Prostate Cancer Detection Rate of Transperineal Prostate Biopsy: Cognitive vs Software Fusion, A Multicenter Analysis.

OBJECTIVE: To compare clinically significant prostate cancer detection with TP-TBx utilizing software vs cognitive fusion. It is established that MRI prior to prostate biopsy improves detection of clinically significant cancer (csPCa, Grade Group ≥2). MRI/US fusion targeted biopsy via a transperineal approach (TP-TBx) is increasing in utilization due to the clean percutaneous approach that greatly reduces postbiopsy infection. However, the comparative effectiveness of formal software fusion over cognitive fusion remains under studied. MATERIALS AND METHODS: We performed a retrospective multicenter study from June 2020 to July 2022 including age, race, prostate-specific antigen (PSA), prostate volume, PI-RADS, lesion size(s), number of cores sampled, indication (elevated PSA, prior negative, active surveillance) and anesthesia type. Surgeon preference determined use of cognitive (PrecisionPoint) vs software fusion techniques. Multivariable logistic regression determined factors associated with TP-TBx detection of csPCa. RESULTS: We identified 490 patients (201 cognitive, 289 software fusion) who underwent TP-TBx. Patient age, PSA, number of targets, and PI-RADS were similar (all P > .05). Software fusion TP-TBx had 4 [95% confidence interval (CI) 3-5] more (estimated median difference) systematic cores sampled. csPCa was detected in 44% of all patients. In adjusted analysis, cognitive vs software fusion was similar in detection of csPCa (odds ratio 1.46, 95% CI 0.82-2.58). CONCLUSION: Cognitive vs software fusion TP-TBx has similar csPCa detection, despite fewer systematic cores taken with cognitive fusion. The expense, additional time requirement, and similar outcomes of software fusion platforms confers higher value to cognitive TP-Bx.

Evaluating the Learning Curve for In-office Freehand Cognitive Fusion Transperineal Prostate Biopsy.

OBJECTIVE: To define the learning curve of the in-office, freehand MRI-ultrasound cognitive fusion transperineal prostate biopsy (CTPB) by assessing cancer detection, biopsy core quantity and quality, procedure times, and complications over the initial experience. METHODS: We reviewed 110 consecutive CTPB performed March 2021-September 2022 by a urologist inexperienced with the PrecisionPoint platform. The study period was divided into quarters to assess for temporal variation in outcomes. Univariable and multivariable analysis modeled the learning curve. RESULTS: Across quarters, there were no differences in the detection of clinically significant prostate cancer (Q1:50%, Q2:52%, Q3:50%, Q4:48%, P > .9) or Gleason grade group upgrading by targeted vs systematic biopsy (P = .6). Median procedure times improved with experience (Q1:17 minutes, Q2:14 minutes, Q3:12 minutes, Q4:13 minutes, P = .018). On multivariable analysis, procedure times decreased by 1minute per 20 cases (P < .001). On linear regression, CTPB procedure times approximated transrectal biopsy times after 90 cases (P < .001). The histopathologic core quality did not differ, as evidenced by consistent core length (P = .13) and presence of minimal fibromuscular tissue (P > .9). The most common complications, hematuria and hematospermia, were similar across quarters (P = .7, P = .3, respectively). There was a single episode of urinary retention and no reported infections. CONCLUSION: There is no evidence of a learning curve for CTPB as shown by consistent clinically significant prostate cancer detection, high-quality biopsy cores, and low complications. However, CTPB procedural times begin to approximate cognitive targeted transrectal biopsy times after 90 cases.

Serum cobalamin and methylmalonic acid concentrations in juvenile dogs with parvoviral enteritis or other acute enteropathies.

