Evaluating the Effectiveness of Artificial Intelligence-powered Large Language Models Application in Disseminating Appropriate and Readable Health Information in Urology.

PURPOSE: The Internet is a ubiquitous source of medical information, and natural language processors are gaining popularity as alternatives to traditional search engines. However, suitability of their generated content for patients is not well understood. We aimed to evaluate the appropriateness and readability of natural language processor-generated responses to urology-related medical inquiries. MATERIALS AND METHODS: Eighteen patient questions were developed based on Google Trends and were used as inputs in ChatGPT. Three categories were assessed: oncologic, benign, and emergency. Questions in each category were either treatment or sign/symptom-related questions. Three native English-speaking Board-Certified urologists independently assessed appropriateness of ChatGPT outputs for patient counseling using accuracy, comprehensiveness, and clarity as proxies for appropriateness. Readability was assessed using the Flesch Reading Ease and Flesh-Kincaid Reading Grade Level formulas. Additional measures were created based on validated tools and assessed by 3 independent reviewers. RESULTS: Fourteen of 18 (77.8%) responses were deemed appropriate, with clarity having the most 4 and 5 scores (P = .01). There was no significant difference in appropriateness of the responses between treatments and symptoms or between different categories of conditions. The most common reason from urologists for low scores was responses lacking information-sometimes vital information. The mean (SD) Flesch Reading Ease score was 35.5 (SD=10.2) and the mean Flesh-Kincaid Reading Grade Level score was 13.5 (1.74). Additional quality assessment scores showed no significant differences between different categories of conditions. CONCLUSIONS: Despite impressive capabilities, natural language processors have limitations as sources of medical information. Refinement is crucial before adoption for this purpose.

The effect of testicular trauma on male infertility.

We aim to evaluate the effect of testicular trauma on male reproductive outcomes. The electronic medical record was retrospectively searched using diagnosis codes for testicular trauma and procedure codes for testicular trauma repairs, at Los Angeles County and Parkland Hospitals, for males aged 18-55 years. Charts were reviewed for trauma details, reproductive hormones, and semen analyses. Men were contacted by phone for a fertility and sexual performance survey. Fifty-six patients were identified as having testicular trauma. Twelve were reached by telephone, of which 33.3% had blunt and 66.7% had penetrating traumas. The mean duration since trauma was 41 months. One quarter reported new-onset erectile dysfunction post-trauma, 16.7% endorsed new-onset dysuria, 8.3% endorsed long-term testicular pain. Only two males (16.7%) attempted paternity post-trauma, both with primary infertility. One patient (8.3%) was attempting paternity post-trauma and experiencing primary infertility for 42 months. Two patients (16.7%) had undergone semen analysis testing, both patient-reported as 'normal'. None of the 12 patients we reached were under the care of a urologist. Both short and long-term urologic follow-up is crucial for testicular trauma patients. Despite some experiencing lasting consequences, none of these men were under the care of a urologist.

Hyperandrogenism and Hyperestrogenism Secondary to Mixed Germ-Cell Testicular Tumor.

Testicular cancer with androgen and estrogen secretion is classically associated with Leydig cell tumors. Rare case reports have described this finding in germ-cell tumors along with signs of androgen and estrogen excess including gynecomastia and infertility. We report the case of a 19-year-old male with a non-seminomatous testicular germ-cell tumor found to have hyperandrogenism, hyperestrogenism, and suppression of central sex hormones. Similar findings may be underreported in the literature, and males with suspected testicular malignancy should be appropriately screened for signs of androgen and/or estrogen excess so they can be offered appropriate monitoring and counseling.

Surgeon Assessment of a Novel Multi-Resolution Foveated Laparoscope.

