The prevalence of impostor phenomenon and its association with burnout amongst urologists.

OBJECTIVES: To characterise the prevalence of impostor phenomenon (IP; tendency for high-achieving individuals to perceive themselves as fraudulent in their successes) amongst attending staff in urology, to identify variables that predict more severe impostorism, and to study the association of IP with burnout. SUBJECTS AND METHODS: A survey composed of the Clance Impostor Phenomenon Scale (CIPS), demographic information, practice details, and burnout levels was e-mailed to urologists via urological subspecialty societies. Survey results were analysed to identify associations between IP severity, survey respondent characteristics, and symptoms of professional burnout. This study was conducted in the United States of America. RESULTS: A total of 614 survey responses were received (response rate 11.0%). In all, 40% (n = 213) of responders reported CIPS scores qualifying as either 'frequent' or 'intense' impostorism (i.e., scores of 61-100). On multivariable analysis, female gender, fewer years in practice (i.e., 0-2 years), and lower academic rank were all independently associated with higher CIPS scores (adjusted P < 0.05). Regarding burnout, 46% of responders reported burnout symptoms. On multivariable analysis, increase in CIPS score was independently associated with higher odds of burnout (odds ratio 1.06, 95% confidence interval 1.04-1.07; P < 0.001). CONCLUSION: Impostor phenomenon is prevalent in the urological community and is experienced more severely in younger and female urologists. IP is also independently associated with burnout. Increased female representation may improve IP amongst our female colleagues. More work is needed to determine strategies that are effective in mitigating feelings of IP and professional burnout amongst urologists, particularly those earlier in their careers.

Perioperative Outcomes of Vesicovaginal Fistula Repair by Surgical Approach.

IMPORTANCE: Data comparing perioperative outcomes between transvaginal, transabdominal, and laparoscopic/robotic vesicovaginal fistula (VVF) repair are limited but are important for surgical planning and patient counseling. OBJECTIVE: This study aimed to assess perioperative morbidity of VVF repair performed via various approaches. STUDY DESIGN: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify women who underwent transvaginal, transabdominal, or laparoscopic/robotic VVF repair from 2009 to 2020. Associations of surgical approach with baseline characteristics, blood transfusion, prolonged hospitalization (>4 days), and 30-day outcomes (any major or minor complication or return to the operating room) were evaluated with χ 2 , Fisher exact, and Kruskal-Wallis tests. Multivariable logistic regression models assessed the adjusted association of approach with 30-day complications and prolonged hospitalization. RESULTS: Overall, 449 women underwent VVF repair, including 252 transvaginal (56.1%), 148 transabdominal (33.0%), and 49 laparoscopic/robotic procedures (10.9%). Abdominal repair was associated with a longer length of hospitalization (median, 3 days vs 1 day transvaginal and laparoscopic/robotic; P < 0.001), higher risk of prolonged length of stay (abdominal, 21.1%; transvaginal, 4.0%; laparoscopic/robotic, 2.0%; P < 0.001), major complications (abdominal, 4.7%; transvaginal, 0.8%; laparoscopic/robotic, 0.0%; P = 0.03), and perioperative transfusion (abdominal, 5.0%; transvaginal, 0.0%; laparoscopic/robotic, 2.1%; P = 0.01). On multivariable analysis, the abdominal approach was independently associated with an increased risk of prolonged hospitalization compared with laparoscopic/robotic (odds ratio, 12.3; 95% confidence interval, 1.63-93.21; P = 0.02) and transvaginal (odds ratio, 6.09; 95% confidence interval, 2.87-12.92; P < 0.001) but not with major/minor complications ( P = 0.76). CONCLUSION: Transvaginal and laparoscopic/robotic approaches to VVF repair are associated with lower rates of prolonged hospitalization, major complications, and readmission compared with a transabdominal approach.

Hemorrhagic Cystitis: Making Rapid and Shrewd Clinical and Surgical Decisions for Improving Patient Outcomes.