BACKGROUND: Low serum cobalamin concentrations have been associated with ileal malabsorption in dogs with chronic enteropathy. Increased serum methylmalonic acid (MMA) concentrations indicate cobalamin deficiency on a cellular level. Few studies have evaluated serum cobalamin concentrations or methylmalonic acid concentrations in juvenile dogs with parvoviral enteritis or nonparvoviral acute enteropathies. OBJECTIVES: Evaluate serum cobalamin and methylmalonic acid concentrations in juvenile dogs (6 weeks to 10 months old) with parvoviral enteritis or nonparvoviral acute enteropathy. ANIMALS: Thirty-one juvenile dogs with parvoviral enteritis, 29 dogs with nonparvoviral acute diarrhea (NPVAD), and 40 healthy juvenile control dogs. METHODS: Single-center, prospective, observational, cross-sectional study. Serum cobalamin and, when sufficient serum was available, MMA concentrations were measured. RESULTS: Most serum cobalamin concentrations were within the adult reference interval. Serum cobalamin concentrations in healthy dogs (median, 848 ng/L; range, 293-1912 ng/L) were significantly higher than in dogs with parvoviral enteritis (P = .0002; median, 463 ng/L; range, <150-10 000 ng/L) or dogs with NPVAD (P = .02; median, 528 ng/L; range, 160-8998 ng/L). Serum MMA concentrations were not significantly different between groups (healthy dogs: median, 796 nmol/L; range, 427-1933 nmol/L; parvoviral enteritis: median, 858 nmol/L; range, 554-3424 nmol/L; NPVAD: median, 764 nmol/L; range, 392-1222 nmol/L; P = .1). CONCLUSIONS AND CLINICAL IMPORTANCE: Juvenile dogs with parvoviral enteritis or NPVAD had lower serum cobalamin concentrations than healthy juvenile dogs. However, based on serum MMA concentrations cellular cobalamin deficiency was not apparent.

Robotic-assisted retroperitoneal lymph node dissection for testicular cancer.

PURPOSE OF REVIEW: Robotic-assisted retroperitoneal lymph node dissection (R-RPLND) is an emerging surgical option for testicular cancer with less morbidity than open RPLND. We outline the operative technique used at our center and review contemporary evidence in the advancement of R-RPLND. RECENT FINDINGS: R-RPLND is being applied effectively beyond clinical stage I testicular cancer to treat low-volume, clinical stage II disease in both the primary and postchemotherapy setting. Compared with the open approach, R-RPLND offers shorter hospitalization and less blood loss with comparably low complications and oncologic control. SUMMARY: With ongoing adoption and optimization of R-RPLND, future studies will assess long-term oncologic outcomes and disseminate R-RPLND in the treatment of testicular cancer.

The Future is Female: The Influence of Female Faculty and Resident Representation on Female Applicant Match Rate Amongst Urology Residency Programs Over 3 Years.

OBJECTIVE: To investigate whether there is a correlation between the proportion of female faculty and residents at urology residency programs and the proportion of females matched to those programs. MATERIALS AND METHODS: We utilized official results from 3 consecutive AUA match cycles from 2018 - 2020 to obtain the number of females matched to each program. The number of female residents and faculty members in each program was acquired through querying program websites and contact with residency program coordinators. The correlation between the proportion of females in the newly matched class of residents and the proportion of current female faculty members and residents in that program was calculated for each match cycle. RESULTS: There was a positive correlation between the proportion of matched female applicants and the proportion of female residents in each program for the 2018, 2019, and 2020 match cycles (R = 0.23, P = .01; R = 0.21, P = .02, R = 0.11, p <.001, respectively). There was a positive correlation between the proportion of matched female applicants and the proportion of female faculty at their matched program in the 2018 and 2020 match cycles (R = 0.22, P = .02; R = 0.06, P < .01, respectively). There was no significant predilection of females matching to programs with a female program director or chairperson, and geographic location of program (based on AUA section) did not appear to influence female applicant match rates. CONCLUSION: There has been a consistent trend in the proportion of matched female applicants to urology programs correlating positively with the proportion of female residents at those programs over the past three years. This is indicative of the increased potential for female mentorship and leadership opportunities. Further research is needed to investigate the factors that draw female applicants to urology programs with increased female representation.

Acute aortoiliac and infrainguinal arterial thrombotic events in four patients diagnosed with the novel coronavirus 2019.

The novel coronavirus disease 2019 (COVID-19) pandemic is seriously challenging the healthcare system globally. Endothelial damage and increased coagulation activity have been reported in some patients with COVID-19, resulting in a variety of thrombotic events. We report the cases of four patients with various severities of COVID-19 who had presented with acute arterial thrombosis. Although these are rare events, they carry high morbidity and mortality and require prompt diagnosis and treatment. These cases highlight the major life- and limb-threatening clinical sequelae of COVID-19 that frontline medical providers must be aware can occur even in the absence of previous cardiovascular disease.

