Renal Medullary Carcinoma: The Zebra Amongst the Horses.

A 13-year old Latino male presented with recurrent gross hematuria, 5cm right-sided poorly defined heterogeneous mass, enlarged retrocaval lymph nodes, and 1.2 cm paratracheal lymph node. Given the need for multiple blood transfusions, robot-assisted radical nephrectomy with lymph node dissection was performed. Pathology revealed pT3a high-grade tumor, clear margins, and positive lymph node. Additionally, with multiple sickled RBCs and loss of staining of SMARCB1 in tumor specimen, and hemoglobin electrophoresis suggesting sickle cell trait, diagnosis of metastatic renal medullary carcinoma was confirmed. The patient was enrolled into COG AREN 03B2 trial, and has completed 10 cycles of carboplatin/gemcitabine/bortezomib alternating with cisplatin/gemcitabine/paclitaxel, with no evidence of recurrent disease 9 months post-surgery.

Testicular relapse of acute lymphoblastic leukemia.

Contemporary chemotherapy regimens have led to improved survival and decreased incidence of testicular relapse for pediatric patients with acute lymphoblastic leukemia (ALL). Local therapies to the testes, such as radiotherapy and orchiectomy, are often not necessary given that high-dose chemotherapy agents can overcome the relative blood-testis barrier. However, urologists should be aware of clinical scenarios involving ALL which still warrant testicular biopsy to guide management. Here, we present a case of a 12-year-old boy with high-risk pre-B cell ALL presenting with a testicular relapse and a clinical presentation overlapping with non-infectious epididymo-orchitis.

Urethral pyogenic granuloma in a pediatric patient.

Pyogenic granuloma, also known as lobular capillary hemangioma, is a benign vascular tumor rarely found in the genitourinary tract. Here, we present a case of a 6-year-old boy presenting with gross hematuria who was found to have a mass at the bladder base on ultrasound. Endoscopic resection was performed, revealing the base of the mass originating from the prostatic urethra. Pathology found pyogenic granuloma. This entity has not previously been reported to arise from the pediatric urethra and should be considered on the differential for children presenting with gross hematuria and those found to have bladder or urethral masses.

The role of in-person focus groups in the management of urinary incontinence in women from a mixed-methods, randomized pilot study.

PURPOSE: To assess the quantitative and qualitative components of in-person focus groups as a potential intervention for female patients with urinary incontinence. METHODS: Women over the age of 18 seeking treatment for UI were randomized to standard care with focus group participation or to standard care alone. All participants completed validated questionnaires: MESA, UDI-6, OAB-SAT-q, PGI-S, PGI-I, SQoL-F, PHQ-9, IPAQ at the beginning and conclusion of the study. Questionnaires were analyzed with repeated measures of ANOVA models in an intention-to-treat manner. Three moderated focus group sessions were held and audio recorded. Recordings were transcribed and categorized by frequency into themes using grounded theory methodology. RESULTS: A total of ten control and eight intervention participants agreed to participate. Seven women attended all three focus group sessions and were included in the final analysis. Transcripts from focus group sessions observed women identified most with (1) urinary incontinence (UI) as a chronic disease, (2) shame managing UI, and (3) social constraints of toileting. Participants self-reported appreciation of focus group participation and desire for on-going sessions. Analysis of the questionnaires did not demonstrate statistically significant differences. CONCLUSION: Data ascertained from questionnaires were unable to demonstrate a meaningful effect in improved treatment outcomes for control and intervention participants. Grounded theory analysis of transcripts identified four primary themes: (1) appreciation of the focus group, (2) UI as a gendered issue, (3) lack of public awareness, and (4) history of negative provider interactions. All focus group participants self-reported interest in attending future focus group sessions.

Opioid Use after Pediatric Urologic Surgery: Is It Really Needed?

OBJECTIVES: To identify factors associated with opioid use after pediatric urologic surgery, use this data to educate our patients and colleagues on decreasing post-operative opioid use, and assess the effectiveness of this approach. METHODS: From 1/2018 - 12/2019, a written questionnaire asking which pain medications were used after surgery was given to patients' families before routine post-operative appointments. A retrospective review of the surveys and patient charts was performed. Demographic factors were compared between patients who did and did not use opioids with Fisher's exact and t tests. Midway through the study, the results were presented to the urology department in an attempt to reduce opioid use over the next year. The number of opioid prescriptions and patients who used opioids after surgery in 2018 versus 2019 was compared. RESULTS: 1001 patients were included with a mean age of 5 years, 96% male. Patients used a mean of 4.5 doses of opioids and 83% had leftover opioids. Factors significantly associated with not using opioids included age less than 3, penile, and endoscopic surgery. Between 2018 and 2019-despite no significant difference in patient age, gender, or procedure type-the number of patients who were prescribed (61% vs 34%, P < .0001) and who used opioids (55 vs 28%, P < .0001) was significantly decreased. CONCLUSION: After pediatric urologic surgery, many patients do not need opioid prescriptions. Reviewing our own opioid use practices and providing education within our department allowed us to significantly decrease the number of opioids prescribed and used after surgery.

