Efficacy of EMLA for Office-based Andrology Procedures Under Local Anesthesia: A Randomized Control Trial.

OBJECTIVE: To evaluate the effectiveness of Eutectic Mixture of Local Anesthetic (EMLA), a topical anesthetic cream, in office-based invasive andrological procedures such as hydrocelectomy, spermatocelectomy, and others, aimed at minimizing pain perception and enhancing the overall patient experience. METHODS: A double-blinded randomized controlled trial was conducted for patients undergoing scrotal andrology surgeries under LA. Power calculation was performed with an estimated sample size of 72. Participants were randomly assigned in a 1:1 ratio to topical EMLA + LA versus LA alone. In the post-operative recovery area, patient will be asked to complete a VAS questionnaire rating pain with LA administration and pain with procedure. Analysis comparing VAS pain scores of both groups was performed using the independent sample t-test method. RESULTS: Seventy-two patients were included in our analysis, with 36 in the control and 36 in the intervention arm. For patient pain with administration of LA, the control arm reported an average VAS pain score of 4.31, compared to 3.72 in the intervention arm (P = .319). For patient pain with procedure, patients in the control arm reported a median VAS pain score of 3.47 compared to 3.03 (P = .432) in the intervention arm. Overall, 86% (62/72) of patients reported that they would either be "very likely" (4/5) or "highly likely" (5/5) to undergo future procedures under local anesthetic. CONCLUSION: While performing scrotal surgeries under LA appears to be well tolerated and a feasible option, the application of EMLA cream does not appear to significantly alter patient-reported outcomes.

Radiographic predictors of muscle-invasive upper tract urothelial cancer: A Canadian cohort.

INTRODUCTION: Accurate diagnostic staging of upper tract urothelial cancer (UTUC) is challenging. Endoscopic staging is limited by its ability to provide adequate sampling of deeper layers of the ureter and renal pelvis. Further ability to accurately predict invasive disease would aid in better selecting the appropriate treatment for patients. We aimed to analyze the ability of preoperative cross-sectional radiologic findings to predict pathologic outcomes, including tumor grade, muscle-invasive disease, and presence of lymphovascular invasion (LVI). METHODS: All patients diagnosed with localized UTUC (cN0M0) who underwent nephroureterectomy between February 2012 and December 2018 in Manitoba, Canada, were identified. Preoperative radiologic characteristics, including the presence and severity of hydronephrosis, as well as tumor location were recorded. Patients' and pathologic characteristics were also recorded. Logistic regression analysis was used to assess the association between radiologic variables and pathologic outcomes at radical surgery. RESULTS: A total of 112 pathology reports of patients with UTUC were obtained. The median age was 70 years (range 50-87), and 58.8% of patients were men. On univariate analysis, ureteric location on computed tomography (odds ratio [OR] 2.240, 95% confidence interval [CU] 1.049- 4.783, p=0.037) and presence of hydronephrosis (OR 2.455, 95% CI 1.094-5.506, p=0.0029) were each independently associated with locally invasive disease (>pT2). No radiologic variables were found to be a predictor of adverse pathology on multivariable analysis. Only the presence of hydronephrosis was associated with high-grade disease on univariate analysis (OR 2.533, 95% CI 1.083-5.931, p=0.032). CONCLUSIONS: Our findings suggest a limited role for cross-sectional imaging in predicting the presence of high-grade disease, LVI, or locally advanced disease in UTUC.

The safety and efficacy of ambulatory urologic surgery: A paradigm shift towards optimizing resource utilization in outpatient settings.