Hemorrhagic cystitis (HC) can be one of the most challenging clinical scenarios for urologists to manage. It most commonly occurs as a toxicity of pelvic radiation therapy or in patients treated with the oxazaphosphorine class of chemotherapy. Successful management of HC necessitates a stepwise approach with a thorough understanding of the various treatment options. Once ensuring hemodynamic stability, conservative management includes establishing bladder drainage, manual clot evacuation, and continuous bladder irrigation through a large-bore urethral catheter. If gross hematuria persists, operative cystoscopy with bladder clot evacuation is often required. There are multiple intravesical options for treating HC, including alum, aminocaproic acid, prostaglandins, silver nitrate, and formalin. Formalin is an intravesical option that has caustic effects on the bladder mucosa and is most often reserved as a last-line intravesical treatment. Non-intravesical management tools include hyperbaric oxygen therapy and oral pentosan polysulfate. If needed, nephrostomy tube placement or superselective angioembolization of the anterior division of the internal iliac artery can be performed. Finally, cystectomy with urinary diversion is a definitive, albeit invasive, treatment option for refractory HC. While there is no standardized algorithm, treatment modalities typically progress from less to more invasive. Clinical judgement and shared decision-making with the patient are required when choosing therapies for managing HC, as success rates are variable and some treatments may have significant or irreversible effects.

Spinal anesthesia in infants undergoing urologic surgery duration greater than 60 minutes.

INTRODUCTION: Spinal anesthesia (SA) has been safely utilized in infants. There are limited data regarding the safety and efficacy of SA in pediatric urologic surgery lasting ≥60 min. We outlined the perioperative course for infants undergoing single-injection 0.5% plain bupivacaine SA-only for urologic procedures lasting ≥60 min. OBJECTIVE: To characterize the safety and efficacy of SA for urologic surgery in infants lasting ≥60 min. METHODS: We reviewed our prospectively maintained database of infants undergoing SA for urologic procedures lasting ≥60 min from May 2018 to March 2021. Patients received preoperative intranasal dexmedetomidine, some received intranasal fentanyl, and all patients received lidocaine cream applied preoperatively over the lumbar spine. Oral sucrose on a pacifier was provided as needed, and the patient's arms were swaddled for the procedure. Success was defined as no conversion to general anesthesia. Time points for start/end of spinal injection, procedure duration, wheels in/out of operating room (OR), and discharge were collected. RESULTS: Of 245 cases conducted with SA during the study period, 76 (31%) infants underwent surgery lasting ≥60 min. Of these, 73 (96%) were successfully completed with SA alone. In the 3 cases converted to general anesthesia, 2 (67%) required mask anesthesia after 96 and 169 min (for the last <10 min of surgery), and one was converted to intubation before start of surgery. Median patient age was 6 (IQR 5-7) months, and median procedure length was 95 (IQR 75-120) minutes. Following initial preoperative intranasal dexmedetomidine ± fentanyl, at least one additional dose of IV sedative was given in 27 (36%) cases at a median time of 90 (IQR 60-120) minutes into surgery. Following closure, patients exited the OR after a median 10 (IQR 8-12) minutes and subsequently discharged after spending a median of 73 (IQR 61-96) minutes in recovery. DISCUSSION: We describe pediatric urologic surgical cases lasting ≥60 min that employed single-injection intrathecal bupivacaine alone without adjunct intrathecal agents. In this report, SA was safely utilized in infants undergoing urologic procedures lasting at least 60 min, with about 40% of patients receiving additional IV dexmedetomidine and fentanyl. Non-medication measures (swaddling, oral sucrose) were important for maximizing patient comfort. Communication between surgeon and anesthesia as cases progress is key to maintaining adequate anesthesia. CONCLUSION: A single-injection bupivacaine-only spinal anesthesia approach for urologic surgery lasting over an hour and up to 3 h is safe and effective in infants. Selecting appropriate candidates for SA should be a joint decision between the surgeon and the anesthesiologist.

Prospective, Randomized Comparison of Dual-Lumen vs Single-Lumen Flexible Ureteroscopes in Proximal Ureteral and Renal Stone Management.

