Income Disparities in Survival and Receipt of Neoadjuvant Chemotherapy and Pelvic Lymph Node Dissection for Muscle-Invasive Bladder Cancer.

Background: Muscle-invasive bladder cancer (MIBC) is a potentially fatal disease, especially in the setting of locally advanced or node-positive disease. Adverse outcomes have also primarily been associated with low-income status, as has been reported in other cancers. While the adoption of neoadjuvant cisplatin-based chemotherapy (NAC) followed by radical cystectomy (RC) and pelvic lymph node dissection (PLND) has improved outcomes, these standard-of-care treatments may be underutilized in lower-income patients. We sought to investigate the economic disparities in NAC and PLND receipt and survival outcomes in MIBC. Methods: Utilizing the National Cancer Database, a retrospective cohort analysis of cT2-4N0-3M0 BCa patients with urothelial histology who underwent RC was conducted. The impact of income level on overall survival (OS) and the likelihood of receiving NAC and PLND was evaluated. Results: A total of 25,823 patients were included. This study found that lower-income patients were less likely to receive NAC and adequate PLND (≥15 LNs). Moreover, lower-income patients exhibited worse OS (Median OS 55.9 months vs. 68.2 months, p < 0.001). Our findings also demonstrated that higher income, treatment at academic facilities, and recent years of diagnosis were associated with an increased likelihood of receiving standard-of-care modalities and improved survival. Conclusions: Even after controlling for clinicodemographic variables, income independently influenced the receipt of standard MIBC treatments and survival. Our findings identify an opportunity to improve the quality of care for lower-income MIBC patients through concerted efforts to regionalize multi-modal urologic oncology care.

Hand, foot, and mouth disease presenting with a testicular mass in an adult.

The majority of solid testicular tumors are treated with orchiectomy given the high risk of malignancy. We present a case of a testicular mass in an adult patient in the setting of recent hand, foot, and mouth disease that was managed conservatively with serial ultrasounds. Even though cases of viral-associated testicular masses are rare, this differential diagnosis should be considered in patients with a new testicular mass in the setting of recent viral infection and negative tumor markers. For these patients, observation may be an option instead of immediate orchiectomy.

Efficacy of cytoreductive radical cystectomy in metastatic urothelial bladder cancer based on site and number of metastases.

BACKGROUND: Recent studies have highlighted the overall survival (OS) benefit of cytoreductive radical cystectomy (CRC) in metastatic bladder cancer (mBCa). Cytoreductive surgery has been established in other urologic cancers. However, the efficacy of CRC and optimal criteria for patient selection in mBCa is unclear. This study investigated the oncologic efficacy of CRC, particularly emphasizing the location and number of metastasis sites as a predictor of survival and treatment response. METHODS: A retrospective analysis of cT2-4N0-3M1 mBCa patients treated with multiagent chemotherapy between 2004 and 2019 was conducted using the National Cancer Database. Patients were classified by additional treatment with CRC or conservative local treatment (CLT), consisting of transurethral resection of bladder tumor, radiation, or no local treatment and propensity score (PS) matched. Kaplan-Meier analysis and multivariate Cox Proportional Hazards model assessed the effect of CRC or CLT on OS within the matched cohort and in four subgroups (1) patients with only distant lymph node (LN) metastasis vs. any organ metastasis, (2) patients with single metastasis vs. multiple metastases. Sensitivity analysis estimated the influence of unmeasured confounders on CRC OS benefit. RESULTS: Propensity matching yielded 247 and 251 patients treated with CRC and CLT, respectively. Median OS in patients who received CRC was greater than that of patients treated with CLT (20.4 months vs. 12.0 months, P < 0.001). CRC was associated with reduced mortality risk in patients with only distant LN metastases (HR = 0.545, P = 0.039), any organ metastasis (HR = 0.421, P < 0.001), and single visceral metastasis (HR = 0.483, P = 0.002). However, CRC did not significantly improve OS in patients with multiple metastases (HR = 0.501, P = 0.064). CONCLUSION: These findings demonstrate an OS benefit of CRC with multiagent chemotherapy and pinpoint multiple visceral metastases as a potential contraindication for CRC. Although limited by the influence of unmeasured confounders, these findings may inform future prospective investigations into CRC.

Traumatic injury of an ectopic kidney with iatrogenic ureteral injury and endovascular control of aberrant renal vessel.

