Authorship in Urology: A Gender Reveal.

OBJECTIVE: To evaluate female author representation in urologic literature as compared to the proportion of female practicing urologists. METHODS: A cross-sectional study was designed to analyze trends in women authorship of urology publications in 2019 as compared to AUA 2019 census data. The 5 highest impact urologic journals in 2019 were identified using the publicly available SCImago Journal Rank (SJR) indices. Author genders and study categorization were independently determined by 2 authors. Chi-squared test was used for statistical analyses. RESULTS: The 5 highest impact urologic journals in 2019 as per SJR were European Urology, Journal of Urology, British Journal of Urology International, Prostate Cancer and Prostatic Diseases, and Nature Reviews Urology. A total of 501 publications were included for analysis. Women comprised 22.1% of first authors and 14.6% of senior authors. The proportion of publications authored by women was significantly higher than would be expected based on population proportions from the AUA 2019 census data for women as both first (P < .0001) and senior author (P =.0005). Similarly, women authorship was significantly higher than expected for basic science (P < .0001), clinical medicine (P <.0001), economics/practice management (P =.0002), editorial (P =.0027), and review/meta-analysis (P <.0001) publications. CONCLUSION: The present study demonstrates that women contribute to the urologic literature significantly more than would be expected based on the proportion of practicing female urologists. However, with the persistence of gender gap in academic medicine promotions, further research into contributing factors and strategies for improvement are needed to promote greater women representation in academia.

Urological Education in United States Medical Schools: Where Are We Now and How Can We Do Better?

INTRODUCTION: While urological complaints increase in aging populations and conditions commonly require management by multiple physician specialty types, exposure to formal urological education in United States medical schools is limited and has been decreasing over time. We aim to update the current status of urological education in the United States curriculum and delve further into the subject matter being taught and the type and timing of this education. METHODS: An 11-question survey was developed to describe the current status of urological education. The survey was distributed using Survey Monkey to the American Urological Association's medical student listserv in November 2021. Descriptive statistics were used to summarize survey findings. RESULTS: Of 879 invitations sent, 173 responded (20%). Most (112/173, 65%) of respondents were in their fourth year. Only 4 (2%) reported that their school had a required clinical urology rotation. Kidney stones (98%) and urinary tract infections (100%) were the most frequent topics taught. The least exposure included infertility (20%), urological emergencies (19%), bladder drainage (17%), and erectile dysfunction (13%). Videos and case vignettes were the preferred learning modalities and the majority (84%) of respondents were familiar with the American Urological Association's medical student curriculum material. CONCLUSIONS: The majority of United States medical schools do not have a required clinical urology rotation and some core urological topics are not taught at all. Future incorporation of urological educational material through video and case vignette learning may be the best opportunity to provide exposure to clinical topics that will commonly be encountered regardless of chosen medical discipline.

Feasibility and Utility of Mobile Applications for the Evaluation of Urology Residents' Surgical Competence.

OBJECTIVE: To provide real-time assessment and feedback on the competency of urology residents' surgical skill via mobile applications and examine their feasibility and utility. MATERIALS AND METHODS: Two mobile application-based systems (SIMPL and myTIPreport) were sequentially implemented for the case-by-case assessment of residents' performance of surgical skills at a single institution. Data was collected regarding residents' perception of their feedback pre- and post-implementation of the applications. Faculty were surveyed after their implementation to determine their feasibility and utility. RESULTS: 297 individual evaluations were completed with SIMPL and 822 with myTIPreport over four and eleven months respectively. Post-implementation, residents showed significantly improved perceptions regarding the quantity and personalization of surgical skill feedback (P = .043 and .005 respectively). A majority (75%) of the faculty found the mobile applications feasible to use, an improvement compared to prior methods of resident evaluation, and would recommend continued use. CONCLUSION: This study represents the first documented use of real-time surgical competency assessment in urology. The use of mobile applications to evaluate urology residents' surgical competency in clinical practice is both feasible and useful. Their use may allow for more individualized surgical skill teaching during training and for the verification of the surgical skills necessary to practice autonomously.

Extracapsular extension on multiparametric magnetic resonance imaging better predicts pT3 disease at radical prostatectomy compared to perineural invasion on biopsy.

