Abstracts from the New England Section of the AUA 2020: A Virtual Experience

NE AUA 2020 Abstracts Surgical Management of Urethral Bulking Agent Complications in Women Michael E. Goltzman, MD 1 , Richard T. Kershen, MD 2 1 UConn Health, Farmington, CT; 2 Tallwood Institute of Urology, Hartford Healthcare Medical Group, Hartford, CT Introduction: Urethral bulking agent (UBA) injection serves as a quick, minimally invasive method for the treatment of stress urinary incontinence (SUI) in women. When injected submucosally these agents restore continence via urethral coaptation. Though bovine collagen (Contigen™) served as the predominant injectable agent for years, a variety of synthetic agents includingMacroplastique®, Durasphere® and Coaptite® have risen to prominence. Though widely utilized, there is only sparse data in the literature regarding potential complications of these agents. In this case series, we describe UBA complications in four patients requiring surgical management as well as the techniques utilized to resolve these complications. Materials &Methods: This study entails a retrospective reviewof four patients presenting for evaluation and management of complications related to injection of UBAs to a single surgeon between 2016 and 2020. Presenting symptoms, diagnostic evaluation, surgical management and outcomes are reviewed. The presenting symptoms were described as either early-onset (< 12 mo) or late-onset (> 12 mo) according to first report. Results: Patient characteristics and management strategies are presented in Table 1. The most common presenting symptoms included urinary urgency, vaginal pain and dyspareunia. In most cases, voiding dysfunction occurred early after the bulking therapy. In all cases, cystourethroscopy identified agent erosion or local inflammatory response (Figure 1); imaging was performed in 3 cases (1 MRI, 2 CT). To date, transvaginal excision has been performed in two patients, with two patients awaiting definitive operation. Patients undergoing transvaginal excision presented with vaginal pain and necessitated urethral reconstruction (Figure 2). Open excision of the UBA resulted in improvement or complete cure of symptoms. Both patients developed recurrent SUI, with one patient requiring a salvage pubovaginal sling procedure to date. Conclusions: The majority of UBA complications, including urinary tract infection, hematuria, and urinary retention are considered mild and transient and may be managed with non-surgical interventions. 1 For patients in whom conservative management fails or for more severe complications (i.e. erosion, abscess, palpable mass and chronic pain) transurethral or transvaginal excision of bulking agent and associated granulomas should be considered. Though open excision is a major surgical endeavor, complete relief of symptoms can be achieved, albeit with a risk of de-novo SUI. Physicians should have a high level of suspicion for bulking agent erosion or granuloma development in all patients with a history of prior injection presentingwith lower urinary tract symptoms and/or pain. 1 De VriesAM, Wadhwa H, Huang J, Farag F, Heesakkers JPFA, Kocjancic E. Complications ofUrethralBulkingAgentsforStressUrinaryIncontinence:AnExtensiveReviewIncluding Case Reports. Female Pelvic Med Reconstr Surg. 2018;24(6):392-398. 66 Scientific Session VII: Female/Neuro Time toOperating Room is Significantly Longer if EmergencyDepartment Presentation Occurs “After Hours” for Patients with Pyelonephritis and Obstructing Stones Timothy K. O’Rourke, Jr., MD , David W. Sobel, MD, Marcelo Paiva, M.P.P., Praveen Rajaguru, M.P.H., Christopher Tucci, MS., R.N., Gyan Pareek, MS., MD Brown University/Rhode Island Hospital, Providence, RI Introduction: Obstructive pyelonephritis secondary to obstructing ureteral calculi is considered a urological emergency. Patients with hemodynamic instability and signs of florid sepsis are emergently taken for ureteral stent or percutaneous nephrostomy tube placement. However, for patients without these presenting signs or symptoms but still in need of decompression, there is question as to the necessity of emergency surgery. We sought to explore time from diagnosis to operating room (OR) in patients with regard to the time of day and day of the week that the patient presented to the emergency department (ED) and its effect on hospital length of stay, a surrogate measure for clinical course and morbidity. Materials & Methods: A retrospective review of all patients presenting to the ED with obstructive pyelonephritis secondary to obstructing ureteral calculi at a single academic institution betweenMay 2017 and December 2019 was performed. Patient demographics, day of the week of presentation, as well as time of ED presentation and clinical course including times of imaging completion confirming diagnosis and time to OR were analyzed. Patients were categorized as having presented during “business hours” 6 AM - 6 PM or “after hours” 6 PM - 6 AM. Student’s t-test and one-way analysis of variance (ANOVA) were utilized to detect differences between groups. Results: A total of 131 patients with infected or septic stones who underwent urgent or emergent cystoscopy and ureteral stent placement were reviewed. Patients who presented to the ED during standard business hours were taken to the operating room on average more expeditiously (Mean = 250 minutes, SD = 220) than those who presented after hours (Mean = 406 minutes, SD = 207; t(29) = 3, p =.005). No significant difference in LOS was detected between these two groups (Mean = 69.8 hours, SD = 59.6 [business hours] versus mean = 53.1 hours, SD = 49.6 [after hours]; t(40) = 1.4, p =.16). No differences were detected in time from imaging diagnosis to OR [F(6,106) = 0.99, p =.44] nor length of stay [F(6,122) = 1.88, p =.09] based on the individual day of the week of ED presentation. Conclusions: The time to operating room is significantly different basedwhether patients with pyelonephritis and an obstructing stone present to the ED during “business hours” or “after hours.” Patients who presented to the ED “after hours” experienced a significant delay in time from diagnosis to arrival to the OR for definitive surgical management compared to those presenting during “business hours.” Despite this, there was no difference in hospital length of stay between these groups, suggesting no significant impact on morbidity or clinical course in those deemed clinically stable for non-emergent stent placement. This suggests that in the appropriate clinical context stent placement may be performed non-emergently without significant effect on a patient’s overall clinical course. Further studies should focus on the effect this may have on hospital and surgeon resources. 65 29