Citations

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.

Objective To define the natural history, patterns of recurrence and treatment modalities for local prostate cancer (PCa) recurrence following radical prostatectomy (RP) and radiation therapy (RT), and to investigate factors that could predict metastasis‐free survival (MFS) in this unique patient population. Methods We queried a prospectively maintained PCa registry to identify men developing in‐field recurrence (IFR) following RP and RT from 2008 to 2021 at a single institution. IFR was defined as biopsy‐proven recurrent PCa or the presence of persistent positron emission tomography‐avid lesions in the prior radiation field without evidence of metastasis. Cox regression was conducted to determine predictors of MFS. Kaplan–Meier methods were used to calculate MFS, cancer‐specific survival (CSS) and overall survival (OS) for patients in three primary therapy categories: cryoablation, androgen deprivation therapy (ADT) alone, and surveillance. Results Of 4575 patients from our registry, 108 (2.3%) with IFR were identified. The median (interquartile range [IQR]) time to IFR from salvage treatment was 78 (50–126) months. A total of 29 patients (26%) were managed with cryoablation, 23 (21%) with ADT, and 28 (25%) with surveillance. The median (IQR) follow‐up was 76 (48–100) months. There were no statistically significant differences in MFS ( P = 0.67) or OS ( P = 0.07) among the three primary treatment cohorts. Patients treated with ADT or cryoablation had longer CSS compared to patients managed with surveillance ( P = 0.047). Conclusions We found that IFR may present years after completion of primary treatment for PCa. While curative management strategies may be attempted, local and distant metastatic recurrence is common and often requires systemic therapy.

Objective: To characterize our single institutional experience with robotic and open uretero-enteric stricture (UES) repair. Materials and Methods: We queried our ureteral reconstructive database for UES repair between 01/2017 and 10/2023. Patients with <3 months follow-up were excluded. Prior to surgery, patients underwent ureteral rest (4 weeks) with conversion to nephrostomy tube. Clinical characteristics, complications, reconstructive success (uretero-enteric patency), need for repeat intervention, and renal function were assessed in patients undergoing open and robotic UES reconstruction. Results: Of 50 patients undergoing UES repair during the study period, 45 were included for analysis due to complete follow-up (34 [76%] robotic and 11 [24%] open repair). UES repair was performed in 50 renal units a median of 13 months (interquartile range 7–30) from index surgery, and most often involved the left renal unit (34/50; 68%). Compared with robotic, open cases were significantly more likely to have undergone open cystectomy (100% vs 68%, p = 0.04), have longer strictures (median 4 vs 1 cm, p < 0.001), require tissue substitution (27% vs 3%, p = 0.04), and have lengthier postoperative hospitalization (5 vs 2 days, p < 0.001). There was no significant difference in total operative time (410 vs 322 minutes) or 30d major complications (18% vs 21%). At a follow-up of 13 months, per patient reconstructive success was 100% (11/11) for open and 97% (33/34) for robotic, respectively. Conclusion: In select patients with short UES unlikely to require advanced reconstructive techniques, a robotic-assisted approach can be considered. Careful patient selection is associated with limited morbidity and high reconstructive success.

Objectives To characterise the prevalence of impostor phenomenon (IP; tendency for high‐achieving individuals to perceive themselves as fraudulent in their successes) amongst attending staff in urology, to identify variables that predict more severe impostorism, and to study the association of IP with burnout. Subjects and Methods A survey composed of the Clance Impostor Phenomenon Scale (CIPS), demographic information, practice details, and burnout levels was e‐mailed to urologists via urological subspecialty societies. Survey results were analysed to identify associations between IP severity, survey respondent characteristics, and symptoms of professional burnout. This study was conducted in the United States of America. Results A total of 614 survey responses were received (response rate 11.0%). In all, 40% ( n = 213) of responders reported CIPS scores qualifying as either ‘frequent’ or ‘intense’ impostorism (i.e., scores of 61–100). On multivariable analysis, female gender, fewer years in practice (i.e., 0–2 years), and lower academic rank were all independently associated with higher CIPS scores (adjusted P < 0.05). Regarding burnout, 46% of responders reported burnout symptoms. On multivariable analysis, increase in CIPS score was independently associated with higher odds of burnout (odds ratio 1.06, 95% confidence interval 1.04–1.07; P < 0.001). Conclusion Impostor phenomenon is prevalent in the urological community and is experienced more severely in younger and female urologists. IP is also independently associated with burnout. Increased female representation may improve IP amongst our female colleagues. More work is needed to determine strategies that are effective in mitigating feelings of IP and professional burnout amongst urologists, particularly those earlier in their careers.