Transvaginal repair of neobladder vaginal fistula with martius flap

ABSTRACT Introduction: Neobladder vaginal fistula (NVF) is a known complication after cystectomy and orthotopic diversion in women, occurring in 3-5% of women. Possible risk factors for fistula formation include compromised tissue vascularity due to surgical dissection and/or radiotherapy, suture line proximity, local tissue recurrence, and injury to the vaginal wall during dissection. The surgical repair of a NVF can be challenging secondary to vaginal shortening, atrophy, local inflammation from chronic exposure to urinary leakage, and the proximity of the neobladder to the anterior vaginal wall. In this video, we present transvaginal repair of a NVF with Martius flap interposition. Materials and Methods: This is the case of a 47 year old woman with a history of radical cystectomy and creation of a Studer pouch secondary to bladder cancer two years prior who subsequently developed a NVF. Evaluation included an office cystoscopy which demonstrated a 3-4mm left-sided neobladder vaginal fistula at the level of the ileal-urethral anastomosis. No pelvic organ prolapse or evidence of bladder cancer recurrence was appreciated. Results: A vaginal approach for the NVF repair was performed with a Martius flap interposition. A water-tight closure was achieved without any intraoperative or immediate postoperative complications. The urethral Foley was removed at 2 weeks and by 4 weeks the patient did not report any urinary leakage. Conclusions: Neobladder vaginal fistula is a rare complication following cystectomy and orthotopic urinary diversion that can be repaired using a transvaginal approach. A Martius flap interposition is important to augment success of the repair. If a transvaginal approach fails a transabdominal approach or conversion to cutaneous diversion may be necessary.

Transvaginal repair of Neobladder Vaginal Fistula with Martius Flap.

Introduction: Neobladder vaginal fistula (NVF) is a known complication after cystectomy and orthotopic diversion in women, occurring in 3-5% of women. Possible risk factors for fistula formation include compromised tissue vascularity due to surgical dissection and/or radiotherapy, suture line proximity, local tissue recurrence, and injury to the vaginal wall during dissection. The surgical repair of a NVF can be challenging secondary to vaginal shortening, atrophy, local inflammation from chronic exposure to urinary leakage, and the proximity of the neobladder to the anterior vaginal wall. In this video, we present transvaginal repair of a NVF with Martius flap interposition. Materials and Methods: This is the case of a 47 year old woman with a history of radical cystectomy and creation of a Studer pouch secondary to bladder cancer two years prior who subsequently developed a NVF. Evaluation included an office cystoscopy which demonstrated a 3-4mm left-sided neobladder vaginal fistula at the level of the ileal-urethral anastomosis. No pelvic organ prolapse or evidence of bladder cancer recurrence was appreciated. Results: A vaginal approach for the NVF repair was performed with a Martius flap interposition. A water-tight closure was achieved without any intraoperative or immediate postoperative complications. The urethral Foley was removed at 2 weeks and by 4 weeks the patient did not report any urinary leakage. Conclusions: Neobladder vaginal fistula is a rare complication following cystectomy and orthotopic urinary diversion that can be repaired using a transvaginal approach. A Martius flap interposition is important to augment success of the repair. If a transvaginal approach fails a transabdominal approach or conversion to cutaneous diversion may be necessary.

Comparing the Predictive Power of Preoperative Risk Assessment Tools to Best Predict Major Adverse Cardiac Events in Kidney Transplant Patients.

BACKGROUND: Patients undergoing kidney transplantation have increased risk of adverse cardiovascular events due to histories of hypertension, end-stage renal disease, and dialysis. As such, they are especially in need of accurate preoperative risk assessment. METHODS: We compared three different risk assessment models for their ability to predict major adverse cardiac events at 30 days and 1 year after transplant. These were the PORT model, the RCRI model, and the Gupta model. We used a method based on generalized U-statistics to determine statistically significant improvements in the area under the receiver operator curve (AUC), based on a common major adverse cardiac event (MACE) definition. For the top-performing model, we added new covariates into multivariable logistic regression in an attempt to create further improvement in the AUC. RESULTS: The AUCs for MACE at 30 days and 1 year were 0.645 and 0.650 (PORT), 0.633 and 0.661 (RCRI), and finally 0.489 and 0.557 (Gupta), respectively. The PORT model performed significantly better than the Gupta model at 1 year (p=0.039). When the sensitivity was set to 95%, PORT had a significantly higher specificity of 0.227 compared to RCRI's 0.071 (p=0.009) and Gupta's 0.08 (p=0.017). Our additional covariates increased the receiver operator curve from 0.664 to 0.703, but this did not reach statistical significance (p=0.278). CONCLUSIONS: Of the three calculators, PORT performed best when the sensitivity was set at a clinically relevant level. This is likely due to the unique variables the PORT model uses, which are specific to transplant patients.

