New avenue of diagnostic stewardship: procedural stewardship for recurrent urinary tract infections in female patients.

Introduction: Societal guidelines offer a weak recommendation to perform cystoscopy for female patients with recurrent urinary tract infections (rUTI) of advanced age and/or with high-risk features. These guidelines lack the support of robust data and are instead based on expert opinion. In this retrospective cohort study, we aim to determine the utility of cystoscopy in patients with and without high-risk features for rUTI. Materials and methods: We identified 476 women who underwent cystoscopy for the evaluation of rUTI at a single tertiary academic medical center from May 1, 2015 and March 15, 2021. Patients were excluded if they had a competing indication for cystoscopy. Risk factors, demographic information, cystoscopic findings, and patient outcomes were analyzed. Results: 192 (41.1%) were classified as having complicated UTI. We identified six patients (1.3%) with findings that prompted management to significantly impact patient outcomes. All six patients had high-risk features. 14 patients (3.0%) were found to have mucosal abnormalities prompting biopsy, three of which required general anesthesia. All 14 biopsies were ultimately benign. Conclusions: Our findings demonstrate a low diagnostic yield and increased risk exposure for women undergoing cystoscopy for the evaluation of complicated rUTI. Additionally, our observations support prior studies indicating that cystoscopy has limited utility in the evaluation of rUTI without high-risk features.

A Multi-Institutional Experience Utilizing Boari Flap in Robotic Urinary Reconstruction.

Objectives: There is presently scarce literature describing the outcomes of patients undergoing robotic ureteral reconstruction (RUR) using the Boari flap (BF) technique. Herein, we report our prospective, multi-institutional experience using BF in patients undergoing robotic urinary reconstruction. Patients and Methods: We reviewed our prospective, multicenter database for all patients undergoing RUR between September 2013 and September 2021 in which a BF was utilized. Preoperative, perioperative, and follow-up data were collected and analyzed. Major complications were defined as a Clavien-Dindo classification grade >2. Surgical failure was defined as recurrent symptoms, obstruction on imaging, or the need for additional surgical interventions. Results: We identified 50 patients who underwent RUR using a BF. Four (8%) underwent the Single Port approach. Twenty-four patients (48%) were active or former tobacco users. Thirty-four patients (68%) had previously undergone abdominal surgery, 17 (34%) had prior ureteral stricture interventions, and 9 (18%) had prior abdominopelvic radiation. The most common stricture etiology was malignancy (34.4%). The median follow-up was 15.0 months with a 90% (45/50) success rate. The five documented cases of failure occurred at a median of 1.8 months following the procedure. Conclusion: In the largest prospective, multi-institutional study of patients undergoing RUR with BF in the literature to date, we demonstrate a low rate of complications and a high rate of surgical success in three tertiary academic medical centers. All observed failures occurred within 2 months of surgical intervention.

Robotic ureteral reconstruction for recurrent strictures after prior failed management.

Objectives: To describe our multi-institutional experience with robotic ureteral reconstruction (RUR) in patients who failed prior endoscopic and/or surgical management. Materials and Methods: We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients who underwent RUR between 05/2012 and 01/2020 for a recurrent ureteral stricture after having undergone prior failed endoscopic and/or surgical repair. Post-operatively, patients were assessed for surgical success, defined as the absence of flank pain and obstruction on imaging. Results: Overall, 105 patients met inclusion criteria. Median stricture length was 2 (IQR 1-3) centimetres. Strictures were located at the ureteropelvic junction (UPJ) (41.0%), proximal (14.3%), middle (9.5%) or distal (35.2%) ureter. There were nine (8.6%) radiation-induced strictures. Prior failed management included endoscopic intervention (49.5%), surgical repair (25.7%) or both (24.8%). For repair of UPJ and proximal strictures, ureteroureterostomy (3.4%), ureterocalicostomy (5.2%), pyeloplasty (53.5%) or buccal mucosa graft ureteroplasty (37.9%) was utilized; for repair of middle strictures, ureteroureterostomy (20.0%) or buccal mucosa graft ureteroplasty (80.0%) was utilized; for repair of distal strictures, ureteroureterostomy (8.1%), side-to-side reimplant (18.9%), end-to-end reimplant (70.3%) or appendiceal bypass (2.7%) was utilized. Major (Clavien >2) post-operative complications occurred in two (1.9%) patients. At a median follow-up of 15.1 (IQR 5.0-30.4) months, 94 (89.5%) cases were surgically successful. Conclusions: RUR may be performed with good intermediate-term outcomes for patients with recurrent strictures after prior failed endoscopic and/or surgical management.

Does Utilizing IRIS, a Segmented Three-dimensional Model, Increase Surgical Precision During Robotic Partial Nephrectomy?