INTRODUCTION: Risk assessment for non-organ-confined prostate cancer (PCa) is important in the surgical planning for radical prostatectomy (RP). Perineural invasion (PNI) on prostate biopsy has been associated with adverse pathological outcomes at prostatectomy. Similarly, the identification of suspected extracapsular extension (ECE) on multiparametric magnetic resonance imaging (mpMRI) has been shown to predict non-organ-confined disease. However, no prior study has compared these factors in predicting adverse pathology at prostatectomy. We evaluated mpMRI ECE and prostate biopsy PNI on multivariable analysis to determine their ability to predict pathological stage at time of RP. METHODS: We retrospectively investigated the prostatectomy database at our institution to identify men who underwent prostate biopsy with pre-biopsy mpMRI and subsequent RP from 2013-2017. Multivariable regression analysis was performed to compare the association of mpMRI ECE (mECE) and PNI on prostate biopsy on the likelihood of finding pT3 disease on pathology post-prostatectomy. RESULTS: Of a total 454 RP between 2013 and 2017, 191 patients met our inclusion criteria. Stage pT2 and pT3+ were found in 120 (62.8%) and 71 (37.2%) patients, respectively. Patients with mECE had 4.84 cumulative odds of worse pathological stage on RP (p=0.045) compared to PNI on biopsy, which showed cumulative odds of 2.25 (p=0.048). When controlling only for those patients without PNI, mECE was still found to be a significant predictor of pT3 disease at RP (p=0.030); however, in patients without mECE, PNI was not significant (p=0.062). CONCLUSIONS: While mECE and biopsy PNI were both associated with worse pathological stage on RP, mECE had significantly higher cumulative odds compared to PNI. The significant predictive ability of mECE adds further clinical value to the use of mpMRI in PCa management. While validation in a larger cohort is required, these factors have important clinical implications with regards to early diagnosis of advanced disease and surgical planning.

Primary follicular lymphoma of the bladder mimicking inflammatory condition: Case report and review of the literature.

Primary lymphoma of the bladder is rare and may present with nonspecific symptoms and infection. Primary follicular lymphoma of the bladder is extremely rare with only a dozen reported cases. We present one case clinically mimicking an inflammatory process. A 79 year-old woman presents with recurrent urinary tract infections, urinary incontinence and frequency. Cystoscopic examination demonstrated a raised but flat lesion, suspicious for inflammatory lesion. Biopsy revealed a diagnosis of follicular lymphoma, grade 1-2. The presentation of primary follicular lymphoma of the bladder may be nonspecific, therefore it is important to consider this diagnosis in patients with unremitting symptoms.

Role of multi-parametric MRI of the prostate for screening and staging: Experience with over 1500 cases.

OBJECTIVE: Contemporary prostate cancer (PCa) screening modalities such as prostate specific antigen (PSA) and digital rectal examination (DRE) are limited in their ability to predict the detection of clinically significant disease. Multi-parametric magnetic resonance imaging (mpMRI) of the prostate has been explored as a staging modality for PCa. Less is known regarding its utility as a primary screening modality. We examined our experience with mpMRI as both a screening and staging instrument. METHODS: mpMRI studies performed between 2012 and 2014 in patients without PCa were cross-referenced with transrectal ultrasonography (TRUS) biopsy findings. Statistical analyses were performed to determine association of mpMRI findings with overall cancer diagnoses and clinically significant (Gleason score ≥7) disease. Subgroup analyses were then performed on patients with a history of prior negative biopsy and those without a history of TRUS biopsy. mpMRI studies were also cross-referenced with RP specimens. Statistical analyses determined predictive ability of extracapsular extension (ECE), seminal vesicle involvement (SVI), and pathologic evidence of clinically significant disease (Gleason score ≥7). RESULTS: Four hundred biopsy naïve or prior negative biopsy patients had positive mpMRI studies. Overall sensitivity, specificity, positive and negative predictive values were 94%, 37%, 58%, and 87%, respectively and 95%, 31%, 42%, and 93%, respectively for overall cancer detection and Gleason score ≥7 disease. In patients with no prior biopsy history, mpMRI sensitivity, specificity, positive and negative predictive values were 94%, 36%, 65%, and 82%, for all cancers, and 95%, 30%, 50%, and 89% for Gleason score≥7 lesions, respectively. In those with prior negative biopsy sensitivity, specificity, positive and negative predictive values were 94%, 37%, 52%, and 90% for all cancers, and 96%, 32%, 36%, and 96% for Gleason score ≥7 lesions, respectively. Seventy-four patients underwent radical prostatectomy (RP) after mpMRI. Lesion size on mpMRI correlated with the presence of Gleason score ≥7 cancers (p = 0.005). mpMRI sensitivity, specificity, positive and negative predictive values were 84%, 39%, 81%, and 44% respectively, for Gleason ≥7 cancer. For ECE and SVI, sensitivity and specificity were 58% and 98% and 44% and 97%, respectively. CONCLUSION: mpMRI is an accurate predictor of TRUS biopsy and RP outcomes. mpMRI has significant potential to change PCa management, particularly in the screening population, in whom a significant proportion may avoid TRUS biopsy. Further studies are necessary to determine how mpMRI should be incorporated into the current PCa screening and staging paradigms.

