Patient Perpetrated Sexual Harassment of Urologists: A Survey Based Study.

INTRODUCTION: Patient perpetrated sexual harassment has been studied with family physicians, surgical residents and dermatologists with the prevalence ranging from 27% to 77%. To our knowledge this phenomenon has not yet been studied in urology. METHODS: We surveyed urologists in the United States about their age, employment/training status and their experiences of patient perpetrated sexual harassment. Surveys were anonymous and hosted on a web based platform. Pearson chi-square analysis was used to assess risk factors and descriptive statistics were used to describe prevalence. RESULTS: A total of 190 urologists completed the survey. Patient perpetrated sexual harassment was reported by 49.5% of respondents. Women were more likely to report patient perpetrated sexual harassment when compared with men, at 69% and 23%, respectively (p <0.0001). Being a resident/fellow portended higher rates of patient perpetrated sexual harassment compared to staff/attendings, at 69% and 44%, respectively (p=0.004). Respondents 40 years or younger were more likely to have reported patient perpetrated sexual harassment when compared to those 41 years old or older, at 65% and 39%, respectively (p=0.001). CONCLUSIONS: The results of this survey study suggest that the prevalence of patient perpetrated sexual harassment in the field of urology may be high. Professional societies should perform further investigation into this matter. We suggest proactive development of guidelines and protocols to address patient perpetrated sexual harassment in urology.

Cystoscopically Guided Repair of a Posterior Perforation of Augmented Bladder.

Background: Augmentation cystoplasty for the management of neurogenic bladder is one of the mainstays of pediatric urology. This procedure has multiple well-known complications. The most dangerous of these complications is bladder perforation, which has a mortality rate of 23% to 25% in large part caused by delayed presentation and sepsis. This case report discusses a novel method for identifying the perforation using endourologic techniques to allow for easier repair. Case Presentation: A 24-year-old woman with a history of spina bifida s/p augmentation cystoplasty with appendicovesicostomy and rectus fascia bladder neck sling 5 years ago presented to the emergency department with a 2-day history of decreased oral intake, nausea, vomiting, fevers, diffuse abdominal pain, and distention. She was found on CT cystogram to have a contrast extravasation from the posterior-dependent portion of the bladder and a large retrovesical fluid collection. On exploratory laparotomy, a leak from the posterior portion of the bladder was confirmed. Owing to the conditions in the abdomen and the patient's obese body habitus, the perforation was very difficult to view. A 17F rigid cystoscope was utilized and the perforation was identified on the posterior inferior portion of the bladder at the anastomotic line. A wire was passed through the perforation into the abdomen where it was seen and an 18F council catheter was then placed in an antegrade manner from the abdomen. Placement of the catheter and inflation of the balloon did not cause any additional apparent damage to the bladder mucosa. With the catheter on traction, the dependent bladder could be pulled back into the operative field, allowing complete observation of the defect for water-tight two-layer closure. Conclusion: Bladder perforation after augmentation cystoplasty is a potentially life-threatening complication that can be difficult to repair. This article serves to present a novel way to identify and facilitate repair of the defect intraoperatively using endourologic principles for a posterior defect.

TeamSTEPPS Improves Operating Room Efficiency and Patient Safety.

The objective was to evaluate the effect of TeamSTEPPS on operating room efficiency and patient safety. TeamSTEPPS consisted of briefings attended by all health care personnel assigned to the specific operating room to discuss issues unique to each case scheduled for that day. The operative times, on-time start rates, and turnover times of all cases performed by the urology service during the initial year with TeamSTEPPS were compared to the prior year. Patient safety issues identified during postoperative briefings were analyzed. The mean case time was 12.7 minutes less with TeamSTEPPS (P < .001). The on-time first-start rate improved by 21% with TeamSTEPPS (P < .001). The mean room turnover time did not change. Patient safety issues declined from an initial rate of 16% to 6% at midyear and remained stable (P < 0.001). TeamSTEPPS was associated with improved operating room efficiency and diminished patient safety issues in the operating room.

Urological outcomes in the omphalocele exstrophy imperforate anus spinal defects (OEIS) complex: experience with 80 patients.