INTRODUCTION: Amidst substantial surgical waitlists, novel methods are needed to improve the delivery of surgical care in Canada. One strategy involves shifting select surgeries from hospitals into community ambulatory centers, which expedite procedures and allow hospitals to prioritize critical and complex patients. We sought to evaluate surgical outcomes at a novel Canadian urologic clinic and surgical center. METHODS: A retrospective study was conducted at a novel accredited surgical facility and outpatient ambulatory clinic from August 2022 to August 2023. Procedures ranged from scrotal and transurethral surgeries to inflatable penile prosthesis insertion. Traditional outpatient procedures, including vasectomy and cystoscopy, were excluded. All patients were discharged the same day and seen 4-6 weeks post-procedure. Variables of interest included surgery type, anesthesia administered, additional clinic appointments, unplanned family physician appointments, visits to the emergency department (ED), and hospital admissions. RESULTS: In a 12-month period, 519 surgeries were performed. The mean patient age was 49.6±17.3 years, with most classified as American Society of Anesthesiologists (ASA) 1-2 (88.8%). Most (95.8%, n=497) patients did not require medical care outside the clinic before scheduled followup; 2.5% (n=13) visited the ED presenting for wound concerns, postoperative pain, query infection, or catheter-related concerns. Only 1.7% (n=9) required an unscheduled appointment with their family physician, with concerns being inadequate postoperative pain management (n=4) or suspected infection (n=4). No patient required hospital admission. CONCLUSIONS: Many urologic surgeries classically performed in hospital operating rooms can be safely performed in a non-hospital, outpatient surgical facility with preservation of good outcomes. This strategy can potentially improve the efficiency of urologic healthcare delivery in select patients.

Outcomes following inguinal and subinguinal urologic procedures under deep intravenous sedation.

INTRODUCTION: We aimed to investigate the surgical outcomes following inguinal and subinguinal urological procedures under deep intravenous sedation (DIVS) with multimodal local anesthesia (LA). METHODS: We conducted a retrospective cohort study from September 2022 to December 2023 including adult patients deemed eligible for day surgery (American Society of Anesthesiologist score 1-3) undergoing radical orchiectomy (RO), microscopic varicocelectomy (MV), or microscopic denervation of spermatic cords (MDSC). All procedures were performed at a single urologic ambulatory surgical center and outpatient clinic, and by a single surgeon (PP). Procedures were performed through a subinguinal or inguinal approach with DIVS and adjunctive multimodal LA. We evaluated intraoperative complications and relevant surgical outcomes and parameters. RESULTS: A total of 103 patients were included in the analysis with a mean age ± standard deviation of 37.3±9.6. This included 25 patients who underwent RO, 54 patients who underwent MV, and 24 patients who underwent MDSC. All procedures were completed successfully without intraoperative complications. Oncologic outcomes were preserved, fertility outcomes improved, and pain scores reduced similar to the expected rates in the literature. CONCLUSIONS: Our preliminary results demonstrate the safety, effectiveness, and feasibility of performing inguinal and subinguinal urologic procedures under DIVS with LA. These findings suggest that this technique preserves high-quality care while avoiding unnecessary risks of general or spinal anesthesia, representing an opportunity to transfer these cases outside of hospitals' operating rooms into outpatient ambulatory centers.

Outcomes and patient tolerability of radical inguinal orchiectomy under deep intravenous sedation.

INTRODUCTION: Radical inguinal orchiectomy (RO ) is indicated for the management of testicular tumors and is universally performed under general anesthetic in the hospital. The need to perform radical orchiectomy in an expeditated fashion can result in logistical difficulties, often necessitating this procedure to happen after-hours on a semi-emergent basis. These logistical difficulties have been exacerbated by the backlog of cases from the COVID-19 pandemic. A similar procedure - inguinal hernia repair - is regularly performed under local anesthesia with minimal complications. Thus, we sought to evaluate the feasibility of performing radical orchiectomy under deep intravenous sedation in an ambulatory surgery center. METHODS: We evaluated our single-surgeon (PP), prospective database of patients who underwent RO between September 2022 and February 2023 at the Men's Health Clinic Manitoba. Patients were given a combination of deep sedation, ilioinguinal nerve block, and local anesthetic. Tolerability was assessed both perioperatively and at 4-6 weeks' followup. We reviewed the medical records for any postoperative complications. RESULTS: Eight patients underwent RO under deep sedation during the study period. All patients tolerated the surgery well and were discharged shortly after surgery. Average operative time was 40 minutes and length of stay was 46 minutes. There were no perioperative complications. CONCLUSIONS: Our pilot study demonstrates that RO can be safely and effectively performed under deep sedation. This anesthetic combination can be used both in-hospital and out-of-hospital settings, thereby resulting in faster recovery, shorter length of stay, and favorable patient and provider satisfaction.