Review of appendiceal onlay flap in the management of complex ureteric strictures in six patients.

OBJECTIVES: To evaluate appendiceal onlay flap ureteroplasty for repairing complex right proximal and mid-ureteric strictures. PATIENTS AND METHODS: Between August 2006 and August 2012 four women and two men (mean age 34.2 years) underwent right laparoscopic appendiceal onlay flap ureteroplasty. The mean stricture length was 2.5 cm. Stricture formation was secondary to impacted ureteric stones in three patients and failed pyeloplasty for congenital pelvi-ureteric junction obstruction in the remaining three. Each patient had ipsilateral flank pain before surgery. RESULTS: The mean operating time, estimated blood loss and hospital stay were 244 min, 175 mL and 3.2 days, respectively. No intra- or peri-operative complications were noted. The objective success rate was 100% (all patients had radiographic and/or endoscopic resolution of their ureteric strictures). The subjective success rate was 66%, (two patients developed recurrent discomfort, which upon exploration was found to be attributable to fibrosis away from the appendiceal onlay graft, where the gonadal vessels crossed the ureter). Both patients with recurrent pain underwent laparoscopic ureterolysis and bladder advancement flap proximal to the appendiceal onlay, which markedly improved one patient's pain but the other patient continued to have discomfort, ultimately resulting in a laparoscopic nephroureterectomy. CONCLUSIONS: Appendiceal onlay ureteroplasty is a viable treatment option for patients with complex right proximal and mid-ureteric strictures, while minimising the potential morbidity of appendiceal and ileal interposition.

Open, laparoscopic, and robotic ureteroneocystotomy for benign and malignant ureteral lesions: a comparison of over 100 minimally invasive cases.

INTRODUCTION: Laparoscopic (LAP) and robot-assisted laparoscopic (RAL) approaches have been applied to ureteroneocystostomies (UNC) although such experience has been limited to a small number of patients and limited follow-up. Herein, we detail our experience with over 100 minimally invasive UNC, the largest such series to date. METHODS: All minimally invasive UNC performed at our institution between 1997 and 2013 and all open UNC performed between 2008 and 2013 were identified. Perioperative parameters of relevance were identified and recorded. Chi-squared and ANOVA with post hoc Tukey analysis were performed for all categorical and continuous variables, respectively. RESULTS: A total of 130 patients met our study criteria. One hundred five underwent the minimally invasive approach (20 RAL and 85 LAP). Mean follow-up duration was 504 days. Patients in the RAL, LAP, and open cohorts were of similar age, gender and laterality distribution, American Society of Anesthesiologists (ASA) score, body-mass index, history of previous abdominal surgery, history of prior treatment for the ureteral lesion, and surgical indication ( Table 1 ). Operative time was similar across all cohorts (235-257 minutes, p=0.123). Estimated blood loss (EBL) was significantly lower in the RAL and LAP cohorts (100 and 150 mL) compared to their open counterparts (300 mL, p=0.001) although a decrease in hematocrit was similar across all groups. Only four intraoperative complications (4.7%) and two (2.4%) conversions to open were identified in the LAP group, without statistical significance. No intraoperative complications or conversions were identified in the RAL or open cohorts. Median length of stay (LOS) was significantly shorter in the minimally invasive cohorts compared to open (p<0.002). Ninety-day readmission rates (18.8-20%), major complications (10-20%), and failure rates (5.9-16%) were highest in the open cohort although without statistical significance. CONCLUSION: RAL or LAP UNC is feasible, safe, and comparable to the open technique with some perioperative benefit in EBL, LOS, and stent duration.

Strange Vibes - Novel Presentation of Prostatitis.

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has significant variability in its presentation. In this study, we present 2 novel cases of prostatitis in which "buzz" is described as the primary pain symptom. These cases describe patients with the primary complaint of "cell phone-like buzzing" within the perineum, with accompanying urinary symptoms consistent with prostatitis. CP/CPPS is a multifactorial disease within which psychological, inflammatory, neurologic, and neuromuscular etiologies are at play. As in other disease descriptions, a buzzing sensation represents the interaction of multiple pathways that have significant overlay with CP/CPPS. As such, we believe buzzing might represent a new symptom of CP/CPPS.