OBJECTIVE: To review the urological management and outcomes of patients with the OEIS (omphalocele, exstrophy of the bladder, imperforate anus, spinal abnormalities) complex. PATIENTS AND METHODS: 80 patients with the OEIS complex managed at a single institution between 1974 and 2009 were reviewed. RESULTS: 37 had initial closure at our institution (2 failed - 5%); 22 with successful closure were referred for incontinence; 15 failed closure at an outside institution (2 of whom are awaiting closure); 6 are skin-covered variants. Osteotomy was performed in 39/43 (91%) with successful closure versus 8/17 (47%) who failed initial bladder closure. 40 were dry (56%), but most needed additional urinary reconstruction: 2 had small bowel neobladders; 32 (84%) had augmentation cystoplasty; 30 (79%) had a continent catheterizable channel; only 9 (24%) were continent with an intact urethra. Bladder neck reconstruction allowed dryness in 7 (18%). 45 patients had XY genotype--19 had female gender assignment at birth. All patients with XX genotype had female gender assignment. CONCLUSIONS: Osteotomy improves success of initial bladder closure. A bladder neck procedure, catheterizable channel, and augmentation cystoplasty will be required in the majority of patients to attain urinary dryness.

Failed exstrophy closure.

Children with bladder exstrophy present a formidable surgical challenge. Like all major reconstructive surgeries, the best hope for a favorable outcome lies in achieving success in the first operative attempt. Regardless of the surgical approach, however, complications do occur. A failed exstrophy closure is a major complication with significant implications on the long-term surgical outcome and ultimate fate of the urinary tract. Successful repeat exstrophy closure can be accomplished in most cases when performed in conjunction with pelvic osteotomy and proper postoperative immobilization. Modern staged repair of exstrophy, complete primary repair of exstrophy, and immediate continent urinary diversion have been advocated by different groups in the management of a failed exstrophy closure. It is apparent that compared with children who undergo successful primary closure, a failed closure with subsequent successful repeat closure makes the child much less likely to achieve sufficient bladder growth to be considered for bladder neck reconstruction, and furthermore, makes them less likely to have a successful bladder neck reconstruction even when they are an acceptable candidate. Although acceptable dryness rates after repeat closure can ultimately be obtained, they are typically at the expense of a commitment to intermittent catheterization and continent diversion.

Epidemiologic insights into pediatric kidney stone disease.

The epidemiology of pediatric kidney stone has not yet been as rigorously defined as that of adult kidney stone disease. Herein, we review our recent epidemiologic works characterizing pediatric stone disease using the Kids' Inpatient Database (KID). Specifically we investigated the age and gender distribution of pediatric kidney stone disease, changes in disease prevalence over time, and medical comorbidities associated with this disorder. We identified patients by International Classification of Disease 9th Edition (ICD-9) codes for renal and ureteral calculi as the primary diagnosis. Medical comorbidities were identified using specific comorbidity software. Statistical comparisons between children with and without stone disease were performed. In the first decade of life, stone disease was more prevalent among males than females; however, in the second decade of life females were more commonly affected. Of note, there was a significant increase in treated stone disease across both genders between 1997 and 2003. We also found that the risk of kidney stone diagnosis in children younger than 6 years of age was significantly associated with hypertension and diabetes mellitus. The gender distribution among pediatric stone formers varies significantly by age, although overall females have a greater prevalence than males. There is also a strong association of stone disease and both diabetes and hypertension, although this was only observed in children less than 6 years of age. Taken all together, these findings suggest that urolithiasis in the young child is a complex systemic disease process.

Neuro-orthopedic manifestations of the omphalocele exstrophy imperforate anus spinal defects complex.

PURPOSE: The omphalocele-exstrophy-imperforate anus-spinal defects complex is a severe multisystem congenital defect. To comprehensively care for these patients one must appreciate the neurological and orthopedic impact on the overall health of the child. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 73 children with omphalocele-exstrophy-imperforate anus-spinal defects who were treated at our institution, identifying neurological and orthopedic anomalies, ambulatory ability and voiding status. RESULTS: No neurological data were available on 5 patients. Of the remaining 68 patients 9 had no spinal anomaly, 57 had spina bifida, 1 had hemivertebrae and 1 had coccygeal hypoplasia. We further classified the 47 spina bifida cases as spina bifida occulta in 6, meningocele/lipomeningocele in 12, myelomeningocele/lipomyelomeningocele in 24 and sacral agenesis in 6. Of the patients with spina bifida 35 had cord tethering. Commonly identified orthopedic anomalies were vertebral malformation in 59 patients, scoliosis in 25, clubfoot in 14 and limb length discrepancy in 8. Ambulatory status in 62 patients of walking age revealed that 37 ambulated fully, 15 ambulated with devices, 2 ambulated minimally with devices and 8 were wheelchair bound. Continence data were available on 61 closed cases. Of these patients 26 were incontinent, including 3 with conduit diversion, 1 with ureterostomy and 1 with vesicostomy. A total of 35 patients were socially continent, of whom 30 catheterized via a continent abdominal stoma and 5 voided/catheterized via the urethra. CONCLUSIONS: Early evaluation for neurosurgical and orthopedic anomalies is vital in these children. Despite the high incidence of spinal pathology most patients ambulate without assistance. Few children with omphalocele-exstrophy-imperforate anus-spinal defects achieve continence via the urethra. Vigilant followup is necessary to identify potentially correctable conditions.