The management of traumatic injuries in patients with ectopic kidneys presents special challenges. There is a paucity of literature regarding optimal strategies for renal salvage. We describe a case of a patient who presented in hemorrhagic shock after a motor vehicle collision. On initial operative exploration, he was found to have a large retroperitoneal mass. Subsequent imaging demonstrated a large retroperitoneal hematoma and an ectopic kidney. The patient was successfully treated with a combination of open renorrhaphy and endovascular angioembolization. This case demonstrates the importance of a multidisciplinary approach to treating these complex injuries.

Immediate and delayed migration of Onyx embolisation into the renal collecting system.

We present a case of Onyx embolisation of a renal pseudoaneurysm following partial nephrectomy with collecting system involvement with subsequent migration of Onyx into the renal collecting system resulting in renal obstruction. This occurred both immediately after embolisation and again 8 years after embolisation. Both cases required ureteroscopic surgical intervention. In the first instance, the pieces were removed using basket extraction. In the second, laser lithotripsy was used in addition to basket extraction. While there are a few cases of embolisation coils eroding into the renal collecting system, this is the second reported case of Onyx migration and the first where ureteroscopy with laser lithotripsy was used. The patient is doing well and undergoing surveillance ultrasounds to ensure there is no further Onyx migration. This may be a consideration for patients with pseudoaneurysm embolisation especially in the setting of prior collecting system damage.

How well do urology residency program webpages recruit underrepresented minorities?

INTRODUCTION: Historically, the field of medicine has suffered from a lack of diversity. This project examines if urology residency program websites were actively attempting to recruit underrepresented minority applicants with the hypothesis that while some programs would attempt to attract such applicants on their website, the majority would not. MATERIALS AND METHODS: A cross-sectional analysis of program webpages for information regarding underrepresented minorities was performed. Electronic Residency Application Service residency database was used to identify 130 urology residency programs. Three were no longer accepting residents and were not included. The publicly available webpages of 137 urology residency training programs identified were reviewed. RESULTS: Only 26.3% (36) of programs included any information regarding diversity or inclusion on their webpage. The most common references to diversity were a link to a Department of Diversity and Inclusion (28, 20.4%) and information regarding a "commitment to diversity" (28, 20.4%). Only two programs included all seven categories searched for. CONCLUSIONS: Residency program websites may be an important tool to recruit underrepresented minorities and currently there is significant room for improvement. Given that urology is already behind other fields in terms of representation, it is especially important to make an active, visible attempt to recruit underrepresented minorities.

A Cross-Sectional Evaluation of Outcomes of Pediatric Thyroglossal Duct Cyst Excision.

INTRODUCTION: Thyroglossal duct cysts (TGDCs) are the most common form of congenital neck cysts. They may become infected causing dysphagia or respiratory distress. Accordingly, the treatment is always surgical removal. OBJECTIVES: The objectives of this article were to examine complications following TGDC excision by surgical specialty, demographics, and comorbid conditions. METHODS: A retrospective review of the National Surgical Quality Improvement Program database was performed. Pediatric cases from January 1, 2014 to November 1, 2015 with a current procedure terminology code of 60,280 (excision of TGDC or sinus) were included. Statistical analysis was performed to assess associations between complications and surgical specialty, demographics, and comorbidities. RESULTS: Of the 867 cases that met inclusion criteria, the median age was 4 years. There were 448 males (52.3%) and 408 females (47.7%). Thirty-six patients (4.2%) experienced at least one 30-day complication. The most predominant complications were reoperation (19 patients, 2.2%), readmission (18 patients, 2.1%), and surgical site infection (16 patients, 1.9%). There was no statistically significant difference between complications and surgical specialty. In those experiencing a complication, there was a statistically significant difference between males (86.1%) and females (13.9%). Of patients with at least one comorbidity, 36.67% had a complication, while 17.22% did not have a complication. There was also a statistically significant difference in the percentage of patients with a past medical history of asthma between those with at least one complication (16.67%) compared to those without any complications (4.76%). CONCLUSIONS: excision is a generally safe procedure across surgical specialties. There is a higher complication rate in males compared to females as well as those with a history of at least one medical comorbidity and those with asthma. The most common 30-day complications are reoperation, readmission, and surgical site infection.

Review, monitor, educate: A quality improvement initiative for sustained chest radiation reduction in pediatric trauma patients.

