Dayron Rodríguez

Aims To evaluate the presentation, risk factors, diagnostic workup, management, and outcomes of Macroplastique (MPQ) erosions. Methods We performed a retrospective chart review of women experiencing MPQ erosion at two tertiary care centers (United States and United Kingdom). Data collected included age, presenting symptoms, parity, comorbidities, hormone replacement therapy, sexual activity, and smoking status. Previous surgical history, time from MPQ injection, urine culture results, and cystoscopic and imaging findings were also reviewed. Development of stress urinary incontinence (SUI) after MPQ removal and subsequent SUI treatments were recorded. Results From 2012 to 2018, 18 patients were identified with a median follow‐up time of 24 months (interquartile range [IQR] 8‐33). All patients presented with recurrent urinary tract infections (rUTI) and had cystoscopic evidence of MPQ erosion. The most common location of erosion was the bladder neck area (72%). Median time to presentation since MPQ injection was 14 months (IQR 11‐35). The majority of patients (72%) had a previous history of anti‐incontinence surgery. The overall success rate of endoscopic management defined as resolution of presenting symptoms including rUTI was 80%. The majority of patients (80%) developed recurrent SUI following MPQ resection with 33% requiring a subsequent autologous fascial sling placement. Conclusion MPQ erosions present predominantly with UTI, sometimes years after the original injection, and may necessitate endoscopic management with satisfactory results in most patients. Following excision of MPQ, these patients are highly likely to experience SUI recurrence and need to be appropriately counseled. Some may require additional subsequent autologous fascial sling placement for treatment of their SUI symptoms.

Inflatable penile prosthesis (IPP) surgery is an effective, safe and satisfactory treatment option for medication-refractory erectile dysfunction. Postoperative complications include infection, mechanical failure, erosion, and pain. Current literature suggests the need for a better approach to postoperative pain management after IPP surgery. Clinical studies have demonstrated that postoperative pain is different in diabetic patients. We sought to determine if there is a difference in pain after IPP placement in diabetics. This is a single-institution retrospective review. The main outcome measure was the number of 30-day postoperative visits for pain. The secondary outcome included differences in how pain was managed. The top HbA1c quartile was compared with the other HbA1c quartiles. Diabetes was present in 92 (54.4%) patients and 96% of these had HbA1c > 8. Significant postoperative pain was more common in patients with HbA1c > 8 (41% vs 13%, p = 0.047) and resulted in more unplanned visits (27% vs 11%, p = 0.042). Patients with HbA1c > 8 with significant postoperative pain were more likely to be managed with opioids and gabapentin (30% vs 14%, p = 0.05). There were no statistical differences in age between diabetics and non-diabetics (mean 59 vs 61, p = 0.193). Hispanic and African-American patients represented 87% of the poorly controlled diabetics compared with only 13% of white patients (p < 0.001). Poorly controlled diabetics had more medical comorbidities (p < 0.001). On logistic regression, a HbA1c > 8 was predictive of an unplanned visit for pain with an OR of 2.83 (p = 0.04). Significant pain after IPP surgery was higher in diabetics with HbA1c > 8, which resulted in more unplanned 30-day postoperative visits. Patients with significant postoperative pain were managed with a combination of opioids and gabapentin. Future studies are required to optimize pain management in diabetics following IPP placement.

Introduction: To evaluate outcomes following urethral Macroplastique (MPQ) injection in women with stress urinary incontinence (SUI) following suburethral sling removal (SSR) for synthetic sling complications.Methods: Following Institutional Review Board approval, charts of non‐neurogenic women with SUI after SSR who underwent MPQ injection(s) and had at least 6 months minimum follow‐up were reviewed from a prospectively maintained database. Demographic data, questionnaire (Urogenital Distress Inventory‐6 [UDI‐6] and Quality of Life) scores, and pad usage were recorded. Patients were followed with repeat questionnaires and three‐dimensional ultrasound evaluating MPQ volume. Success following MPQ was defined as a composite score of a UDI‐6 question 3 score of 0 to 1 at last visit and no additional anti‐incontinence therapy.Results: From 2011 to 2018, 70 women with mean age 62.7 years met study criteria. At a mean follow‐up of 46.4 ± 1.5 months, the success rate after the first MPQ injection was 46%. Following a repeat MPQ injection when indicated, the overall success rate for the entire cohort was 69%. Despite the objective failure, the majority of patients reported subjective improvement (83%) and reduced pad usage (78%). On multivariate analysis: age, body mass index, previous hysterectomy, hormone replacement therapy, type of sling removed and baseline urodynamics (UDS) parameters were not predictors of MPQ failure. Higher parity was a predictor of MPQ failure (hazard ratio = 1.980; P = .032).Conclusion: MPQ injection is a durable and effective management option for SUI following SSR, although a second injection may be required to achieve the desired success.

