Kemble, Jayson

ABSTRACT Background There is limited data regarding the surgical outcomes of urosymphyseal fistula (USF) repair with primary repair or autologous tissue transfer. We performed a study to compare outcomes of USF repair with primary repair, VRAM flap, and omental flap. Methods We retrospectively identified patients with a diagnosis of USF who underwent fistula decompression and urinary tract reconstruction. The minimal follow‐up was 3 months. Patients with distal urethral obstruction, radiation cystitis, or a non‐viable sphincter underwent anterior exenteration and flap transfer. Results Fifty‐six patients were included. Eleven patients underwent surgical management for USF using primary repair (19.6%), 34 had omental flap‐based reconstruction (60.8%), and a VRAM flap was used in 11 patients (19.6%). The 90‐day rate of sepsis was lower with omentum flap transposition (3%) compared with VRAM flap (27%) or primary repair (18%, p = 0.041). The rate of fistula recurrence was lower in the omentum flap group compared with USF primary repair (30%) or VRAM flap repair group (27.3%, p = 0.04). On multivariable analysis, USF repair with the omentum flap decreased the odds of fistula recurrence 90 days after surgery compared with primary repair (OR 0.012, p = 0.011) but not when compared with VRAM. Conclusion The omentum flap may offer a better safety profile in terms of decreasing the rate of early sepsis and rate of fistula recurrence for USF repair in comparison to primary repair. There is limited evidence regarding the superiority of the omentum flap to decrease the rate of late fistula recurrence when compared with the VRAM flap.

ABSTRACT Purpose There is limited evidence regarding the optimal timing of urosymphyseal fistula (USF) repair. Our aim was to conduct a comparative analysis evaluating the postoperative complications and surgical outcomes among patients undergoing surgery for USF, comparing those treated in an early versus delayed fashion. Methods Fifty‐eight patients with diagnosis of USF and who underwent fistula decompression, pubic bone resection, and urinary tract reconstruction were included. Patients who underwent USF repair within 100 days of diagnosis were classified as having early repair, while those treated after 100 days were considered to have delayed repair. Results Thirty‐one underwent delayed USF repair (53.4%), while 27 underwent early repair (46.6%). Most patients were male (96.8%). The median age (72 years vs . 69 years, p = 0.13) and mean BMI (28.7 vs . 28.6, p = 0.97) were comparable between groups. The rate of overall 90‐day complications following USF repair was comparable between groups (77.4% vs . 63%, p = 0.228). We did not find a difference between the rates early complications among groups. The rates of long‐term recurrent pain (46.7% vs . 11.1%, p = 0.004), recurrent osteomyelitis (20% vs . 0%, p = 0.014), and fistula (23.3% vs . 3.7%, p = 0.033) were higher in the delayed USF repair group compared to the early USF repair group. The follow up time was similar between groups too (25.43‐months vs . 32.8‐months, p = 0.257). Conclusion While early USF repair might not affect the incidence of early complications within 90 days post‐surgery, it is associated with reduced rates of long‐term recurrent pain, recurrent osteomyelitis, and fistula recurrence compared to delayed USF repair.

Abstract Background Erectile dysfunction (ED) is a known precursor and sequela of cardiovascular disease (CVD), with ED severity predicting CVD severity. Aim This study aimed to evaluate the utility of ceramide levels in patients with ED. Methods We initiated ceramide testing in all patients with ED. We retrospectively analyzed ceramide levels from electronic records and stratified by severity of symptoms using the erectile function domain of the International Index of Erectile Function (IIEF). Outcomes The study aimed to determine whether abnormal ceramide levels were associated with ED severity and increased cardiovascular risk. Results Three hundred and fifty-four patients were reviewed, of whom 253 (71.5%) had moderate or higher ED. A statistically significant difference in abnormal ceramide values was found in patients with moderate to severe symptoms, and the odds of getting an abnormal ceramide test were increased based on the IIEF scoring alone (odds ratio [OR] 2.3 [1.04-5.12]; P-value = .034). Clinical Implications Serum ceramide testing could be beneficial in identifying cardiovascular risk in men with ED, potentially prompting cardiac referrals and lifestyle modifications. Strengths and Limitations The strengths of this study include a large sample size and the use of a well-established scale, while the limitations include the retrospective nature of the study and the need for further research to validate the findings. Conclusion Patients undergoing management for ED may benefit from serum ceramide testing and subsequent cardiac referral.