Failed exstrophy closure: management and outcome.

OBJECTIVE: In a series of failed exstrophy closures, to identify determinants of successful repeat closure and the impact of failed closure on the fate of the lower urinary tract and continence status. PATIENTS AND METHODS: We performed a retrospective review of operative notes and medical records of patients with a history of one or more failed exstrophy closures in 1978-2007. The primary surgical endpoints were failure rate of repeat closure attempts, mode of continence surgery and continence outcome. Continence was defined as achieving a dry interval of >3h and voiding through the urethra. RESULTS: We identified 122 patients (85 male/37 female) who had undergone repeat closure following failure. The success rate of repeat closure attempts at our institution was 98%. Of the 94 patients who had undergone successful repeat closure, definitive continence management and had their dryness evaluated, 38 were candidates for bladder neck reconstruction and 17(18%) were continent. Of the remaining patients, 90% were able to attain dryness, but at the expense of clean intermittent catheterization and continent urinary diversion. CONCLUSION: A failed exstrophy closure has significant implications for long-term surgical outcome. Reclosure can be accomplished in the majority of cases. In comparison to patients with successful primary closure, the rates of urethral continence following successful repeat closure were lower.

Progression of chronic kidney disease in children with vesicoureteral reflux: the North American Pediatric Renal Trials Collaborative Studies Database.

PURPOSE: We describe a cohort of children with chronic kidney disease due to vesicoureteral reflux. We compared the rate of progression to end stage renal disease in those patients to the rate in children with another cause of chronic kidney disease and identified potential risk factors for progression. MATERIALS AND METHODS: We performed a retrospective cohort study using data from the North American Pediatric Renal Trials and Collaborative Studies Registry. Patients with vesicoureteral reflux as a cause of chronic kidney disease were compared to 2 other diagnostic cohorts. The 3 groups were compared with respect to baseline characteristics and progression to end stage renal disease based on diagnostic category. Multivariate analysis was performed to identify risk factors for progression to end stage renal disease using Cox proportional hazards regression model. RESULTS: Data on 6,981 patients were available for analysis. Patients with vesicoureteral reflux as a cause of chronic kidney disease had a significantly slower rate of progression to end stage renal disease than patients with renal aplasia, hypoplasia or dysplasia and all other causes (log rank p <0.0001). On multivariate analysis of risk factors for progression to end stage renal disease in patients with vesicoureteral reflux as the cause of chronic kidney disease we found that, in addition to older age and more advanced chronic kidney disease stage, a history of urinary tract infection at registration was significantly associated with an increased risk of progression. CONCLUSIONS: Children with vesicoureteral reflux had a slower rate of progression to end stage renal disease than children with another cause of chronic kidney disease even after controlling for multiple possible confounders. In children with vesicoureteral reflux as the cause of chronic kidney disease older age, higher chronic kidney disease stage and history of urinary tract infection are significantly associated with the risk of progression to end stage renal disease.

Sex prevalence of pediatric kidney stone disease in the United States: an epidemiologic investigation.

OBJECTIVES: To define the sex prevalence of inpatient hospital discharges for pediatric patients diagnosed with upper urinary tract stone disease. METHODS: The study examined inpatient admissions for pediatric urolithiasis in 2003, using the Healthcare Cost and Utilization Project Kids' Inpatient Database. We used the International Classification of Disease, 9th edition, Clinical Modification codes, to identify patients with a principal diagnosis of renal (592.0) or ureteral (592.1) calculi. Sex prevalence was assessed, and the results were stratified by age group. RESULTS: In the 2003 Kids' Inpatient Database, the sex distribution among pediatric patients with stone formation varied significantly by age. In the first decade of age, a male predominance was found that had shifted to a female predominance in the second decade. Overall, however, girls in the pediatric population were more commonly affected by stones than were boys. CONCLUSIONS: In this nationally representative sample, the sex distribution of pediatric urolithiasis varied with age, with boys more commonly affected in the first decade of age and girls in the second decade. Although the reason for this unique epidemiologic finding is not readily apparent, additional studies can build on this hypothesis-generating work.

Bladder neck transection for intractable pediatric urinary incontinence.