BACKGROUND: We developed a multi-resolution foveated laparoscope (MRFL) to improve situational awareness in laparoscopic surgery. We assessed surgeon objective task performance and subjective attitudes with MRFL when used for box trainer tasks and porcine surgery. METHODS: The MRFL simultaneously obtains a wide-angle view and a magnified view. The 2 images are displayed simultaneously. 6 urologists and 2 general surgeons performed box trainer and porcine surgery tasks with the MRFL and a standard laparoscope. Task time, use of display options, and subjective assessments were obtained. RESULTS: Subjectively, surgeons rated situational awareness, depth perception, and instrument interference as comparable between the prototype MRFL and laparoscope for trainer tasks. For porcine surgery, the MRFL was rated as having less interference than the standard laparoscope. The image quality of the MRFL was rated interior to the standard laparoscope. Participants found the different viewing modes useful for different roles and reported that they would likely use the MRFL for conventional laparoscopic and robotic surgery. Objectively, box trainer task time was comparable for 2 of 3 tasks with the remaining task shorter for the standard laparoscope. Porcine nephrectomy and oophorectomy were feasible with the prototype MRFL, although nephrectomy task time was significantly longer than traditional laparoscopy. CONCLUSIONS: The MRFL demonstrated feasibility for performing complex surgery. Surgeons had favorable attitudes toward its features and likelihood to use the device if available. Users utilized different view types for different tasks. Longer MRFL task times were attributed to poorer image quality of the prototype.

Techniques and Outcomes of MRI-TRUS Fusion Prostate Biopsy.

PURPOSE OF REVIEW: The goal of this study is to review recent findings and evaluate the utility of MRI transrectal ultrasound fusion biopsy (FBx) techniques and discuss future directions. RECENT FINDINGS: FBx detects significantly higher rates of clinically significant prostate cancer (csPCa) than ultrasound-guided systematic prostate biopsy (SBx), particularly in repeat biopsy settings. FBx has also been shown to detect significantly lower rates of clinically insignificant prostate cancer. In addition, a dedicated prostate MRI can assist in more accurately predicting the Gleason score and provide further information regarding the index cancer location, prostate volume, and clinical stage. The ability to accurately evaluate specific lesions is vital to both focal therapy and active surveillance, for treatment selection, planning, and adequate follow-up. FBx has been demonstrated in multiple high-quality studies to have improved performance in diagnosis of csPCa compared to SBx. The combination of FBx with novel technologies including radiomics, prostate-specific membrane antigen positron emission tomography (PSMA PET), and high-resolution micro-ultrasound may have the potential to further enhance this performance.

Differences in Implementation Outcomes of a Shared Decision-Making Program for Men with Prostate Cancer between an Academic Medical Center and County Health Care System.

BACKGROUND: Shared decision making (SDM) has long been advocated as the preferred way for physicians and men with prostate cancer to make treatment decisions. However, the implementation of formal SDM programs in routine care remains limited, and implementation outcomes for disadvantaged populations are especially poorly described. We describe the implementation outcomes between academic and county health care settings. METHODS: We administered a decision aid (DA) for men with localized prostate cancer at an academic center and across a county health care system. Our implementation was guided by the Consolidated Framework for Implementation Research and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. We assessed the effectiveness of the DA through a postappointment patient survey. RESULTS: Sites differed by patient demographic/clinical characteristics. Reach (DA invitation rate) was similar and insensitive to implementation strategies at the academic center and county (66% v. 60%, P = 0.37). Fidelity (DA completion rate) was also similar at the academic center and county (77% v. 80%, P = 0.74). DA effectiveness was similar between sites, except for higher academic center ratings for net promoter for the doctor (77% v. 37%, P = 0.01) and the health care system (77% v. 35%, P = 0.006) and greater satisfaction with manner of care (medians 100 v. 87.5, P = 0.04). Implementation strategies (e.g., faxing of patients' records and meeting patients in the clinic to complete the DA) represented substantial practice changes at both sites. The completion rate increased following the onset of reminder calls at the academic center and the creation of a Spanish module at the county. CONCLUSIONS: Successful DA implementation efforts should focus on patient engagement and access. SDM may broadly benefit patients and health care systems regardless of patient demographic/clinical characteristics.

Grade IV Renal Laceration in a 13-Year-Old Boy With Cross-fused Renal Ectopia.

A 13-year-old boy presented with gross hematuria following a skateboarding accident and was found to have cross-fused renal ectopia of the left kidney with a grade IV right renal laceration and urinary extravasation. Despite a double-J ureteral stent, urinoma drain, and indwelling bladder catheter, his urinoma drain maintained high output. He underwent a ureteral stent exchange and upsizing. A percutaneous nephrostomy tube was subsequently placed for maximal urinary diversion, which ultimately led to the resolution in his urinary leak. This case highlights our endourologic approach to manage a severe urinary leak despite conservative measures in a pediatric patient with a renal anomaly.

Durable biochemical response following adrenal metastasectomy for oligometastatic castrate-resistant prostate cancer.