A Retrospective Cohort Study on Rehospitalization following Expanded Criteria Donor Kidney Transplantation.

BACKGROUND: Expanded criteria donor (ECD) kidneys are commonly used but are associated with increased graft failure. Graft failure is in turn related to rehospitalization within thirty days post transplant. Our goal was to determine whether ECD kidneys independently lead to rehospitalization within 30 days, 1 year, and 2 years after transplant. METHODS: All adult first-time recipients of deceased donor kidneys transplanted from 2003-2012 at our center were reviewed. Models included demographics, medical comorbidities, center for disease control high-risk kidney, ECD kidney, ischemia times, cause of renal failure, immunosuppressive regimen, positive psychiatric screening, alcoholism, surgeon, year the transplant was performed, years on dialysis before transplant, and the number of inpatient hospitalizations within 6 months prior to transplant. We conducted Andersen-Gill modeling and propensity score matching followed by logistic regression. We also used multivariable linear regression to predict average length of stay during rehospitalization. RESULTS: More ECD patients had a rehospitalization at 1 year (70.3% versus 59%, log-rank test p=0.014). Thirty-day and 2-year time marks were not significant. Andersen-Gill models predicting successive hospitalizations yielded HR of 1.42 (p=0.002) and 1.32 (p=0.015) for ECD patients at 1 and 2 years of after transplantation, respectively. Propensity score matching and logistic regression showed a significant relative risk of 1.630 at one year (p=0.033) and 1.313 at two years (p=0.268). There was no significant association between ECD and subsequent lengths of hospital stay. CONCLUSION: Receiving an ECD kidney is independently associated with multiple readmissions within 2 years of transplant but unrelated to length of stay.

Durability and cumulative functional patency of transposed and nontransposed arteriovenous fistulas.

OBJECTIVES: Preoperative duplex scanning of arm and forearm veins has increased the creation of autogenous arteriovenous (AV) fistulas. However, the cumulative functional patency and durability of transposed AV fistulas (TAVF) compared with nontransposed AV fistulas (AVF) and prosthetic bridging grafts (AVG) remains ill-defined. METHODS: From January 1998 to December 2002, 245 dialysis access procedures were performed at University Hospital and the Veteran Affairs Medical Center in New Jersey. Follow-up data were available for 125 procedures (TAVF, n = 42; AVF, n = 30; AVG, n = 53) performed in 97 patients. All access procedures were planned on the basis of preoperative duplex scans of arm and forearm veins. Functional patency was defined as ability to cannulate and hemodialyze patients successfully. Primary and secondary cumulative functional patency of TAVFs, AVFs, and AVGs was determined with life table analysis, and differences were analyzed with the log-rank test. Differences in revision rates, including thrombolysis, thrombectomies, and operative revisions, were determined with the Fisher exact t test. RESULTS: Mean follow-up was 18 months (range, 4-24 months). For TAVFs, AVFs, and AVGs, primary functional patency rate at 1 year was 76.2%, 53.3%, and 47.2%, respectively, and at 2 years was 67.7%, 34.4%, and 25.5%, respectively. Similarly, secondary functional patency rate at 1 year was 83.2%, 66.7%, and 58.5%, respectively, and at 2 years was 74.6%, 56.2%, and 40.2%, respectively. Primary and secondary functional patency rates for TAVFs were superior to those for AVGs at 1 and 2 years (P <.001). AVFs had superior secondary functional patency rate at 2 years, compared with AVGs (P <.05), and TAVFs had superior primary and secondary patency rates at 2 years, compared with AVFs (P <.05). AVGs required significantly more revisions than did TAVFs (28.5% vs 54.7%; P <.001) or AVFs (36.7% vs 54.7%; P <.05). CONCLUSIONS: Preoperative duplex scanning of upper arm and forearm veins facilitated successful creation of all types of autogenous fistulas at our institution. TAVF cumulative functional patency rates were superior compared with AVGs and AVFs. Furthermore, TAVFs and AVFs were more durable and required fewer revisions than did AVGs. When preoperative duplex criteria indicate that TAVFs can be performed, they should be the initial access of choice, because of their superior long-term patency and durability.