Introduction: We sought to compare the safety, efficacy, efficiency, and surgeon experience during upper urinary tract stone management with single-lumen (SLFU) vs dual-lumen flexible ureteroscopes (DLFU). Materials and Methods: Seventy-nine patients with proximal ureteral or renal stone burden <2 cm were randomized to a SLFU or DLFU. We recorded times for ureteroscopy (URS), laser lithotripsy, stone basketing, as well as intraoperative and postoperative complications. The rate of stone clearance and stone free status were calculated using CT imaging. Surgeons completed a survey after each procedure rating various metrics regarding ureteroscope performance. Results: Thirty-five patients from the single-lumen group and 44 patients from the dual-lumen group had comparable median URS time (37 vs 35 minutes, p = 0.984) and basketing time (12 vs 19 minutes; p = 0.584). Median lithotripsy time was decreased in the dual-lumen group (single: 6 vs dual: 2 minutes, p = 0.017). The stone clearance rate was superior in the dual-lumen group (single: 3.7 vs dual: 7.1 mm3/min, p = 0.025). The absolute stone-free rate (SFR) was superior for the dual-lumen group (single: 26% vs dual: 48%, p = 0.045). No differences in intraoperative (single: 0% vs dual: 2%; p = 0.375) and postoperative complications (single: 7% vs dual: 11%, p = 0.474) were observed. Surgeons' ratings of the dual-lumen ureteroscope was superior for visibility, comfort, ease of use, and overall performance. Conclusions: The use of the dual-lumen ureteroscope in patients with renal and proximal ureteral stones <2 cm provided shorter lithotripsy time, higher stone clearance rates, improved SFR, and superior surgeon ratings when compared with SLFUs.

Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review.

BACKGROUND: Congenital penile curvature (CPC) is corrected surgically by various corporoplasty or tunica albuginea plication techniques, but the optimal surgical approach is not well-defined. AIM: To provide a comprehensive evaluation of the published literature pertaining to outcomes with penile plication and corporoplasty techniques for surgical management of CPC. To determine if plication or corporoplasty offers superior outcomes in surgical correction of CPC. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Checklist. The following databases were queried from inception to March 18, 2020 to search for studies describing surgical treatment of CPC: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. OUTCOMES: Objective and subjective postoperative outcomes including penile straightening, shortening, penile sensory changes, and reoperation rates for both corporoplasty and tunica albuginea plication were summarized. RESULTS: Fifty-five articles comprising 2,956 patients with CPC who underwent a plication procedure (n = 1,375) or corporoplasty (n = 1,580) were included. The definition of "treatment success" varied widely and most often involved subjective patient reporting (22 studies; 40%) or objective assessment (15 studies; 27%). We considered curvature correction to be satisfactory if there was self-reported patient satisfaction or residual curvature after correction of <20˚. Reported rates of successful straightening ranged from 75 to 100% and 73 to 100% for plication and corporoplasty, respectively. A comprehensive and accurate assessment of surgical outcomes for CPC correction, such as satisfactory penile straightening, reoperation rates, glans sensory changes, and other complications was limited by significant inter-study heterogeneity with respect to the reporting of treatment outcomes. CLINICAL IMPLICATIONS: While both plication and corporoplasty appear to be safe and effective options in the treatment of CPC, definitive conclusions cannot be drawn with respect to treatment superiority due to low-quality study design, methodology flaws, and significant heterogeneity in reporting. STRENGTH & LIMITATIONS: This report represents the most comprehensive review of CPC surgical management. However, there is a significant lack of standardization in the reporting of treatment outcomes for CPC, thereby limiting the reliability of the published data summarization encompassed by our review. CONCLUSION: Both plication and corporoplasty demonstrate high success rates and relatively low complication rates in the treatment of CPC, albeit with low-level evidence available in most research publications. Robust comparison of the surgical techniques used to correct CPC is limited by significant variation in reporting methods used in the literature. C. J. Britton, F. A. Jefferson, B. L. Findlay, et al. Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review. J Sex Med 2022;19:364-376.

Can preoperative renal mass biopsy change clinical practice and reduce surgical intervention for small renal masses?