Robotic assisted laparoscopic simple suprapubic prostatectomy - The Smith Institute for Urology experience with an evolving technique.

OBJECTIVE: Despite a multitude of minimally invasive surgical options available for benign prostatic enlargement, open simple prostatectomy (OSP) remains the standard for large prostates (typically greater than 100 g). OSP, however, is associated with significant morbidity. Recently, a few reports touting robotic application to simple prostatectomy have been published. Herein, we reviewed our series of robotic assisted laparoscopic simple suprapubic prostatectomy (RALSSP) and detailed modifications in our technique as our experience increased. METHODS: All RALSSP cases performed between January 2013 and January 2014 were reviewed for demographics, pre-operative features, and perioperative outcomes. All parameters were tabulated and mean values were calculated. Student's t-test was utilized with p < 0.05 deemed significant. Details regarding surgical technique were reviewed and highlighted. RESULTS: Fifteen patients underwent RALSSP during this period. Mean age of these men was 68.7 years. Mean body mass index (BMI) was 28.5 kg/m2. American Society of Anesthesiologists (ASA) score was on average 2.6. Average International Prostate Symptom Score (IPSS) was 16.2 with the majority of men experiencing some adverse clinical sequela of such benign prostatic hyperplasia (BPH). For those patients not in retention, preoperative post-void residual (PVR) was 428 mL. All patients underwent successful RALSSP without need for conversion or need for blood transfusion. Mean estimated blood loss (EBL) was 290 mL. Five patients underwent other concurrent procedures (e.g., cystolithotomy). Mean length of hospital stay (LOS) was 2.4 days and only five patients required continuous bladder irrigation (CBI) postoperatively. Postoperative PVR improved to a mean of 33 mL and IPSS improved to 4.5 (p < 0.001). No major complications were identified. Adaptation of low transverse cystotomy, utilization of a robotic tenaculum in the #3 arm with its control by a surgeon on a second console, and the utilization of mucosal advancement have all subjectively aided in performance of RALSSP and perioperative outcomes. CONCLUSION: RALSSP allows for feasible performance of prostate adenoma enucleation with low risk of blood transfusion, short LOS, and significant improvement in IPSS and PVR; all while maintaining a minimally invasive approach. The use of a robotic tenaculum controlled by the secondary console and the mucosal advancement facilitate excellent outcomes and may play a role in minimizing hematuria and need for CBI.

Renal cell recurrence for T1 tumors after laparoscopic partial nephrectomy.

OBJECTIVES: There is lack of consensus in the Urology community regarding surveillance after laparoscopic partial nephrectomy (LPN), particularly for patients with stage I tumors. The purpose of this article is to characterize the rate of recurrence after partial nephrectomy in a low risk cohort. METHODS: Data were collected on all laparoscopic partial nephrectomies performed at a single institution from January 2006 through May 2011. Patients without at least 1 year of follow-up information were excluded from examination. Patients were stratified based on the pathologic tumor stage at the time of partial nephrectomy. Patients with stage I (a and b) tumors were then examined for recurrence. RESULTS: A total of 639 patients underwent LPN during the time period. Of this, 360 patients had stage T1 renal cell carcinoma (RCC) (302 with pT1a and 58 with pT1b) and met research criteria. There were 8 recurrences (2.2%) within this cohort ( Table 1 ). All of the tumors were of clear cell histology and none had Furhman grade 1 histology. Only one of these patients had a positive margin at the time of partial nephrectomy and all patients had negative biopsy of the tumor resection bed. A majority of the recurrences occurred locally in the ipsilateral kidney or retroperitoneum. Most of the recurrences occurred within 1-2 years postoperatively. CONCLUSIONS: Approximately 2% of patients who underwent LPN for RCC with resultant low risk, stage I tumor pathology developed metastasis. There were no recurrences in nonclear cell pathologies and no recurrences with Furhman grade 1 or tumors smaller than 3 cm.

Hilar clamping versus off-clamp laparoscopic partial nephrectomy for T1b tumors.