A prospective evaluation of patient perspectives and financial considerations during prostate cancer treatment decision-making.

INTRODUCTION: In universal healthcare systems, patients may still encounter financial obstacles from cancer treatments, potentially influencing treatment decision-making. We investigated the relationship between socioeconomic status and treatment decision-making as it pertains to patient values, preferences, and perceived barriers to care for localized prostate cancer. METHODS: We conducted a prospective study of patients undergoing a prostate biopsy for the initial detection of prostate cancer. Sociodemographic variables were collected, with validated instruments used to determine health literacy levels. Patients were divided into two groups using self-reported income; those with a positive identification of prostate cancer underwent additional surveys to ascertain their knowledge of their diagnosis, treatment-related preferences, and socioeconomic barriers to care. Descriptive statistics were used. RESULTS: Of 160 patients, approximately one-third were classified as having low health literacy. Within the low-income group, education levels were lower (34.6% had less than high school education vs. 10.2% in the high-income group) and unemployment rates higher (75.0% unemployed vs. 38.9% in the high-income group). Low-income patients with prostate cancer placed greater importance on indirect out-of-pocket expenses related to treatment (78.3% vs. 33.3%, p=0.001), higher emphasis on treatment-related travel time (50% vs. 15.1%, p=0.004), and more often had difficulty paying for healthcare services in the past (30.9% vs. 9.1%, p=0.02). CONCLUSIONS: Patients with lower household incomes have unique treatment values and decision-making preferences. They may experience additional challenges and barriers to obtaining cancer care, at least partly related to indirect costs. These findings should be considered when framing prostate cancer treatment discussions and designing patient-facing health information.

A Predictive Model for Kidney Failure After Nephrectomy for Localized Kidney Cancer: The Kidney Cancer Risk Equation.

RATIONALE & OBJECTIVE: Nephrectomy is the mainstay of treatment for individuals with localized kidney cancer. However, surgery can potentially result in the loss of kidney function or in kidney failure requiring dialysis/kidney transplantation. There are currently no clinical tools available to preoperatively identify which patients are at risk of kidney failure over the long term. Our study developed and validated a prediction equation for kidney failure after nephrectomy for localized kidney cancer. STUDY DESIGN: Population-level cohort study. SETTING & PARTICIPANTS: Adults (n=1,026) from Manitoba, Canada, with non-metastatic kidney cancer diagnosed between January 1, 2004, and December 31, 2016, who were treated with either a partial or radical nephrectomy and had at least 1 estimated glomerular filtration rate (eGFR) measurement before and after nephrectomy. A validation cohort included individuals in Ontario (n=12,043) with a diagnosis of localized kidney cancer between October 1, 2008, and September 30, 2018, who received a partial or radical nephrectomy and had at least 1 eGFR measurement before and after surgery. NEW PREDICTORS & ESTABLISHED PREDICTORS: Age, sex, eGFR, urinary albumin-creatinine ratio, history of diabetes mellitus, and nephrectomy type (partial/radical). OUTCOME: The primary outcome was a composite of dialysis, transplantation, or an eGFR<15mL/min/1.73m2 during the follow-up period. ANALYTICAL APPROACH: Cox proportional hazards regression models evaluated for accuracy using area under the receiver operating characteristic curve (AUC), Brier scores, calibration plots, and continuous net reclassification improvement. We also implemented decision curve analysis. Models developed in the Manitoba cohort were validated in the Ontario cohort. RESULTS: In the development cohort, 10.3% reached kidney failure after nephrectomy. The final model resulted in a 5-year area under the curve of 0.85 (95% CI, 0.78-0.92) in the development cohort and 0.86 (95% CI, 0.84-0.88) in the validation cohort. LIMITATIONS: Further external validation needed in diverse cohorts. CONCLUSIONS: Our externally validated model can be easily applied in clinical practice to inform preoperative discussions about kidney failure risk in patients facing surgical options for localized kidney cancer. PLAIN-LANGUAGE SUMMARY: Patients with localized kidney cancer often experience a lot of worry about whether their kidney function will remain stable or will decline if they choose to undergo surgery for treatment. To help patients make an informed treatment decision, we developed a simple equation that incorporates 6 easily accessible pieces of patient information to predict the risk of reaching kidney failure 5 years after kidney cancer surgery. We expect that this tool has the potential to inform patient-centered discussions tailored around individualized risk, helping ensure that patients receive the most appropriate risk-based care.