INTRODUCTION: The role of renal biopsy prior to surgical intervention for a renal mass remains controversial despite the fact that for all other urological organs except the testicle, biopsy inevitably precedes treatment as is true for all other specialties dealing with solid masses (e.g. thyroid, breast, colon, liver, etc.). Accordingly, we sought to determine the impact of a routine biopsy regimen on the course of patients with cT1a lesions in comparison with a contemporary series of cT1a individuals who went directly to treatment without a preoperative biopsy. METHODS: We analyzed a multi-institutional, prospectively maintained database of patients who underwent an office-based, ultrasound-guided, renal mass biopsy (RMB) for a cT1a renal mass (i.e. ≤4cm in largest dimension). Controls were selected from all patients in the database who had a cT1a renal lesion but did not undergo RMB. Both groups were analyzed for differences in treatment modality and surgical pathology results. RESULTS: A total of 72 RMB and 73 control patients were analyzed. The groups were similar in regards to their baseline characteristics. Overall RMB diagnostic rate was 75%. Surgical pathology revealed that excision of benign tumors was eight-fold less in the RMB cohort compared to the control group (3% vs. 23%; P < 0.001). Additionally, the rate of active surveillance in the RMB cohort was nearly three times higher at 35% vs. 14% for the controls (P < 0.001). Biopsy was concordant with surgical pathology in 97% of cases for primary histology (i.e. benign vs. malignant), 97% for histologic subtype, and 46% for low (I or II) vs. high (III or IV) grade. On multivariate analysis patients who underwent surgical intervention without preoperative RMB were 6.7 times more likely to have benign histopathology compared to patients who underwent preoperative RMB (OR 6.7, 95% CI = 0.714 - 63.626, P = 0.096). There were no procedural or post-procedural RMB complications. CONCLUSIONS: For patients with cT1a lesions, the implementation of routine office-based RMB led to a significant decrease in the rate of surgical intervention for benign tumors. This practice also resulted in a higher rate of active surveillance for the management of renal cortical neoplasms with benign histopathology compared to a control group.

Vasectomy Reversal Online Marketing Practices: What Are We Putting Out There?

OBJECTIVE: To determine characteristics of providers marketing vasectomy reversal (VR) online, degree of information available online, the ease with which patients can compare providers, and the differences in VR practice patterns between academic and private practices. MATERIALS AND METHODS: We identified VR practices operating within the top 50 most populous metropolitan areas in the US. Practice websites were reviewed to obtain information such as provider educational background, level of magnification, ability to perform vasoepididymostomy, surgical volume, and cost. Based on information available, providers were assigned a novel REVERSAL score created by the authors. Descriptive statistics were used to compare results. RESULTS: Of the 107 providers identified (29 academic, 78 private), the majority were male urologists with a Doctor of Medicine degree. Academic providers were more likely to have fellowship training than private practice providers, 96.6 vs 43.6%, respectively (P = 0.00001). Compared to non-urologists, urologists were less likely to purchase online ads or disclose cost. Non-urologists charged significantly less than urologists, $3,584 ± 1,554 and $6,591 ± 1,518, respectively (P = 0.00001). Only one provider provided complete information as defined by REVERSAL score of 12, with the majority (61.7%) of providers achieving score ≤6. CONCLUSION: There is significant lack of transparency in publicly available information from VR practices. Practices should implement measures to improve dissemination of information to the public, so that patients can more easily compare providers and make informed decisions regarding VR.

Crowd-Sourced Assessment of Surgical Skills of Urology Resident Applicants: Four-Year Experience.

OBJECTIVE: To determine a) if surgical skills among urology resident applicants could be reliably assessed via crowdsourcing and b) to what extent surgical skills testing impacts resident selection. DESIGN: Interviewees completed the following surgical skills tasks during their interview day: open knot tying (OKT), laparoscopic peg transfer (LPT), and robotic suturing (RS). Urology faculty and crowd-workers evaluated each applicant's video-recorded performance using validated scoring and were assessed for agreement using Cronbach's alpha. Applicants' USMLE scores, interview scores, and Jefferson Scale of Physician Empathy (JSPE-S) scores were assessed for correlation with skills testing scores and match rank. Additionally, a survey was distributed to interviewees assessing match outcomes. SETTING: University of California Irvine Department of Urology, Surgical Skills Laboratory PARTICIPANTS: All 94 urology residency interviewees at the University of California Irvine Department of Urology from 2015-2018 were invited to complete the three surgical skills tasks on their interview day. RESULTS: Survey responses were received from all 94 interviewees (100%). Crowd and expert agreement was good (α=0.88), fair (α=0.67), and poor (α=0.32) for LPT, RS, and OKT scores, respectively. The skills testing scores did not correlate with match rank, USMLE score, or JSPE-S score. On multivariate analysis, only interview score (r= -0.723; p<0.001) and faculty LPT score (r=-0.262; p=0.001) were significant predictors of match rank. Interviewees who reported matching into a top 3 residency choice had significantly higher faculty LPT scores than those who did not (11.9 vs. 9.7, p=0.03). CONCLUSIONS: Surgical skills overall did not significantly impact match rank. Expert assessment of laparoscopic peg transfer skills and interview performance among urology resident applicants correlated with match rank.