PURPOSE: We report the indications, technique and outcome of a large series of children who underwent bladder neck transection for intractable urinary incontinence. MATERIALS AND METHODS: We retrospectively reviewed demographics, operative details, complications and outcomes of 76 patients (47 males, 29 females) who underwent bladder neck closure at our institution between 1996 and 2006. Mean patient age at the time of the procedure was 12 years, 10 months. The most common diagnosis was bladder exstrophy. Of the patients 31 had undergone prior bladder neck reconstruction (30) or sling repair (1). All patients underwent concomitant augmentation and creation of a catheterizable stoma. RESULTS: A total of 50 patients had more than 12 months of followup (mean 44, range 12 to 128). Continence was achieved initially in 86% of the patients (43 of 50). Of the 7 primary failures 2 leaked via the urethra and 5 via the stoma. Six of these patients achieved dryness with revision, for a final continence rate of 98%. A single renal unit suffered significant loss of function during this period. New, nonobstructive hydronephrosis developed in 8 additional renal units. Stones developed in 30% of the patients. There were no spontaneous bladder ruptures. CONCLUSIONS: Bladder neck transection in combination with enterocystoplasty and creation of a continent catheterizable stoma is an effective approach to incontinent cases with severely damaged bladder outlets and poor quality bladders in which other reconstructive approaches either have failed or are deemed likely to fail. Specific concerns regarding the risk of poor renal outcomes and perforation seem unwarranted at present.

Complications of complex lower urinary tract reconstruction in patients with neurogenic versus nonneurogenic bladder--is there a difference?

PURPOSE: The complications of lower urinary tract reconstruction have been well documented in children with neurogenic bladders. While most series include small numbers of nonneurogenic diagnoses, this group is typically underrepresented. Despite a number of fundamental anatomical and functional differences, a direct comparison of surgical complications of lower urinary tract reconstruction in patients with neurogenic vs nonneurogenic bladders has not been performed. MATERIALS AND METHODS: We identified patients undergoing lower urinary tract reconstruction incorporating enterocystoplasty from 1996 to 2006. We performed a retrospective review of operative notes and medical records of patients who met inclusion criteria. Patients were divided into a neurogenic group and a nonneurogenic group based on the underlying diagnosis. The 2 groups were compared with respect to demographics, historical data, operative techniques, perioperative morbidity, long-term complications and need for surgical revision. RESULTS: Of the 127 patients who met inclusion criteria 72 were assigned to the nonneurogenic group and 55 to the neurogenic group. Overall the rates of significant perioperative morbidity (39%), long-term complications (54%) and need for surgical revision (39%) were substantial. The rates of catheter related complications, rehospitalization for dehydration and spontaneous bladder rupture were higher in the neurogenic group (p <0.05). CONCLUSIONS: Reconstruction of the lower urinary tract in children is associated with a considerable rate of complications and need for surgical revision regardless of whether the bladder is neurogenic or nonneurogenic. Children with neurogenic bladders are more prone to spontaneous rupture, catheter mishaps and early rehospitalization for dehydration.

Phase I clinical trial of a HER-2/neu peptide (E75) vaccine for the prevention of prostate-specific antigen recurrence in high-risk prostate cancer patients.

PURPOSE: The E75 peptide is an immunogenic peptide from the HER-2/neu protein that is substantially expressed in prostate cancer. We are conducting a clinical trial of an E75/granulocyte macrophage colony-stimulating factor vaccine to prevent post-prostatectomy prostate-specific antigen (PSA) recurrences in high-risk prostate cancer (HRPC) patients. EXPERIMENTAL DESIGN: Prostate cancer patients at high risk for recurrence were prospectively evaluated and identified by the validated Center for Prostate Disease Research (CPDR)/CaPSURE high-risk equation. From these high-risk equation patients, 27 HER-2/neu-expressing prostate cancer patients were enrolled. HLA-A2+ patients (n = 17) were vaccinated, whereas HLA-A2- patients (n = 10) were followed as clinical controls. Local/systemic toxicities, immunologic responses, and time to recurrence were measured. RESULTS: This vaccine is safe with only minor toxicities observed. Additionally, the vaccine is immunogenic with all patients showing both in vivo and in vitro phenotypic and functional immune responses, although variable. HLA-A2+ patients were found to have larger tumors, higher postoperative Gleason scores, and more high-risk CPDR scores than HLA-A2- patients. Despite these differences, disease-free survival was not different between the vaccinated HLA-A2+ patients and the HLA-A2- controls at a median follow up of 23 months. Three of the four vaccinated patients that recurred had rising PSAs at the initiation of the trial. Ex vivo phenotypic assays were predictive of recurrences and correlated in general with functional assays. CONCLUSIONS: The E75 vaccine strategy is safe and effective in eliciting an immune response against the HER-2/neu protein in HRPC patients and may be useful as a preventive strategy against disease recurrence. Vaccination in response to a rising PSA may be too late.