Chronic kidney damage pathology score for systematic assessment of the non-neoplastic kidney tissue and prediction of post-operative renal function outcomes.

To establish a systematic histological assessment of non-neoplastic kidney (NNK) tissue at the time of nephrectomy to evaluate a patient's risk of developing post-operative renal dysfunction, a combined prospective pathologic assessment of the NNK and a retrospective clinical chart review was conducted. A blinded nephropathologist performed standardized assessment of glomerular sclerosis, tubulointerstitial fibrosis, arteriosclerosis, and hyaline arteriolosclerosis. Combined these formulated the chronic kidney damage pathology score (CKDPS). Multivariate logistic regression models were developed to assess the effect of CKDPS and other clinical factors on renal function up to 24 months following nephrectomy (partial or radical). 156 patients were included in the analysis with a median age of 60 years. 70% patients underwent radical nephrectomy. A history of hypertension and/or diabetes was present in 55.8% and 22.1%, respectively. Higher CKDPS (particularly glomerular global sclerosis and arteriosclerosis scores), radical nephrectomy, and reduced baseline estimated glomerular filtration rate (eGFR) were associated with worsening post-operative renal function outcomes. The systematic assessment of non-neoplastic kidney tissue at the time of renal surgery can help identify patients at risk of post-operative renal dysfunction. CKDPS represents a standardized and prognostically relevant histologic reporting system for non-neoplastic kidney tissue.

The Comparative Outcomes of Radical Prostatectomy versus Radiotherapy for Nonmetastatic Prostate Cancer: A Longitudinal, Population-Based Analysis.

PURPOSE: The comparative effectiveness of radical prostatectomy (RP) versus radiation therapy (RT) for prostate cancer remains a largely debated topic. Utilizing a provincial population-based linked data set from an equal-access, universal health care system, we sought to compare outcomes among patients treated with either radiation or prostatectomy for nonmetastatic prostate cancer. MATERIALS AND METHODS: We performed a retrospective cohort study by linking several administrative data sets to identify patients who were diagnosed with prostate cancer between 2004 and 2016 in Manitoba, Canada and who were subsequently treated with either RP or RT. Cox proportional hazard models with inverse probability of treatment weighting were used to compare rates of all-cause mortality, as well as prostate cancer specific mortality (PCSM) between patients who underwent RP vs RT. RESULTS: During the study period, 2,540 patients underwent RP and 1,895 underwent RT for prostate cancer. Unadjusted overall survival was higher for RP vs RT (5-year overall survival 95.52% for RP compared with 84.55% for RT, p <0.0001). In inverse probability of treatment weighting-adjusted Cox regression analysis, compared to patients in the RP groups, patients in the RT group had an increased rate of all-cause mortality (HR 1.93, 95% CI 1.65-2.26, p <0.0001), and PCSM (HR 3.98, 95% CI 2.89-5.49; p <0.0001). CONCLUSIONS: RT was associated with higher all-cause mortality and PCSM rates compared with RP. These findings highlight the importance of comparative effectiveness research to identify treatment disparities and warrant further investigation.

The Association between Income Status and Treatment Selection for Prostate Cancer in a Universal Health Care System: A Population-Based Analysis.