Comparison of Conventional and Triple Bolus Computerized Tomographic Urography Protocols for Radiation Dose Reduction in Hematuria Evaluation: A Randomized Controlled Trial.

PURPOSE: Computerized tomographic urography is the diagnostic tool of choice for evaluating hematuria. In keeping with the ALARA (As Low As Reasonably Achievable) principle, we evaluated a triple bolus computerized tomography protocol designed to reduce radiation exposure. MATERIALS AND METHODS: Patients with macroscopic or microscopic hematuria were prospectively randomized to conventional computerized tomography (100) or triple bolus computerized tomography (100). The triple bolus computerized tomography protocol entails 2 scans: pre-contrast scan followed by 3 contrast injections at 40 seconds, 60 seconds and 20 minutes prior to the second scan to capture all 3 phases. The conventional computerized tomography protocol requires 4 scans: pre-contrast scan, and 3 post-contrast scans at the corticomedullary, nephrographic and excretory phases. Radiation exposure and the detection of urological pathology were recorded based on radiology reports. RESULTS: There were no differences in patient demographics or body mass index between the 2 groups. Triple bolus computerized tomography exposed patients to 33% less radiation (1,715 vs 1,145 mGy*cm for conventional vs triple bolus computerized tomography; p <0.001). For macroscopic hematuria, the pathology detection rates were 70% for triple bolus and 73% for conventional computerized tomography (p=0.72). For microscopic hematuria, the detection rates were 59% for triple bolus and 50% for conventional computerized tomography (p=0.68). In both groups, the rates of detection of urolithiasis, renal cysts, urological masses, bladder pathology and prostate pathology were no different between triple bolus and conventional computerized tomography. CONCLUSIONS: In both the settings of macroscopic and microscopic hematuria evaluation, triple bolus computerized tomography significantly reduces radiation exposure while providing equivalent detection of genitourinary pathology compared to conventional computerized tomography. The ability to detect upper tract filling defects was not specifically tested.

Interactive Virtual Reality Renal Models as an Educational and Preoperative Planning Tool for Laparoscopic Donor Nephrectomy.

OBJECTIVE: To evaluate the efficacy of interactive virtual reality (iVR) in providing a three-dimensional (3D) experience with the donor's anatomy for surgeons and patients, we present a retrospective, case-controlled study assessing the impact of iVR renal models prior to LDN on both surgical outcomes and patients' understanding of the procedure. MATERIALS AND METHODS: Twenty patients undergoing LDN were prospectively recruited; their contrast-enhanced CT scans were transformed into iVR models. An iVR platform allowed the surgeons to rotate and deconstruct the renal anatomy; patients could also view their anatomy as the procedure was explained to them. Questionnaires assessed surgeons' understanding of renal anatomy after CT alone and after CT+iVR. Surgeons also commented on whether iVR impacted their preoperative plan. Patients assessed their anatomical understanding and anxiety level before and after iVR. Surgical outcomes for the iVR cohort were compared to a retrospectively matched, non-iVR cohort of LDN patients. RESULTS: Surgeons altered their preoperative plan in 18 of 20 LDNs after viewing iVR models. Patients reported better understanding of their anatomy (5/5) and noted decreased preoperative anxiety (5/5) after viewing iVR. When compared to the non-iVR group, the iVR group had a 25% reduction in median operative time (P < .001). In terms of surgical outcomes, patients in the iVR group had a 40% lower median relative change in postoperative creatinine (P < .001). CONCLUSION: Preoperative viewing of iVR models altered the operative approach, decreased the operative time, and improved donor patient outcomes. iVR models also reduced patients' preoperative anxiety.

Characterization of intracalyceal pressure during ureteroscopy.

