Yang Md, David

AbstractBackgroundThe advent of antibiotic-coated devices has reduced the rate of inflatable penile prosthesis (IPP) infections; however, this may have altered microbial profiles when infections do occur.AimTo describe the timing and causative organisms behind infection of infection retardant–coated IPPs in the context of our institution’s perioperative antimicrobial protocols.MethodsWe retrospectively reviewed all patients undergoing IPP placement at our institution from January 2014 to January 2022. In all patients, perioperative antibiotic administration was congruent with American Urological Association guidelines. Boston Scientific devices are impregnated with InhibiZone (rifampin and minocycline), and all Coloplast devices were soaked in rifampin and gentamicin. Intraoperative irrigation was performed with betadine 5% irrigation prior to November 2016 and with vancomycin-gentamicin solution afterward. Cases involving prosthesis infection were identified, and variables were extracted from the medical record. Descriptive and comparative statistics were tabulated to identify clinical characteristics, including patient comorbidities, prophylaxis regimen, symptom onset, and intraoperative culture result. We previously reported an increased infection risk with Betadine irrigation and stratified results accordingly.OutcomesThe primary outcome was time to infectious symptoms, while the secondary outcome was description of device cultures at the time of explantation.ResultsA total of 1071 patients underwent IPP placement over 8 years with an overall infection rate of 2.6% (28/1071). After discontinuation of Betadine, the overall infection rate was significantly lower at 0.9% (8/919) with a relative risk of 16.9 with Betadine (P < .0001). Primary procedures represented 46.4% (13/28). Of 28 patients with infection, only 1 had no identified risk factors; the remainder included Betadine at 71% (20/28), revision/salvage procedure at 53.6% (15/28), and diabetes at 50% (14/28). Median time to symptoms was 36 days (IQR, 26-52); almost 30% of patients had systemic symptoms. Organisms with high virulence, or ability to cause disease, were found in 90.5% (19/21) of positive cultures.Clinical ImplicationsOur study revealed a median time to symptoms of just over 1 month. Risk factors for infection were Betadine 5% irrigation, diabetes, and revision/salvage cases. Over 90% causative organisms were virulent, demonstrating a microbial profile trend since antibiotic coating development.Strengths and LimitationsThe large prospectively maintained database is a strength along with the ability to follow specific changes in perioperative protocols. The retrospective nature of the study is a limitation as well as the low infection rate, which limits certain subanalyses from being performed.ConclusionIPP infections present in a delayed manner despite the rising virulence of infecting organisms. These findings highlight areas for improvement in perioperative protocols in the contemporary prosthetics era.

Abstract Peyronie's disease (PD) is associated with significant psychosocial distress, including anxiety, depression, and negative effects on interpersonal relationships. We report outcomes in a patient who researched an enzymatic supplement intended for oral administration for treatment of PD and subsequently self-injected it intravascularly. The enzyme, a combination of serrapeptase and nattokinase, resulted in vascular necrosis of the upper extremity. Despite attempts to salvage the limb, he ultimately required transhumeral amputation. Although extreme, this case illustrates the potential risks of non–Food and Drug Administration–approved therapies, the significant psychosocial impact that PD can have on patients' emotional well-being, and the extent to which some may go to seek treatment. Yang D, Savage J, Kohler T, et al. Vascular Necrosis of the Upper Extremity After Self-Treatment for Peyronie's Disease. Sex Med 2021;9:100282.