PURPOSE OF REVIEW: An off-clamp, or zero-ischemia, approach to laparoscopic partial nephrectomy has been a proposed means of preserving global renal function by preventing ischemia to normal renal parenchyma. However, for clinical stage T1b tumors this provides a unique challenge as the large size of these tumors further complicates an already difficult procedure. This review provides an overview of outcomes for laparoscopic partial nephrectomies performed with or without hilar clamping for clinical stage T1b tumors. RECENT FINDINGS: There is a paucity of data for laparoscopic partial nephrectomies for this larger tumor size. The feasibility of performing laparoscopic partial nephrectomy for renal tumors 4-7 cm in size has clearly been demonstrated. Not unexpectedly, using an off-clamp technique during laparoscopic partial nephrectomy has variably shown increased intraoperative blood loss when compared to hilar controlled procedures. This does not, however, seem to translate into increased risk of transfusion or loss of visualization leading to compromise in oncologic outcomes. Lastly, some data suggest improved short-term and long-term preservation of renal function as estimated by estimated glomerular filtration rate. SUMMARY: With accumulating data pointing to the long-term health benefits of nephron sparing surgery over radical nephrectomy and its oncologic equivalency confirmed, there is an increased push to perform partial nephrectomy for larger tumors. As demonstrated in the setting of a solitary kidney, every minute of warm ischemia counts and ischemia is an important modifiable variable that impacts renal function. As such, off-clamp dissection has potential advantages. The reviewed data show that foregoing hilar clamping for T1b tumors is not only feasible, but is likely beneficial with respect to renal function and does not appear to carry an increased risk of transfusion despite increased blood loss.

Predictors for negative ureteroscopy in the management of upper urinary tract stone disease.

OBJECTIVE: To identify factors predictive of negative ureteroscopy (URS). Although computed tomography (CT) scans are sensitive in assessing upper tract calculi, there is increased effort to limit CT radiation exposure. On occasion, patients undergo URS and it is discovered that the stone has already passed. METHODS: Retrospective chart review was conducted on all URS cases for renal and ureteral stones performed by a single surgeon from August 2003 to May 2008. Renal units were examined separately and excluded for stone size >10 mm, staged procedures, and previously placed ureteral stents. Negative URS cases were compared with those where stones were identified for differences in stone size, location, presence of preoperative pain, time interval since CT, presence of hydronephrosis, and use of medical expulsive therapy (MET). RESULTS: Two-hundred fifty-six cases were identified. Twenty-five of 256 renal units (9.8%) did not have stones upon direct visualization. Stone size (P < .001) and stone location (P = .043) were significantly associated with outcome on univariate analysis. On multivariate analysis, only stone size was significant (P < .001). CONCLUSION: Negative URS occurred in almost 10% of cases, with reasonable chance of spontaneous stone passage. Our data support smaller stone size and distal location as predictive of negative URS as opposed to preoperative pain, presence of hydronephrosis, and use of MET. Time interval since CT was not predictive. Rate of negative ureteroscopy is not insignificant, thus patients with small, distal stones who elect to undergo URS should be counseled regarding negative URS with an alternative being repeat imaging.

Is a safety wire necessary during routine flexible ureteroscopy?

BACKGROUND AND PURPOSE: The use of flexible ureteroscopy (URS) for nephrolithiasis has been rapidly expanding. Initially, safety guidewires were maintained alongside the ureteroscope during stone manipulation to prevent loss of access and allow stent insertion in the event of perforation. We intend to determine the safety of flexible URS without a separate safety guidewire in a large series of patients. METHODS: A retrospective chart review was performed on all cases of flexible URS with laser lithotripsy performed by a single surgeon from August 2003 to May 2008. Preoperative patient characteristics, radiographic stone sizes, operative findings, and postoperative outcomes were recorded. Patients with renal or ureteropelvic junction (UPJ) stones were isolated for a qualitative data analysis. RESULTS: Flexible URS was performed on 305 kidneys in 246 consecutive patients, of which 59 cases were bilateral. Cases were subdivided into complicated and uncomplicated. Two hundred seventy cases were uncomplicated and performed without a safety guidewire. No intraoperative complications resulted from the lack of a safety guidewire, including no cases of lost access, ureteral perforation/avulsion, or need for percutaneous nephrostomy tube. Thirty-five cases were complicated, necessitating a safety guidewire. Of these, 16 had concomitant obstructing ureteral stones, 5 had encrusted ureteral stents, and 14 had difficult access because of large stone burden or aberrant anatomy. CONCLUSIONS: This study demonstrates that, in a large series of patients, a safety guidewire was not necessary for routine cases of flexible URS with laser lithotripsy on renal or UPJ stones. Particular cases with complicated anatomy, difficult access, concomitant ureteral stones, simultaneous stone basketing, or bulky stone burden still necessitate use of a safety guidewire because of increased risk of adverse outcomes.