PURPOSE: To provide the first report of measuring intracalyceal pressures during ureteroscopy (URS). METHODS: A prospective single-center clinical study using a cardiac pressure guidewire to measure intracalyceal pressure during flexible URS was performed. Eight patients (45 calyces) undergoing URS for nephrolithiasis were included. A Verrata® pressure guide wire was passed through the working channel of a dual lumen flexible ureteroscope and into the calyces while irrigation was maintained at 150 mmHg. Pressure was measured in the renal pelvis, upper pole, interpolar, and lower pole calyces both with and without a ureteral access sheath (UAS). The pressure in each location with and without a UAS was compared. The correlation between calyceal pressure and infundibular dimensions (width, length) was determined. RESULTS: Intracalyceal pressure was significantly lower in each region when a UAS was used. Compared to patients with a 12/14Fr UAS, those with a 14/16Fr UAS had significantly lower pressure in the interpolar (25.3 ± 13.1 vs. 44.0 ± 27.5 mmHg, p = 0.03) and lower pole (16.2 ± 3.5 vs. 49.2 ± 40.3 mmHg, p = 0.004) calyces. Interpolar calyceal pressure in the presence of a UAS was significantly higher than the renal pelvis pressure (RPP) (30.8 ± 19.6 vs. 17.9 ± 11.0 mmHg, p = 0.004). CONCLUSIONS: During flexible URS, RPP strongly correlates with, but does not uniformly represent, the intracalyceal pressure. With a 14/16Fr UAS and an inflow pressure of 150 mmHg, RPP and intracalyceal pressure never exceed the threshold for renal backflow.

Evaluation of Interactive Virtual Reality as a Preoperative Aid in Localizing Renal Tumors.

Introduction: A detailed understanding of renal tumor anatomy is required to perform partial nephrectomy. We evaluated the utility of a CT-based interactive virtual reality (iVR) display to assist surgeons' understanding of the precise location of the renal tumor. Methods: CT scans and iVR models of 11 patients with a mean R.E.N.A.L. nephrometry score of 6.9 were evaluated. Seven faculty urologists and six urology residents reviewed CT scans and positioned each tumor onto a digital three-dimensional model of the same kidney, although without the tumor present. A week later, participants repeated the session using both iVR models and CT scans. For both time points, the overlap between the surgeon-inserted tumor and the actual tumor location was calculated. Participants answered a 1 to 10 Likert scale survey to gauge their understanding of renal and tumor anatomy based on CT alone vs CT+iVR. Results: Median tumor overlap for the entire cohort was 28% after CT review and 42% after CT+iVR (p = 0.05); among faculty urologists, for CT+iVR vs CT alone, percentage overlap improved (47% vs 33%, p = 0.033) and the incidence of 0% overlap decreased (19%-4%, p = 0.024), respectively. Among residents, there was no significant difference for either percentage overlap or 0% overlap for CT vs CT+iVR. The percentage overlap for the two tumors with high R.E.N.A.L. nephrometry scores (i.e., 10) increased from 51% to 67% after using CT+iVR (p = 0.039). The combination of CT+iVR was an independent predictor of improved overlap vs CT alone (odds ratio 2.22, 95% confidence interval 1.04-4.78, p = 0.039). Faculty surgeons' survey responses showed an improved understanding of the tumor location and shape with the addition of iVR (p < 0.05). Conclusions: The addition of patient-specific iVR models to standard CT imaging improved the ability of faculty urologists to accurately configure the location of a renal tumor, and improved their understanding of tumor anatomy.

A California Cancer Registry Analysis of Urothelial and Non-urothelial Bladder Cancer Subtypes: Epidemiology, Treatment, and Survival.