PURPOSE: Treatment selection for localized prostate cancer is guided by risk stratification and patient preferences. While socioeconomic status (SES) disparities exist for access to care, less is known about the effect of SES on treatment decision-making. We sought to evaluate whether income status was associated with the treatment selected (radical prostatectomy [RP] vs radiation therapy [RT]) for nonmetastatic prostate cancer in a universal health care system. MATERIALS AND METHODS: All men from Manitoba, Canada who were diagnosed with nonmetastatic prostate cancer between 2005 and 2016 and subsequently treated with RP or RT were identified using a provincial cancer database. SES was defined as neighborhood income by postal code and divided into income quintiles (Q1-Q5, with Q1 the lowest quintile and Q5 the highest). Multivariable logistic regression nested models were used to compare whether SES was associated with treatment type received. RESULTS: We identified 3,966 individuals who were diagnosed with nonmetastatic prostate cancer and were treated with RP (2,354) or RT (1,612). After adjusting for demographic and clinicopathological characteristics, as income quintile increased, men were incrementally more likely to undergo RP than RT (range Q2 vs Q1: adjusted OR 1.40, 95% CI 1.01-1.93; Q5 vs Q1: adjusted OR 2.30, 95% CI 1.70-3.12). CONCLUSIONS: As income levels increased there was a stepwise incremental increase in the odds of receiving RP over RT for localized prostate cancer. These results may inform initiatives to better understand the values, priorities and barriers that patients experience when making treatment decisions in a universal health care system.

Abdominoperineal Resection with Absorbable Mesh Repair of Perineal Defect for Fournier's Gangrene: A Case Report.

BACKGROUND: Fournier's gangrene (FG) is a rare but deadly form of necrotizing fasciitis involving the genital, perineal, and anorectal region. Risk factors include diabetes mellitus, immunosuppression, and alcohol misuse. Because multisystem organ failure can rapidly develop, early diagnosis is critical. Treatment includes fluid resuscitation, broad-spectrum antibiotics, and surgical debridement. Uncommonly, extension of perineal infection into adjacent organs can necessitate multivisceral resection, which can make reconstruction a challenge. Even with swift diagnosis and optimal treatment, morbidity and mortality are high. CASE PRESENTATION: A 66-year-old male with a history of diabetes mellitus presented to the emergency department with progressive scrotal pain, swelling, and perineal skin changes. Examination revealed necrosis of the scrotal soft tissues with involvement of the anal canal and rectum. The patient was initiated on intravenous fluids and broad-spectrum antibiotics, then brought immediately to the operating room where surgical care was provided by a urologist, colorectal surgeon, and general surgeon with expertise in complex mesh repair. Extension of necrotic changes travelling proximally through the full thickness of the rectum was noted. The patient underwent extensive scrotal and perineal debridement, laparotomy, abdominoperineal resection (APR), end colostomy, and polyglactin mesh repair of the resultant pelvic floor defect. The patient had appropriate return of bowel function and satisfactory healing of the perineum postoperatively but ultimately died after a ventricular fibrillation-related cardiac arrest precipitated by a flare of idiopathic pulmonary fibrosis. CONCLUSION: Early diagnosis and referral to the appropriate specialists are essential elements of managing FG. Here we present a case with extension of necrotizing soft tissue infection into the rectum, requiring pelvic dissection and APR as well as absorbable mesh use to aid in perineal closure. Despite expedient treatment, poor outcomes with this condition are unfortunately common.

Heterogeneity in urology teaching curricula among Canadian urology residency programs.