Evaluating the Prevalence of Pelvic Floor Disorders in Women in Nonmetropolitan Communities.

INTRODUCTION: Prevalence rates of pelvic floor disorders in women in nonmetropolitan communities compared with metropolitan communities are unknown. We hypothesize that the rates are higher in women in nonmetropolitan communities. METHODS: We accessed the health survey data from the NHANES (National Health and Nutrition Examination Survey) from 2009 to 2010 divided by geocodes into nonmetropolitan (<50,000 inhabitants) and metropolitan communities (>50,000). Responses were analyzed for the following conditions: urinary incontinence and nocturia, bowel urgency and anal incontinence, and symptomatic vaginal bulge. Age-adjusted prevalence rates were estimated using logistic regression. RESULTS: The 2009-2010 NHANES survey was completed nationwide by 302 women in nonmetropolitan communities and 2201 women in metropolitan communities. Overall, prevalence rates of PFDs did not significantly differ between groups. Prevalence rates of urinary incontinence and nocturia at least weekly were similar between metropolitan and nonmetropolitan groups (16.2% vs 14.6%, P = 0.47), with stress incontinence being more common than urgency and other types of incontinence (40% vs 23% and 8%). Women in metropolitan communities reported more bowel urgency than women in nonmetropolitan communities (33.3% vs 26.8%, P = 0.02); however, prevalence rates between both groups are similar with regards to anal incontinence at least once a month or more (9.2% vs 9.0%, P = 0.76). Prolapse symptoms were also not significantly different between the groups (2.4% in both). There was an increase in prevalence in each of the pelvic floor disorder symptoms with age. CONCLUSIONS: Pelvic floor disorders are prevalent and increase with age in women in nonmetropolitan communities at rates similar to women in metropolitan communities.

Multi-Institutional Outcomes of Endoscopic Management of Stricture Recurrence after Bulbar Urethroplasty.

PURPOSE: Approximately 10% to 20% of patients will have a recurrence after urethroplasty. Initial management of these recurrences is often by urethral dilation or direct vision internal urethrotomy. In the current study we describe the outcomes of endoscopic management of stricture recurrence after bulbar urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed bulbar urethroplasty data from 5 surgeons in the TURNS (Trauma and Urologic Reconstruction Network of Surgeons). Men who underwent urethral dilation or direct vision internal urethrotomy for urethroplasty recurrence were identified. Recurrence was defined as the inability to pass a 17Fr cystoscope through the area of reconstruction. The primary outcome was the success rate of recurrence management. Comparisons were made between urethral dilation and direct vision internal urethrotomy, and then between endoscopic management of recurrences after excision and primary anastomosis urethroplasty vs substitutional repairs using time to event statistics. RESULTS: In 53 men recurrence was initially managed endoscopically. Median time to urethral stricture recurrence after urethroplasty was 5 months. At a median followup of 5 months the overall success rate was 42%. Success after urethral dilation was significantly less than after direct vision internal urethrotomy (1 of 10 patients or 10% vs 21 of 43 or 49%, p <0.001) with a failure HR of 3.15 (p = 0.03). Direct vision internal urethrotomy was more effective after substitutional failure than after excision and primary anastomosis urethroplasty (53% vs 13%, p = 0.005). CONCLUSIONS: Direct vision internal urethrotomy was more successful than urethral dilation in the management of stricture recurrence after bulbar urethroplasty. Direct vision internal urethrotomy was more successful in patients with recurrence after substitution urethroplasty compared to after excision and primary anastomosis urethroplasty. Perhaps this indicates a different mechanism of recurrence for excision and primary anastomosis urethroplasty (ischemic) vs substitution urethroplasty (nonischemic).

Lysophosphatidic Acid Stimulates Urokinase Receptor (uPAR/CD87) in Ovarian Epithelial Cancer Cells.

BACKGROUND/AIM: Lysophosphatidic acid (LPA) is a bioactive lipid positively linked with ovarian cancer progression. The multi-functional urokinase receptor (uPAR), a cell-surface glycoprotein, binds and facilitates activation of uPA and laterally regulates integrin and tyrosine kinase receptor activities in promotion of cell migration and invasion. We hypothesized that LPA stimulates uPAR expression and activity in ovarian epithelial cancer cells. MATERIALS AND METHODS: Ovarian epithelial cancer cell lines OVCA 429 and OVCA 433 were stimulated with LPA and examined for uPAR mRNA expression and protein localization. uPA binding to OVCA plasma membranes was measured through enzymatic analysis of affinity-isolated cell-surface proteins. RESULTS: LPA drove cell-surface uPAR aggregation and mRNA expression concomitant with increased cell-surface binding of uPA. Both control and LPA-stimulated uPAR expression and uPA cell-surface association involved phosphatidylinositol 3-kinase, but not p38 or p42 mitogen-activated protein kinase, signaling. CONCLUSION: These data provide mechanistic insight into ovarian epithelial cancer cell progression by demonstrating that LPA drives uPAR expression and uPA binding.