INTRODUCTION: We evaluated epidemiologic trends and survival for bladder cancer histologic subtypes in California patients by comparing urothelial carcinoma of the bladder (UCB) and non-urothelial subtypes including squamous cell carcinoma (SCC), adenocarcinoma (ADC), and small-cell carcinoma (SmCC). MATERIALS AND METHODS: The California Cancer Registry (CCR) was queried for incident bladder cancer cases from 1988 to 2012. Epidemiologic trends based on tumor histology were described. The primary outcome was disease-specific survival (DSS). Kaplan-Meier and multivariable Cox regression survival analyses were performed. RESULTS: A total of 72,452 bladder cancer cases (66,260 UCB, 1390 SCC, 587 ADC, 370 SmCC, and 3845 other) were included. The median age was 72 years (range, 18-109 years). ADC was more common in younger patients. Male:female ratios varied among cancer types (3.1:1 in UCB, 2.9:1 in SmCC, 1.6:1 in ADC, and 0.9:1 in SCC). Most non-urothelial cases (> 60%) presented at advanced stages, whereas most UCB cases (80.6%) were localized. Kaplan-Meier analysis revealed the best 5-year DSS and overall survival (OS) in UCB, whereas the worst outcomes were seen with SCC and SmCC (P < .0001). Multivariable analysis controlling for age, gender, tumor stage, and grade demonstrated that non-urothelial histologic subtypes were associated with significantly worse DSS compared with UCB (SCC hazard ratio [HR], 2.612; SmCC HR, 1.641; and ADC HR, 1.459; P < .0001). CONCLUSIONS: Non-urothelial bladder cancers have worse oncologic outcomes than UCB in California patients. SCC and SmCC are associated with the worst DSS based on univariable and multivariable analyses.

Thulium-fiber laser for lithotripsy: first clinical experience in percutaneous nephrolithotomy.

PURPOSE: To evaluate the efficacy and safety of thulium-fiber laser (TFL) in laser lithotripsy during percutaneous nephrolithotomy (PCNL). METHODS: Patients with stones < 30 mm were prospectively recruited to undergo PCNL using TFL "FiberLase" (NTO IRE-Polus, Russia). Stone size, stone density, operative time, and "laser on" time (LOT) were recorded. Study included only cases managed with fragmentation. Stone-free rate and residual fragments were determined on postoperative computer tomography. Complications were classified using the Clavien-Dindo grade. Stone retropulsion and endoscopic visibility were assessed based on surgeons' feedback using a questionnaire. RESULTS: A total of 120 patients were included in the study with a mean age of 52 (± 1.8) years; of these 77 (56%) were males. Mean stone size was 12.5 (± 8.8) mm with a mean density of 1019 (± 375) HU. Mean operative time was 23.4 (± 17.9) min and mean LOT was 5.0 (± 5.7) min. Most used settings were of 0.8 J/25-30 W/31-38 Hz (fragmentation). The mean total energy for stone ablation was 3.6 (± 4.3) kJ. Overall stone-free rate was 85%. The overall complication rate was 17%. Surgeons reported stone retropulsion that interfered with surgery in 2 (1.7%) cases insignificant retropulsion was noted in 16 (10.8%) cases. Poor visualization was reported in three (2.5%) cases and minor difficulties with visibility in four (3.3%) cases. CONCLUSIONS: TFL is a safe and effective modality for lithotripsy during PCNL and results in minimal retropulsion.

Evaluation of a Diuresis Enhanced Non-Contrast Computed Tomography for Kidney Stones Protocol to Maximize Collecting System Distention.

Purpose: In urolithiasis patients, preoperative non-contrast computed tomography (NCCT) commonly fails to provide sufficient distention of the renal collecting system to allow reliable preoperative planning for how best to approach a stone. Our objective was to evaluate the effect of a novel protocol, including oral hydration and an oral diuretic, on the distention of the renal collecting system. Patients and Methods: Twenty patients with a prior NCCT, who were scheduled to undergo a subsequent NCCT for urolithiasis assessment, were enrolled. Each patient was instructed to ingest 1 L of water and 20 mg of oral furosemide 30 to 60 minutes before their scan (DRINK [DiuResIs Enhanced Non-contrast Computed Tomography for Kidney Stones] protocol). Patients' prior NCCT scan (non-DRINK) was used for comparison. Three-dimensional (3D) reconstruction of DRINK and non-DRINK NCCT studies was performed to determine the volume and surface area of the collecting system. In addition, three faculty endourologists measured the width of the upper and lower pole infundibula and renal pelvis in the axial, coronal, and sagittal views. Results: Among the 20 patients, 13 completed the DRINK protocol as specified. For these 13 patients, 3D reconstruction of the DRINK study collecting systems showed a 63% and a 36% increase in collecting system volume and surface area, respectively (p = 0.02 and p < 0.01, respectively). Also, measurements of the CT images demonstrated a significant (p < 0.05) increase in the collecting system widths in 67% of measurements. Conclusion: The DRINK protocol significantly increased the visible collecting system volume and surface area; in the majority of cases, the upper and lower pole infundibular widths and the width of the renal pelvis were also expanded.