PURPOSE: Preservation of renal parenchyma is a major goal when performing a partial nephrectomy. IRIS anatomical visualization software generates a segmented 3D model, allowing improved visualization of the tumor and surrounding structures. We hypothesize that using IRIS intraoperatively during partial nephrectomy on complex tumors increases the precision of surgical procedures and therefore may result in more tissue preservation. METHODS: We identified 74 non-IRIS and 19 IRIS patients who underwent partial nephrectomy, with nephrometry scores of 9, 10, and 11. Propensity scores were used to match 18 pairs of patients on nephrometry score, age, and tumor volume. Pre- and postoperative imaging (MRI/CT) was obtained. Volumes of the preoperative tumor and preoperative whole kidney were obtained to calculate predicted postoperative whole kidney volume and then compared to actual postoperative whole kidney volume. RESULTS: Mean differences between predicted and actual postoperative whole kidney volumes were 19.2 cm3 (SD=20.2) and 32 cm3 (SD=16.1, P = .0074) for IRIS and non-IRIS groups, respectively. The mean improvement in precision for the IRIS procedure was 12.8 cm3 (95% confidence interval, 2.5 to Inf; P = .02). There was no significant change in mean glomerular filtration rate from baseline to 6 months postoperatively between IRIS and non-IRIS groups (-6.39, SD=15.8 vs -9.54, SD=13.3; P = .5). No significant differences in complication rates (0 vs 1, P = .2), worsening glomerular filtration rate staging (5 vs 4, P = 1), and >25% decrease in glomerular filtration rate (3 vs 4, P = 1) were found between IRIS and non-IRIS groups. CONCLUSIONS: We demonstrated that using IRIS intraoperatively when performing partial nephrectomy on complex tumors is associated with improved surgical precision.

Leveraging the COVID-19 Research Spike to Provide Medical Students with Practical Experience in Data Appraisal and Grant Review.

In April and May 2020, a group of students and professors from the Hackensack Meridian School of Medicine (HMSOM) created an elective to review pre-selected, de-identified COVID-19-related research proposals by physicians and researchers within the Hackensack Meridian Health (HMH) network. Students discussed and rated each proposal's significance, innovation, and approach using grading criteria that paralleled the National Institute of Health's (NIH) study section-based grant review process. In discussing these topics under the guidance of faculty with experience in writing and reviewing research grants, students gained a better understanding of what constitutes a quality research study and a compelling grant proposal.

The Multi-Institutional Experience in Single-Port Robotic Transvesical Simple Prostatectomy for Benign Prostatic Hyperplasia Management.

PURPOSE: Single-port (SP) robotic-assisted simple prostatectomy (RASP) through the transvesical approach is a novel surgical option in the management of large prostatic glands. We present the first multi-institutional study to further assess the perioperative and postoperative outcomes of SP RASP. MATERIALS AND METHODS: From February 2019 to November 2021, 91 consecutive patients of 3 separate institutions underwent transvesical RASP using the da Vinci® SP robotic surgical system. Surgeries were performed by 3 experienced surgeons. Through a suprapubic incision and transvesical access, the SP robot is docked directly into the bladder, and the prostatic enucleation is performed. Prospective data collection, including baseline characteristics, perioperative and postoperative outcomes, was performed. The mean followup period was 4.6 months. RESULTS: The mean (SD) prostate volume was 156 (62) ml. The mean (SD) total operative time was 159 (45) minutes, and the median (IQR) estimated blood loss was 100 (50, 200) cc. The median (IQR) postoperative hospital stay was 21.0 (6.5, 26.0) hours; however, 42% of all patients were discharged the same day. The median (IQR) Foley catheter duration was 5 (5, 7) days. Only 3 patients (3%) developed Clavien grade 2 postoperative complications. At 9-month followup, the median (IQR) International Prostate Symptom Score and quality of life score were 4 (2, 5) and 0 (0, 1), respectively, with a mean (SD) maximum flow rate and post-void residual of 21 (17) ml/second and 40 (55) ml, respectively. CONCLUSIONS: In a multi-institutional setting, the SP RASP promotes a pain-free procedure, same-day discharge, short Foley catheter duration, low complication rate and quick recovery.

Clinical Outcomes of COVID-19 Patients with Pre-existing, Compromised Immune Systems: A Review of Case Reports.

In the ongoing COVID-19 pandemic, all COVID-19 patients are naïve patients as it is the first-time humans have been exposed to the SARS-CoV-2 virus. As with exposure to many viruses, individuals with pre-existing, compromised immune systems may be at increased risk of developing severe symptoms and/or dying because of (SARS-CoV-2) infection. To learn more about such individuals, we conducted a search and review of published reports on the clinical characteristics and outcomes of COVID-19 patients with pre-existing, compromised immune systems. Here we present our review of patients who possess pre-existing primary antibody deficiency (PAD) and those who are organ transplant recipients on maintenance immunosuppressants. Our review indicates different clinical outcomes for the patients with pre-existing PAD, depending on the underlying causes. For organ transplant recipients, drug-induced immune suppression alone does not appear to enhance COVID-19 mortality risk - rather, advanced age, comorbidities, and the development of secondary complications appears required.