The purpose of this study was to describe technical considerations and first outcomes from a single-port robotic-assisted sacrocolpopexy (RSC) using the da Vinci SP platform (Intuitive Surgical, Sunnyvale, CA) and the Levita™ Magnetic Surgical System (San Mateo, CA, USA), a novel magnetic retraction system. Three females with pelvic organ prolapse elected to undergo RSC using the da Vinci SP platform. The supraumbilical incision length was 25 mm through which SP trocar was placed. A 12-mm assistant port was placed in the right upper quadrant. The external magnet was attached to the left side of the bed and used for bowel and bladder retraction. We then proceeded by duplicating the steps of our approach for a RSC performed using a multi-port robotic platform with necessary modifications given the SP approach. Intra-operative outcomes and peri-operative outcomes were collected and reported. The patients were women of 64, 66 and 73 years of age with BMI of 22, 25, and 34, respectively, and POP-Q stage III and IV prolapse. The RSC was performed between 198 and 247 min, estimated blood loss was 10–50 cc, and there were no complications. All patients were discharged home on post-operative day 1. All patients were doing well 1 month out with resolution of bulge symptoms. To our knowledge, this represents the first case series of robotic, magnetic-assisted sacrocolpopexies using the da Vinci SP platform and the Levita™ Magnetic Surgical System. It appears to be a safe and feasible approach, but long-term comparative studies will be necessary to assess functional outcomes.

Introduction: The Mulcahy salvage fundamentally altered the management of penile prosthesis infections (PPI). Central to this procedure is a sequence of antiseptic irrigations that aims to remove and eradicate pathogenic microflora from the infected field, thus preparing for immediate reimplantation. The antiseptic solutions and their respective concentrations, however, have never been evaluated for efficacy. Aim: This review critically examines 3 commonly used antiseptic irrigation solutions (povidone-iodine [PVI], hydrogen peroxide [H2O2], and chlorhexidine gluconate [CHG]) in terms of their antimicrobial activity, cytotoxicity, and clinical use. Methods: A PubMed literature review was performed on articles published between 2003 and 2018. Both preclinical as well as clinical studies from various surgical disciplines were included in this review. Main Outcome Measure: The original salvage protocol selected for irrigation solutions at concentrations that are likely detrimental to native tissue. Results: All 3 agents demonstrate in vitro cytotoxic effects at subclinical concentrations, but H2O2 is associated with the most significant deleterious properties. It does not seem to broaden antimicrobial coverage beyond what is covered by PVI. Dilute PVI (0.35–3.5% with exposure time of at least 3 minutes) possesses the most robust clinical evidence as an intraoperative adjunct, reducing the incidence of postoperative infectious complications. chlorhexidine gluconate is a promising new agent but lacks clinical data. Clinical implication: Improvements in the salvage protocol are warranted based on current evidence. Careful selection of lavage solution and usage of the lowest necessary concentration will help achieve desired antimicrobial activity while avoiding native tissue cytotoxicity. Strength and limitation: The study is limited by its retrospective nature, and the heterogeneity of literature reviewed precluded a formal meta-analysis. Furthermore, future studies will need to address the roles of normal saline and antibiotic irrigations as intraoperative adjuncts for infection prevention. Conclusion: Diluted PVI (0.35–3.5% for 3 minutes) may be beneficial in the prevention of PPI. Evidence supports its use both in the setting of primary implantation as well as salvage of infected hardware. An improved, evidence-based protocol may increase positive outcomes of urologic prosthetic surgery.

This is a single-institution retrospective study of closed suction drain outputs in primary three-piece IPP cases performed between 2014 and 2017 by a single surgeon. The aim was to investigate the impact of closed suction drains (CSD) during penile prosthesis placement. One hundred and sixty-nine patients underwent intraoperative placement of a closed suction drain. Drain outputs were measured at 12 and 24 h, and postoperative complications were documented. There were no hematomas or infections observed within the patient cohort. The drain output decreased significantly between the first and subsequent 12 h period. Surgical time was associated with statistically significant increases in CSD output at 12 and 24 h with a near linear relationship between surgical times and CSD at 12 and 24 h. Penile prosthesis placement in patients on aspirin did not affect the CSD output volume. Closed suction drains should be considered in all patients undergoing placement of inflatable penile prosthesis, particularly in those cases with longer operative time.

Penile shunting is the standard of care in management of ischemic priapism refractory (IPR) to non-surgical interventions. Due to high rates of impotence, corporal fibrosis, and loss of penile length, recent literature suggests these patients benefit from immediate penile prosthesis (PP) placement. An IRB-exempt anonymous electronic survey of the 2168 members of the International Society for Sexual Medicine (ISSM) was conducted. The survey included demographic information, confidence, and experience-related management of IPR. The aim was to evaluate current practice patterns in management of IPR and to investigate the role of immediate PP implantation in the management of prolonged (>36 h) IPR. The survey response rate was 11.6% (n = 251). Most respondents were urologists (173), from the USA (49.1%), and had completed a fellowship in male sexual medicine, men’s health, reconstruction, or andrology (71.1%). The majority (91.3%) see at least one case of prolonged priapism (>36 h) that requires surgical management yearly. When looking at volume in training and after, our respondents had a significantly higher experience with penile prostheses (over 70%, > = 10) as compared with shunts (less than 40%, > = 10). Overall, 70.9% of respondents felt more comfortable with a malleable PP than a shunt. However, penile shunts are still preferred as the first line of surgical management by ~80% of respondents as compared with 12.7% who instead prefer a PP. We also found that under 40% of respondents currently use penile MRI or corporal biopsies in their management of prolonged assessment. This is the first study to assess current clinical practices in management of IPR globally. As in any anonymous self-reported survey-based research, recall and sampling bias are an inherent limitation. Penile shunting for IPR continues to be the preferred treatment despite emerging data. Respondents performed PP surgery routinely and feel more confident placing PP than performing penile shunting procedures.