Prospective Randomized Comparison of Standard Hand Pump Infuser Irrigation vs an Automated Irrigation Pump During Percutaneous Nephrolithotomy and Ureteroscopy: Assessment of Operating Room Efficiency and Surgeon Satisfaction.

Introduction: The objective of this study was to determine if use of an automated irrigation pump (AIP) during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) affects circulating nurse labor, irrigation-related issues, and surgeon and nurse satisfaction when compared to manual hand pump (HP) irrigation. Methods: Eighty consecutive adult patients undergoing unilateral URS or PCNL were prospectively randomized to irrigation with the HP or AIP. Preoperative pump setup time, intraoperative pump maintenance time, total pump time (setup+maintenance), and the number of irrigation-related concerns verbalized by the surgeon intraoperatively were recorded; postoperatively, surgeons and nurses rated their satisfaction with the irrigation system (1 = highly dissatisfied to 10 = highly satisfied). Results: Eighty patients were enrolled (39 AIP and 41 HP); 51 patients underwent URS and 29 patients underwent PCNL. On univariate analysis, the AIP resulted in a significantly reduced total pump time for URS (2.9 vs 5.9 minutes) and PCNL (4.6 vs 33.9 minutes; p < 0.001). The number of irrigation-related concerns was significantly lower in the AIP group during URS (1.2 vs 2.8, p < 0.001), but not during PCNL (1.9 vs 4.0, p = 0.07). The AIP was associated with significantly higher nurse satisfaction during URS (9.2/10 vs 6.5/10, p < 0.001) and PCNL (9.4/10 vs 4.4/10, p = 0.001). There was no significant association between pump type and surgeon satisfaction. On multivariate analysis of URS cases controlling for body mass index and number of stones, use of the AIP was a predictor of total pump time <5 minutes (odds ratio 25.8, 95% confidence interval [CI] 4.0-165.4; p < 0.001) and favorable (8-10/10) nurse satisfaction rating (odds ratio 25.4, 95% CI 4.1-164.0; p < 0.001). Operative time, stone-free rate, and liters of irrigant used with the HP and AIP were similar. Conclusions: During URS and PCNL, the AIP was associated with a significant reduction in irrigation pump time and higher nurse satisfaction.

Initial Evaluation of a Novel Modulated Radiofrequency-based Bladder Denervation Device.

OBJECTIVE: To determine if targeted and modulated radiofrequency ablation (RFA) of the urinary bladder using our novel ablation device (Denerblate) reduces bladder nerve density, potentially leading to a novel strategy for the management of overactive bladder. METHODS: Fifteen pigs were divided into 4 groups: control (n = 3), 1-week (n = 4), 4-week (n = 4) and 12-week (n = 4) survival times. Denerblate was deployed on the trigone area of the bladder. Three 240-second cycles of modulated RFA were applied with 30 seconds between cycles. At the end of each survival term, urinary bladders were harvested for histopathologic evaluation. Nerve count and density were manually calculated. RESULTS: All procedures were successfully completed, and all animals survived to the desired time points. Mean nerve density (nerves/mm2) was highest in the control and 1-week survival group compared to the 4-week and 12-week groups, both of which demonstrated significant diminishment. Nerve density in the bladder neck at control, 1 week, 4 weeks, and 12 weeks were 1.8, 1.35, 0.87, and 0.12, respectively (P <.001). Nerve density in the bladder trigone area at control, 1 week, 4 weeks, and 12 weeks were 1.5, 0.98, 0.65, and 0.112, respectively (P <.001). Epithelial heat injury was observed in 14.3% at 1 week, 10.7% at 4 weeks, but completely resolved by 12 weeks. CONCLUSION: In the porcine model, modulated RFA delivered by our novel device reduced nerve density in the bladder neck and trigone by 88.6% and 88.9% at 12 weeks without evidence of lasting epithelial injury.