risk stratified followup protocol is $430 per patient vs $2,827 per patient using standard close followup practice. An estimated 7,761 urethroplasties were performed in the United States in 2010. Assuming that 60% were excision and primary anastomosis, and with more than 5 years of followup, the risk stratified protocol was projected to yield an estimated savings of $11,165,130. Sensitivity analysis showed that the symptom based, risk stratified followup protocol was far more cost-effective than standard close followup in all settings. Less than 1% of patients would be expected to have an asymptomatic recurrence using the risk stratified followup protocol.

CONCLUSIONS

A risk stratified, symptom based approach to urethroplasty followup would produce a significant reduction in health care costs while decreasing unnecessary followup visits, invasive testing and radiation exposure.