Clinical History: The case is a 17-year-old boy with a history of bilateral grade 4 vesicoureteral reflux and end-stage renal disease who underwent a living-unrelated donor renal transplantation in November 2021. He presented in June 2022 with vague abdominal pain and creatinine 4.3 mg/dL. Physical Examination: Transplant biopsy showed no evidence of acute rejection. Antegrade nephrostogram at the time of nephrostomy tube placement demonstrated hydronephrosis and a focal stricture of the proximal transplant ureter. His anatomy was further complicated because of prior ligation of his native distal right ureter at the time of transplant and intraperitoneal location of his transplant kidney through a peritoneal window. Diagnosis: Focal proximal stricture of transplant ureter. Intervention: Given the complex anatomy, a 3D-printed anatomical model was created to facilitate surgical planning. The 3D model highlighted a complex trajectory of the proximal ureter and strictured segment directly posterior to the transplant hilar vessels. In addition, the transplant kidney was directly overlying the dome of the bladder because of its intraperitoneal location. Given these anatomic considerations, the patient underwent an uncomplicated robot-assisted ureteropelvicostomy between his native left ureter and transplant renal pelvis. Follow-Up/Outcomes: Total robotic operative time was 2 hours 17 minutes. He was dismissed on postoperative day 1 with a creatinine nadir equivalent to his post-transplant baseline at 10-week follow-up. 3D-printed models have utility in select cases with complex anatomy. These models facilitate accurate regional and spatial anatomy of critical structures to enable effective operative planning. No competing financial interests exist. Patient consent statement: Patient consented to the use of nonidentifiable intraoperative photography and video recording for the purpose of medical education and publication in professional journals. Source of 3D model: Mayo clinic 3D Anatomic Modeling Laboratory. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No funding was received for this article. Music: All music was from Pixabay.com, royalty free. Runtime of video: 04 mins 58 secs

Clinical History: A 60-year-old man with a history of muscle invasive small cell carcinoma of the bladder underwent robot-assisted radical cystectomy with pelvic lymph node dissection and Indiana pouch creation. He underwent aspiration and endoscopic urethral fulguration for a symptomatic lymphocele without improvement. Physical Examination: Clear fluid draining per urethra. CT of abdomen/pelvis showed unchanged loculated fluid collections within the dependent pelvis 2 months after aspiration and urethral fulguration. Diagnosis: Pelvic lymphocele with drainage per urethra. Intervention: Fulguration and closure of the urethral stump using a laparoscopic suture device (RD-180; LSI Solutions, Rochester, NY) and novel endoscopic sheath (JNW Urtract TM ; LSI Solutions). Before surgery, a pigtail drain was placed in the pelvic fluid collection. The proximal stump was fulgurated using the bipolar plasma band through a 27F cystourethroscope (Olympus Surgical Technologies America, Westborough, MA) to facilitate scarring. The stump was closed using the RD-180 under direct observation in a figure of eight manner both proximally at the opening and 1 cm distally. Knots were fashioned using the Ti-Knot fastener (LSI Solutions). Total operative time 37 minutes. Follow-Up/Outcomes: Patient was dismissed same-day following surgery. CT scan 2 months postoperatively demonstrated resolution of pelvic fluid collection, and his drain was removed. He remains asymptomatic without recurrence or urethral drainage 4 months postoperatively. To our knowledge, this is the first described case of endoscopic closure of a urethral stump in the setting of persistent drainage from a pelvic lymphocele. Fulguration with endoscopic closure using a novel device is both a safe and efficacious alternative to performing urethral fulguration alone. No competing financial interests exist. No funding was received for this article. Patient consent statement: Patient consented to the use of nonidentifiable intraoperative photography and video recording for the purpose of medical education and publication in professional journals. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music: All music was from Pixabay.com, royalty free. Runtime of video: 4 mins 4 secs

Objectives To compare the carbon footprint and environmental impact of single‐use and reusable flexible cystoscopes. Materials and Methods We analysed the expected clinical lifecycle of single‐use (Ambu aScope™ 4 Cysto) and reusable (Olympus CYF‐V2) flexible cystoscopes, from manufacture to disposal. Performance data on cumulative procedures between repairs and before decommissioning were derived from a high‐volume multispecialty practice. We estimated carbon expenditures per‐case using published data on endoscope manufacturing, energy consumption during transportation and reprocessing, and solid waste disposal. Results A fleet of 16 reusable cystoscopes in service for up to 135 months averaged 207 cases between repairs and 3920 cases per lifecycle. Based on a manufacturing carbon footprint of 11.49 kg CO 2 /kg device for reusable flexible endoscopes and 8.54 kg CO 2 /kg device for single‐use endoscopes, the per‐case manufacturing cost was 1.37 kg CO 2 for single‐use devices and 0.0017 kg CO 2 for reusable devices. The solid mass of single‐use and reusable devices was 0.16 and 0.57 kg, respectively. For reusable devices, the energy consumption of reusable device reprocessing using an automated endoscope reprocessor was 0.20 kg CO 2 , and per‐case costs of device repackaging and repair were 0.005 and 0.02 kg CO 2 , respectively. The total estimated per‐case carbon footprint of single‐use and reusable devices was 2.40 and 0.53 kg CO 2 , respectively, favouring reusable devices. Conclusion In this lifecycle analysis, the environmental impact of reusable flexible cystoscopes is markedly less than single‐use cystoscopes. The primary contributor to the per‐case carbon cost of reusable devices is energy consumption of reprocessing.