Influence of aeration on hydrophobic organic contaminant distribution and diffusive flux in estuarine sediments.

Dredging operations, resuspension events during storms, and bioturbation alter the oxic state of estuarine sediments and induce changes in the composition of dissolved and particle-associated natural organic matter. These changes may alter the distribution of hydrophobic organic chemicals (HOCs) in sediments and their diffusive flux across the sediment-water interface. In this study, the impact of aerating anoxic sediments on the distribution and diffusive flux of a model HOC, 2,2',4,4'-tetrachlorobiphenyl (TeCB), was investigated. Anoxic estuarine sediments collected from three sites along a salinity gradient were used to determine site-specific apparent sorption coefficients for porewater dissolved organic carbon (Kpwdoc) and sediment organic carbon (Koc) under anoxic and oxic conditions. A two-compartment sediment flux model was employed to examine the diffusive flux of TeCB under both oxic states. Aeration of anoxic porewaters resulted in significant decreases in porewater dissolved organic matter (DOMpw) aromaticity as indicated by declines in molar absorptivity at 254 nm (p < 0.005). Aeration also resulted in a 9-13% decrease in DOMpw concentration (p < 0.005) at the two sites exhibiting lower ionic strengths; the high ionic strength site did not exhibit a significant change in DOMpw concentration (p > 0.10). The impact of aeration on TeCB distribution and diffusive flux appeared to be site-specific. Aeration of anoxic sediments induced a significant 1.4 log unit reduction in Kpwdoc at the lowest ionic strength site (p < 0.0005), while sediments from the intermediate ionic strength site exhibited a significant 0.6 log unit increase (p < 0.005). No significant change in sorption to DOMpw was observed for the high ionic strength site (p > 0.10). The sediment displaying the drop in Kpwdoc also exhibited a significant 0.4 log unit drop in Koc (p < 0.01), while the other two sites did not exhibit significant aeration-induced changes in sorption to particle-associated organic matter (p > 0.10). No significant change in diffusive flux was observed for two sites (p > 0.10), while a significant 89-110 mg m(-2) yr(-1) increase in diffusive flux was observed at the low ionic strength site (p < 0.10). This latter result represented approximately a doubling in diffusive flux. In the systems studied, facilitation of TeCB transport across the sediment-water interface by organic colloids did not appear important.

Bcl-xL overexpression blocks bax-mediated mitochondrial contact site formation and apoptosis in rod photoreceptors of lead-exposed mice.

Photoreceptor apoptosis and resultant visual deficits occur in humans and animals with inherited and disease-, injury-, and chemical-induced retinal degeneration. A clinically relevant mouse model of progressive rod photoreceptor-selective apoptosis was produced by low-level developmental lead exposure and studied in combination with transgenic mice overexpressing Bcl-x(L) only in the photoreceptors. A multiparametric analysis of rod apoptosis and mitochondrial structure-function was performed. Mitochondrial cristae topography and connectivity, matrix volume, and contact sites were examined by using 3D electron tomography. Lead-induced rod-selective apoptosis was accompanied by rod Ca(2+) overload, rhodopsin loss, translocation of Bax from the cytosol to the mitochondria, decreased rod mitochondrial respiration and membrane potential, mitochondrial cytochrome c release, caspase-3 activation, and an increase in the number of mitochondrial contact sites. These effects occurred without mitochondrial matrix swelling, outer membrane rupture, caspase-8 activation, or Bid cleavage. Bcl-x(L) overexpression completely blocked all apoptotic events, except Ca(2+) overload, and maintained normal rod mitochondrial function throughout adulthood. This study presents images of mitochondrial contact sites in an in vivo apoptosis model and shows that Bcl-x(L) overexpression blocks increased contact sites and apoptosis. These findings extend our in vitro retinal studies with Pb(2+) and Ca(2+) and suggest that developmental lead exposure produced rod-selective apoptosis without mitochondrial swelling by translocating cytosolic Bax to the mitochondria, which likely sensitized the Pb(2+) and Ca(2+) overloaded rod mitochondria to release cytochrome c. These results have relevance for therapies in a wide variety of progressive retinal and neuronal degenerations where Ca(2+) overload, lead exposure, andor mitochondrial dysfunction occur.