Abstract Aim Up to 10% of patients who undergo nonurological abdominopelvic operations suffer a ureteral injury. While preoperative ureteral stenting to facilitate identification of the ureter is common, it does not reduce the incidence of intraoperative ureteral injury and is not without risk. As we continue to broaden the application of minimally invasive surgical techniques, a new form of ureteral identification and avoidance that does not rely on tactile feedback is needed. We report our initial experience with intraureteral indocyanine green (ICG) for ureteral identification and avoidance during complex robotic‐assisted colorectal surgery. Method Patients undergoing adjunctive ureteral identification during robotic‐assisted colorectal surgery were prospectively identified. Each patient underwent intraureteral ICG administration using rigid cystoscopy (22 Fr). A 5‐Fr open‐ended ureteral catheter was inserted up to 20 cm and used to inject 5 ml of 2.5 mg/ml ICG as the catheter was withdrawn to the ureteral orifice. Intraureteral ICG was then detected using near‐infrared laser fluorescence technology (Firefly®). Results Successful ICG‐enhanced ureteral identification and avoidance was performed in 15 of 16 (94%) patients undergoing robotic‐assisted colorectal surgery. The median ICG instillation time was 11.5 min (range 4–21 min) and the median operative time with ICG visualization was 489 min (8 h 9 min) [range 268–738 min (4 h 28 min–12 h 18 min)]. No patient experienced intraoperative ureteral injury and there were no adverse sequelae or complications associated with intraureteral ICG administration. Conclusion Intraureteral ICG is a safe and effective method of intraoperative ureteral identification and avoidance during complex robotic‐assisted colorectal surgery. Precise and prolonged ureteral visualization was achieved, allowing for long operative times compatible with complex robotic‐assisted operations.

Abstract Introduction Infection remains a persistent complication of penile prosthesis (PP) surgery. Despite popularity of Mulcahy’s PP washout protocol, Betadine has known tissue toxicity. Aim We evaluated PP infection rate based on the type of intraoperative irrigation used, ½ strength Betadine vs vancomycin/gentamicin. Methods We reviewed a prospective database of men undergoing primary, revision, and salvage PPs. No other changes to operative or perioperative techniques occurred after the change in irrigation solution. Univariate and logistic regression analyses were used to evaluate differences in infection rate with use of Betadine vs vancomycin/gentamicin irrigation. Potential confounders were reviewed. Main Outcome Measure The primary outcome was rate of PP infection before and after change of intraoperative irrigation. Results From 2014 to 2018, 217 patients underwent PP placement at our institution by a single surgeon; of whom, 21 (9.7%) experienced an infection (primary = 10 [7.1%], revision = 11 [17.19%], salvage = 0 [0%]). Overall, 152 (70%) received irrigation with Betadine and 65 (30%) with Vancomycin/Gentamicin. Univariate analysis demonstrated significantly increased infection rates with Betadine irrigation (odds ratio [OR]: 4.64, P = .006) and with revision surgery (OR: 2.68, P = .02). Significance of increased infection rate with Betadine was maintained (OR: 9.3; P = .025) after controlling for age, body mass index, Charlson comorbidity index, smoking, diabetes, primary vs revision/salvage, prior penile surgery, use of ectopic reservoir, and adjunctive glanulopexy. Conclusions Changing from intraoperative Betadine to vancomycin/gentamicin solution dramatically reduced infection rates among men undergoing PP placement in both primary and revision cases. We hypothesize that differences in infection rate may relate to the relative toxicity or non-sterile nature of Betadine. Manka MG, Yang D, Andrews J, et al. Intraoperative Use of Betadine Irrigation is Associated With a 9-Fold Increased Likelihood of Penile Prosthesis Infection: Results From a Retrospective Case-Control Study. Sex Med 2020;8:422–427.

ObjectivesTo evaluate the timing and distribution of first renal cell carcinoma metastasis after nephrectomy stratified by nodal status.MethodsWe evaluated patients treated with nephrectomy for sporadic, unilateral renal cell carcinoma between 1970 and 2011 who subsequently developed distant metastasis to three or fewer sites. Site‐specific metastases‐free 2‐year survival rates were estimated using the Kaplan–Meier method. Associations of nodal status with time to metastasis were evaluated using multivariable Cox regression models.ResultsA total of 1049 patients met the inclusion criteria (135 pN1, 914 pN0/x patients). The median time to identification of first distant metastasis for pN1 patients was 0.4 years (interquartile range 0.2–1.1 years) versus 2.2 years (interquartile range 0.6–6.0 years) in pN0/x patients. The most common site of metastasis was to the lung, but this occurred earlier in pN1 patients (median 0.3 years vs 2.0 years). pN1 was associated with significantly lower site‐specific 2‐year metastases‐free survival when compared with pN0/x for lung (37% vs 70%, P < 0.001), bone (63% vs 87%, P < 0.001), non‐regional lymph nodes (60% vs 96%, P < 0.001) and liver metastases (79% vs 91%, P < 0.001). On multivariable analysis, pN1 status remained significantly associated with lung, bone, and non‐regional lymph node (all P < 0.001) metastases, but it was no longer associated with liver metastases (P = 0.3).ConclusionspN1 nodal status in M0 patients treated with nephrectomy for renal cell carcinoma is associated with more frequent early metastasis to sites conferring poor prognosis when compared with pN0/x. Our findings highlight the importance of rigorous, early surveillance though the multimodal use of a comprehensive history, physical, laboratory and radiological studies, as outlined in societal guidelines.