A 77 year-old man was referred to Urology with an enlarging left adrenal mass after treatment with androgen deprivation therapy for metastatic castrate-resistant prostate cancer. He underwent a robotic-assisted left radical adrenalectomy, with pathology revealing metastatic adenocarcinoma consistent with a primary prostate adenocarcinoma. The patient had a durable oncological response to metastasectomy with no evidence of biochemical or radiological recurrence after 5 years of follow-up. Adrenal metastases from prostate cancer are extremely rare, representing only 1% of metastatic cases. Surgical resection of oligometastatic prostate cancer recurrences may be considered in select patients and may improve progression-free survival.

Retained Bullet in the Prostate Causing Lower Urinary Tract Symptoms.

A 41-year-old man presented with a 5-month history of bothersome urinary urgency and frequency. He sustained a gunshot wound to the lower abdomen 15 months prior to presentation. Digital rectal examination revealed a metallic foreign body palpable within the right lobe of the prostate, which was suggestive of a retained bullet fragment within the prostate gland. Cystourethroscopy confirmed a bullet fragment lodged within the right lateral aspect of the prostatic urethra. X-ray of the pelvis illustrated 2 radiopaque foreign bodies projecting at the level of the pubis. The patient deferred surgical retrieval and opted for pharmacological management with anti-cholinergic medication.

Health Changes in Low Income Men Transitioning from a State Funded Prostate Cancer Program to Comprehensive Insurance.

PURPOSE: We evaluated the effect of transitioning from a prostate cancer specific treatment program to comprehensive insurance under the ACA (Patient Protection and Affordable Care Act) on the physical, mental and prostate cancer related health of poor, previously uninsured men. MATERIALS AND METHODS: We assessed general and prostate cancer specific health related quality of life using the RAND SF-12v2™ (12-Item Short Form Survey, version 2) and the UCLA PCI (Prostate Cancer Index) at 3 time points in 24 men who transitioned to comprehensive insurance as the insured group relative to 39 who remained in the prostate cancer program as the control group. We used mixed effects models controlling for treatment and patient factors to measure health differences between the groups during the transition period. RESULTS: Demographics, prostate cancer treatment patterns, and mental, physical and general health were similar before transition in the control and insured groups. After transition men who gained insurance coverage reported significantly worse physical health than men who remained in the prostate cancer program (p = 0.0038). After adjustment in the mixed effects model physical health remained worse in men who gained insurance (p = 0.0036). Mental health and prostate cancer related quality of life did not differ with time between the groups. CONCLUSIONS: Compared to controls who remained in the state funded prostate cancer treatment program for poor, uninsured men, newly insured men reported worse physical health after transitioning to ACA coverage. Providers and policy makers may draw important lessons from understanding the mechanisms of this paradoxical worsening in physical health after gaining insurance. These results inform the development of disease specific models of care in the broader health insurance context.

Feasibility of expert and crowd-sourced review of intraoperative video for quality improvement of intracorporeal urinary diversion during robotic radical cystectomy.

INTRODUCTION: Development of uretero-ileal stricture (UIS) after robotic-assisted radical cystectomy (RARC) may be dependent on surgical technique. Video review of intraoperative technique is an emerging paradigm for surgical quality improvement. We examined whether surgeon-perceived risk of UIS or crowd-sourced assessment of robotic skill are associated with the development of UIS. METHODS: We conducted a case-control study comparing the operative technique of uretero-ileal anastomoses resulting in clinically significant UIS with the contralateral anastomosis for the same patient. De-identified videos were analyzed by 1) five high-volume surgeons; and 2) crowd workers (Crowd-Sourced Assessment of Technical Skill, C-SATS) to determine Global Evaluative Assessment of Robotic Skill (GEARS) score. Mantel-Haenszel common odds ratio (OR) estimates were calculated to assess the association between surgeon performance and the development of UIS. Logistic regression models were used to examine the association between GEARS scores and the development of UIS. RESULTS: A total of 10 UIS videos were compared to eight control videos by five surgeons and 2142 crowd workers. Expert surgeons systematically evaluated intraoperative footage, however, no association between the expert mode response and UIS (OR 0.42; 95% confidence interval [CI] 0.05-3.45; p=0.91) was identified. Crowd-sourced assessment was not predictive of UIS (p=0.62). CONCLUSIONS: We used video review to systematically analyze procedure-specific content and technique. The inability of surgeons to predict UIS may reflect the questionnaire, uncontrolled patient factors, or a lack of power. Crowd-sourced GEARS score was unsuccessful in predicting UIS after RARC.