INTRODUCTION: Postgraduate education is transitioning to a competency-based curriculum in an effort to standardize the quality of graduating trainees. The learning experiences and opportunities in each institution are likely variable, as no standard exists regarding the teaching curriculum offered through residency. The objective of this study is to examine the various teaching curricula among different Canadian urology residency programs and to identify which teaching modalities are prioritized by program directors. METHODS: A 10-question anonymous survey was sent electronically to program directors at all 12 urology residency programs across Canada. Questions were designed to quantify the time allotted for teaching and to assess the various teaching session types prioritized by programs to ensure the successful training of their graduates. We assessed each program's perceived value of written exams, oral exams, didactic teaching session, and simulation sessions. Responses were assessed using a Likert-scale and a ranking format. Descriptive statistics were performed. RESULTS: Overall survey response rate from residency program directors was 75% (9/12). Sixty-seven percent of programs designated one day of teaching per week, whereas 33% split resident teaching over two days. Review of chapters directly from Campbell-Walsh Urology textbook were deemed the most valuable teaching session. Practice oral exams were also prioritized, whereas most programs felt that simulation labs contributed the least to residency education. All programs included review of the core urology textbook in their weekly teaching, while only 67% of programs included faculty-led didactic sessions and case presentations. Forty-four percent of programs included resident-led didactic sessions. Practice oral exams and simulation labs were the least commonly included teaching modalities. CONCLUSIONS: Although most program directors prioritize the review of chapters in the core urology textbook, we found significant heterogeneity in the teaching sessions prioritized and offered in current urology residency curricula. As we move to standardize the quality of graduating trainees, understanding the impact of variable educational opportunities on residency training may become increasingly important.

The development and comparative effectiveness of a patient-centered prostate biopsy report: a prospective, randomized study.

PURPOSE: The prostate biopsy pathology report represents a critical document used for decision-making in patients diagnosed with prostate cancer, yet the content exceeds the health literacy of most patients. We sought to create and compare the effectiveness of a patient-centered prostate biopsy report compared with standard reports. MATERIALS AND METHODS: Using a modified Delphi approach, prostate cancer experts identified critical components of a prostate biopsy report. Patient focus groups provided input for syntax and formatting of patient-centered pathology reports. Ninety-four patients with recent prostate biopsies were block randomized to the standard report with or without the patient-centered report. We evaluated patient activation, self-efficacy, provider communication skills, and prostate cancer knowledge. RESULTS: Experts selected primary and secondary Gleason score and the number of positive scores as the most important elements of the report. Patients prioritized a narrative design, non-threatening language and information on risk classification. Initial assessments were completed by 87% (40/46) in the standard report group and 81% (39/48) in the patient-centered report group. There were no differences in patient activation, self-efficacy, or provider communication skills between groups. Patients who received the patient-centered report had significantly improved ability to recall their Gleason score (100% vs. 85%, p = 0.026) and number of positive cores (90% vs. 65%, p = 0.014). In total, 86% of patients who received the patient-centered report felt that it helped them better understand their results and should always be provided. CONCLUSIONS: Patient-centered pathology reports are associated with significantly higher knowledge about a prostate cancer diagnosis. These important health information documents may improve patient-provider communication and help facilitate shared decision-making among patients diagnosed with prostate cancer.

Disseminated Mycobacterium bovis infection post-kidney transplant following remote intravesical BCG therapy for bladder cancer.

Intravesical Bacillus Camlette-Guérin (BCG) is the treatment of choice for non-muscle invasive bladder cancer, and has been used successfully for over 40 years. A rare and potentially fatal complication of intravesical BCG therapy is BCG-induced sepsis. We report a rare case in which a patient with end-stage renal disease secondary to chronic granulomatous interstitial nephritis underwent remote, pre-transplant intravesical BCG treatment for high-grade non-invasive papillary bladder carcinoma. The patient subsequently received a deceased donor kidney transplant 5 years after BCG therapy, with thymoglobulin induction therapy and standard triple maintenance immunosuppression. Two years post-transplant, he developed BCG-induced sepsis confirmed by cultures from urine, blood, and left native kidney biopsy. He died from disseminated BCG-induced sepsis and failure of his renal allograft. This case highlights the potential adverse reactions associated with intravesical BCG therapy that may occur years after bladder cancer therapy is completed, and should heighten physician awareness for BCG-related infections during pre-transplant assessment and post-transplant care of solid organ transplants recipients.