Abstract Background Adjuvant maneuvers are often necessary to correct residual curvature during inflatable penile prosthesis (IPP) placement in patients with Peyronie's disease (PD). Aim We present our multicenter experience using collagen fleece as graft material for plaque incision and grafting (PIG) during IPP placement in patients with moderate to severe PD. Methods We retrospectively reviewed 51 patients with IPP from 3 sites who underwent PIG with Tachosil (Baxter, IL) collagen fleece. Coloplast (Minneapolis, MN) IPP devices were used. Factors associated with residual curvature, revision, and patient satisfaction were performed using chi-squared analysis. Outcomes We evaluated postoperative outcomes including factors associated with residual curvature, revision, and patient satisfaction. Results The mean compound curvature was 69.6°. The mean follow-up was 10.6 (range 1–38) months. All patients reported erections sufficient for penetrative intercourse at the last follow-up. Residual curvature &lt;15° was noted in 6 of 51 (12%) patients. 3 patients required device revision. 2 patients experienced temporary glanular paresthesia, and no patients experienced device infection. Clinical Implications In our multicenter study, patients experienced substantial curve correction with minimal complications, and in the few patients who had persistent mild curvature, severe preoperative curvature (&gt;60°) was found to be the only risk factor. Strengths & Limitations Our study represents the largest series of patients coming from multiple centers undergoing surgical correction of PD with IPP and collagen fleece grafting. Limitations of this study include the retrospective study design, lack of a comparison group, and modest follow-up. Conclusion PIG using collagen fleece is a safe and effective means of correcting residual curvature after IPP placement in patients with moderate to severe PD.

ObjectiveArtificial urinary sphincter malfunctions can occur in any of the individual components. Preoperative identification of the malfunctioning component can be valuable for patient counseling and surgical planning. The optimal strategy for repair of failed artificial urinary sphincter components is debated given the relative rarity of the situation. The aim of the present study was to evaluate the relationship of time to failure with failed artificial urinary sphincter component and to compare our outcomes of specific component versus complete device replacement.MethodsFrom 1983 to 2011, 1805 artificial urinary sphincter procedures were carried out at Mayo Clinic (Rochester, Minnesota, USA), of which 1072 patients underwent primary artificial urinary sphincter placement. Clinical variables, including time to failure, were evaluated for association with component failure. Bootstrap analysis was used to estimate the differences in time to reach a fixed percentage of component failure.ResultsA total of 115 patients experienced device failure at a median follow up of 4.2 years. Urethral cuff, abdominal reservoir, scrotal pump and tubing malfunction occurred in 53 (4.9%), 26 (2.4%), 11 (1%) and 25 (2.3%) patients, respectively. Increasing age at the time of primary surgery was protective of cuff malfunction (hazard ratio 0.97, P = 0.04). Time to 3% urethral cuff failure outpaced other component failures (P < 0.05). Secondary failure‐free rates after whole device versus specific component revisions were comparable (P = 0.38).ConclusionsClinical predictors for artificial urinary sphincter failure continue to be difficult to establish. Although single component versus entire device replacement have similar outcomes, if pursuing single component revision, we recommend cuff‐first interrogation in devices in place for >3 years, as this represents the most likely component to fail.