Robot-assisted Level II-III Inferior Vena Cava Tumor Thrombectomy: Step-by-Step Technique and 1-Year Outcomes.

BACKGROUND: Level II-III inferior vena cava (IVC) tumor thrombectomy for renal cell carcinoma is among the most challenging urologic oncologic surgeries. In 2015, we reported the initial series of robot-assisted level III caval thrombectomy. OBJECTIVE: To describe our University of Southern California technique in a step-by-step fashion for robot-assisted IVC level II-III tumor thrombectomy. DESIGN, SETTING, AND PARTICIPANTS: Twenty-five selected patients with renal neoplasm and level II-III IVC tumor thrombus underwent robot-assisted surgery with a minimum 1-yr follow-up (July 2011 to March 2015). SURGICAL PROCEDURE: Our standardized anatomic-based "IVC-first, kidney-last" technique for robot-assisted IVC thrombectomy focuses on minimizing the chances of an intraoperative tumor thromboembolism and major hemorrhage. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Baseline demographics, pathology data, 90-d and 1-yr complications, and oncologic outcomes at last follow-up were assessed. RESULTS AND LIMITATIONS: Robot-assisted IVC thrombectomy was successful in 24 patients (96%) (level III: n=11; level II: n=13); one patient was electively converted to open surgery for failure to progress. Median data included operative time of 4.5h, estimated blood loss was 240ml, hospital stay 4 d; five patients (21%) received intraoperative blood transfusion. All surgical margins were negative. Complications occurred in four patients (17%): two were Clavien 2, one was Clavien 3a, and one was Clavien 3b. All patients were alive at a 16-mo median follow-up (range: 12-39 mo). CONCLUSIONS: Robotic IVC tumor thrombectomy is feasible for level II-III thrombi. To maximize intraoperative safety and chances of success, a thorough understanding of applied anatomy and altered vascular collateral flow channels, careful patient selection, meticulous cross-sectional imaging, and a highly experienced robotic team are essential. PATIENT SUMMARY: We present the detailed operative steps of a new minimally invasive robot-assisted surgical approach to treat patients with advanced kidney cancer. This type of surgery can be performed safely with low blood loss and excellent outcomes. Even patients with advanced kidney cancer could now benefit from robotic surgery with a quicker recovery.

Cost Analysis of the Enhanced Recovery After Surgery Protocol in Patients Undergoing Radical Cystectomy for Bladder Cancer.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols for radical cystectomy (RC) aim to improve patient care, reduce complications, and shorten hospital stay while potentially reducing health care expenditure. OBJECTIVE: Evaluate the ERAS protocol for 30-d global costs relative to standard management in the era immediately preceding the initiation of ERAS for RC. DESIGN, SETTING, AND PARTICIPANTS: Overall, 201 consecutive patients (99 with standard management, 102 with an ERAS protocol) who met inclusion criteria and who underwent open RC at a single institution were evaluated. Resource-based costs were collected for the initial surgical admission and for any readmissions or unscheduled clinic visits within 30 d. INTERVENTION: Implementation of the ERAS protocol. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Line-item billing data were transformed using resource-based cost estimates. Tukey-Kramer least squares mean analysis was performed to adjust for cost differences attributable to patient characteristics on multivariate analysis (age <70 yr, male sex, and Charlson comorbidity score 0-1). Adjusted overall costs for the standard and ERAS cohorts were calculated with each line item assigned to 1 of 10 cost centers to identify specific areas of savings or increased expenditures with implementation of ERAS. RESULTS AND LIMITATIONS: Average 30-d costs were $31 139 with standard management and $26 650 after implementation of ERAS, for savings of $4488 per procedure (p<0.0001). Areas of significant ERAS savings included intensive care unit care ($2056), surgical ward costs ($2029), ancillary treatment ($1279), and supplies ($1238), whereas increased ERAS expenditures included costs for drugs ($2088), home health ($590), and unscheduled outpatient visits ($162). Surgical/anesthesia costs were similar between the standard and ERAS groups at $6405 and $6286 respectively. This was a single-institution study. CONCLUSIONS: In addition to clinical benefits, ERAS for RC at our institution also afforded an average cost savings of $4488 per procedure. PATIENT SUMMARY: In this report, we evaluated the cost center-specific expenditures of the ERAS protocol for RC, demonstrating $4488 savings in 30-d costs relative to standard management.