BACKGROUND: We hypothesize that in pediatric trauma patients, CT scans after normal chest x-rays do not add information that alters clinical decision making. METHODS: A retrospective review of trauma patients < 15 years with chest imaging evaluated at a pediatric trauma center between 1/2013 and 6/2019 was performed. Imaging was reviewed for significant findings that could affect care. A guideline was established in January 2017 which emphasized x-rays prior to CTs and no CTs after normal x-rays. A prospective review was performed from 1/2017-6/2019. Pre and post guideline groups were compared. RESULTS: From 2013 to 2016, 246 patients met inclusion. 29.5% had a chest CT after a normal x-ray, only 1.8% (1/57) had a significant result. From 2017 to 2019, 188 patients were reviewed post guideline; only 9.4% received a CT after normal x-ray, of which 6.3% (1/16) were significant. Neither changed clinical management. CONCLUSIONS: Chest CT following normal chest x-ray does not change clinical management in pediatric trauma patients. Monitoring and education following guideline implementation improves long term outcomes.

Development and Implementation of a Pilot Radiation Reduction Protocol for Pediatric Head Injury.

BACKGROUND: Traumatic brain injury is the leading cause of morbidity and mortality for children in the United States. The aim of this study was to develop and implement a guideline to reduce radiation exposure in the pediatric head injury patient by identifying the patient population where repeat imaging is necessary and to establish rapid brain protocol magnetic resonance imaging as the first-line modality. METHODS: A retrospective chart review of trauma patients between 0 and 14 y of age admitted at a pediatric level 2 trauma center was performed between January 2013 and June 2019. The guideline established the appropriateness of repeat scans for patients with Glasgow Coma Scale >13 with clinical neurological deterioration or patients with Glasgow Coma Scale ≤13 and intracranial hemorrhagic lesion on initial head computed tomography (CT). RESULTS: Our trauma registry included 592 patients during the study period, 415 before implementation and 161 after implementation. A total of 132 patients met inclusion criteria, 116 pre-guideline and 16 post-guideline. The number of patients receiving repeat head CTs significantly decreased from 34.5% to 6.3% (P < 0.02). There was also a significant decrease in the mean number of head CT/patient pre-guideline 1.63 (range 1-7) compared with post-guideline 1.06 (range 1-2) (P < 0.02). CONCLUSIONS: CT head imaging is invaluable in the initial trauma evaluation of pediatric patients. However, it can be overused, and the radiation may lead to long-term deleterious effects. Establishing a head imaging guideline which limits use with clinical criteria can be effective in reducing radiation exposure without missing injuries.

Outcomes of pediatric thyroidectomy: a cross-sectional evaluation.

Introduction: Pediatric thyroidectomy is performed by a variety of surgical specialties. Thyroidectomy can result in a number of complications. Previous studies cite that the most common complications in children are pain and transient hypocalcemia. The purposes of this report are to assess the adverse events of thyroidectomies performed in the pediatric population and to assess the relationship between surgical specialties and postoperative thyroidectomy complications. Methods: We conducted a cross-sectional analysis of cases from January 1, 2014 through November 1, 2015 using the National Surgical Quality Improvement Program database for patients undergoing excision of cyst or adenoma of the thyroid, unilateral thyroid lobectomy, or total thyroidectomy. Results: Of the 344 patients who underwent thyroidectomy, 10 (2.9%) experienced at least one complication. The most common complications were readmission, surgical site infections, and wound disruption. There was a statistically significant association between complication incidence and surgical specialty (p=0.006). Pediatric otolaryngology had a statistically significantly higher number of complications than pediatric surgery (p<0.008). Conclusion: Overall, the incidence of adverse events following pediatric thyroidectomy was low.

A cross-sectional evaluation of outcomes of pediatric branchial cleft cyst excision.

OBJECTIVE: To examine complications following pediatric branchial cleft cyst excision by surgical specialty, demographics, and comorbid conditions. METHODS: A retrospective review of the National Surgical Quality Improvement Program database was performed. Pediatric cases from January 1, 2015 through May 1, 2017 with a current procedural terminology code of 42810 (excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues) or 42815 (excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into the pharynx) were included. Statistical analysis was performed to assess associations between complications and surgical specialty, demographics, and comorbidities. RESULTS: Of the 895 cases that met inclusion criteria, the median age was two years and there was an approximately equal number of males (46.8%) and females (53.2%). Forty-five patients (5.0%) experienced at least one 30-day complication, the most predominant of which was superficial surgical site infection. There was no statistically significant difference between complications and surgical specialty, complications and patient demographics, or complications and depth of excision. There was a statistically significant difference (p = 0.05) in the percentage of patients with a past medical history of developmental delay between those with at least one complication (11.1%) compared to those without any complications (4.2%). CONCLUSION AND RELEVANCE: Branchial cleft excision is a generally safe procedure across surgical specialties and patient demographics. There is an association between a history of developmental delay and 30-day postoperative complications.