Abstract Introduction Spongiosal sparing non-transecting anastomotic bulbar urethroplasty has rapidly become the preferred technique for many reconstructive urologists due to reported improvement in postoperative erectile function outcomes. For strictures &lt;2cm, non-transecting techniques without the use of graft augmentation are typically deployed. However, for lengthy bulbar strictures (≥2cm), many advocate for oral mucosa substitution urethroplasty due to the theoretical concern of penile shortening, tethering, or other erectile function related side effects. Although effective, substitution bulbar urethroplasty is associated with additional graft harvest morbidity and may have lower success rates relative to non-substitution non-transecting techniques. Objective We describe outcomes of an extended non-transecting excision-anastomosis urethroplasty for lengthy urethral strictures without the use of graft augmentation. Methods A tertiary center’s urethroplasty database was queried for patients that underwent non-transecting bulbar urethroplasty from 2017-2023. Patients with penile urethral strictures or concurrent urethroplasty procedures were excluded. Stretch penile length (SPL) was assessed by applying gentle traction on the penis and measuring from the base of the penis to the tip of the glans. SPL was assessed perioperatively and at 3-6 month follow-up. Urethral stricture recurrence was defined as need for repeat urethral intervention. Urethral stricture length was determined by intra-operative measurement. Accordingly, patients were then stratified based on stricture length (&lt;2 cm vs ≥2 cm) and tested for association between categorical outcomes (worsening erectile function and reconstructive success) and continuous outcomes (change in SPL) using Fischer’s exact test and Mann Whitney U test. Results A final cohort of 90 patients were identified, with a median urethral stricture length of 1.5 cm (range 0.5-6cm). In addition to dorsal urethrotomy (median 3cm), ventral mucosectomy was performed in 29 (32%) patients (median 2cm). Early postoperative complications occurred in 13 (15%) including UTI (N=4), contrast extravasation at VCUG (N=3), and epididymo-orchitis (N=3). At a median follow up of 13 months (IQR 4-18), a total of 5.5% (5/90) developed stricture recurrence. The overall median change in SPL was 0% (IQR 0-6.7%). De novo ED occurred in 7% (5/67). When stratified by stricture length ≥2cm (N=41) and &lt;2cm (N=49) median length of urethrotomy was 3 cm (2.6-4.0) vs 2 cm (2.0-3.0; p &lt;0.001), respectively. Those with strictures ≥2 cm had greater decreases in relative SPL (median 3.5% vs. 0%, p = 0.003) and higher absolute PVR (median 71 ml vs. 34 ml, p =0.03) at 3 months after surgery. There were no significant differences in relative improvement of Qmax or PVR, stricture recurrence (8% vs 4%), worsening erectile function (10% vs 6%), or complication rates (15% vs 14%) between groups (p-value&gt; 0.05 for all comparisons). Conclusions Spongiosal sparing non-transecting urethroplasty is an effective surgical option for patients with lengthy urethral strictures. It offers comparable relative improvement in functional (Qmax, PVR) and erectile function outcomes, while having a modest impact on SPL all while avoiding the morbidity of graft harvesting. Disclosure No.

Abstract Objective Surgical sterilization, including vasectomy in males and tubal ligation in females, is a highly effective but underutilized contraception method. Adoption rates vary globally mostly due to misconceptions by both the general public and practicing physicians. Our survey aims to explore physicians' knowledge, attitudes and beliefs about surgical sterilization techniques.Study Design A web-based survey of four parts was sent to residents and attending physicians of different specialties in Lebanon between April 2022 and April 2023. 183 physicians responded to the survey. Data was analyzed using IBM SPSS Statistics. A descriptive analysis was performed using the chi-square test for categorical variables and ANOVA for continuous variables.Results Physicians specialized in Urology, OB/GYN, Family medicine and Internal medicine, filled the survey. The majority were resident physicians (79%), male (57%), single (72%) and did not receive training in family planning (73%). Knowledge assessment showed an average score of 5/7. After setting this as a passing score, 60.7% of participants passed the assessment with higher likelihood of passing among attending physicians (84.6%), OB/GYN physicians (94.4%), married participants (80.8%), and physicians who received training in family planning (91.8%). Recommendations varied among specialties, with urologists being more likely to recommend vasectomy depending on the clinical scenario (70–97%). Most physicians perceived the general public preferring tubal ligation as a sterilization method (98%).Conclusion Surgical sterilization is underutilized mostly due to lack of knowledge and cultural beliefs among practicing physicians in our region. Ongoing education is needed in medical training to promote family planning.