LOW-GRADE UROTHELIAL CARCINOMA RECURS AT A TEMPO THAT NATURALLY ACCELERATES OVER TIME.

OBJECTIVES: To investigate the cadence of recurrence in patients with low grade intermediate-risk non-muscle invasive bladder cancer (LG IR-NMIBC) based on clinical determinants. We aim to describe patterns in rates of recurrence to better inform surveillance regimens for this chronic, burdensome, and costly disease. METHODS: Using baseline and follow-up data from participants in the West Midlands' (United Kingdom, UK) Bladder Cancer Prognosis Programme (BCPP), we assessed overall recurrence rate and recurrence-free intervals throughout the follow-up period for IR-NMIBC participants. Recurrence-free intervals were calculated using the Kaplan-Meier method. RESULTS: We identified 379 patients with G1/G2 pTa tumors classified as intermediate risk. Median age was 70 and 284/379 (75%) were male. The median follow-up time was 4.2 years (95% CI: 3.9-4.8). After 5 years of follow-up, 53% of patients had at least one recurrence. One-year recurrence-free survival (RFS) was 75% and 4-year RFS was 50%. The median time to or between 1st, 2nd, 3rd, 4th, and 5th sequential recurrences was 49, 19, 12, 14, and 10 months, respectively. CONCLUSIONS: Over half of patients with IR-NMIBC are destined to recur. Our data suggest that a subset of patients experience acceleration of recurrence over time and that this acceleration may serve as a potential kinetic biomarker for these individuals that could inform surveillance intervals and future treatment strategies.

Benign splenic lesions in BAP1-tumor predisposition syndrome: a case series.

BAP1-Tumor Predisposition Syndrome (TPDS) is caused by germline variants in BAP1 and predisposes to solid tumors. After observation of a radiologically malignant-appearing splenic mass with benign pathology in a patient with BAP1-TPDS, we sought to retrospectively characterize splenic lesions in individuals with BAP1-TPDS seen at a comprehensive cancer center. A dedicated radiology review for splenic abnormalities was performed. We identified 37 individuals with BAP1-TPDS, 81% with a history of cancer. Of 33 individuals with abdominal imaging, 10 (30%) had splenic lesions, and none were shown to be malignant on follow-up. Splenectomy in an individual with suspected splenic angiosarcoma showed a benign vascular neoplasm with loss of nuclear staining for BAP1 in a subset of cells. Benign splenic lesions appear to be common and potentially BAP1-driven in individuals with BAP1-TPDS; confirmation of these findings could lead to more conservative management and avoidance of splenectomy.

Randomized trials of PSA screening.

BACKGROUND: The role of prostate-specific antigen (PSA) testing in prostate cancer (PCa) screening has evolved over recent decades with multiple randomized controlled trials (RCTs) spurring guideline changes. At present, controversy exists due to the indolent nature of many prostate cancers and associated risks of overdiagnosis and overtreatment. This review examines major RCTs evaluating PSA screening to inform clinical practices. METHODS AND MATERIALS: We summarize findings from primary RCTs investigating PSA screening's impact on PCa mortality and incidence: the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, the European Randomized Study of Screening for Prostate Cancer (ERSPC), and the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP). RESULTS: The PLCO Trial randomized men to annual PSA and DRE screening or usual care, reporting no significant difference in PCa mortality between groups at 17 years (RR 0.93, [95% CI: 0.81-1.08]), yet significantly increased detection and concomitant decreased detection in Gleason 6 (RR 1.17, [95% CI: 1.11-1.23]) and 8-10 disease (RR 0.89, [95% CI: 0.80-0.99]) in the screening group, respectively. The ESPRC Trial randomized men across seven European countries to PSA screening every 2-4 years or usual care, noting a 20% reduction in PCa mortality at 9 years (RR 0.81, [95% CI: 0.65-0.98]) and significant decrease in metastatic disease at 12 years (RR 0.70, [95% CI: 0.60-0.82]). The CAP Trial assessed a single PSA screening test's impact on PCa mortality yielding no significant difference in PCa mortality at 10 years (RR 0.96, [95% CI: 0.85-1.08]). Limitations amongst studies included high contamination between study arms and low compliance with study protocols. CONCLUSIONS: While the CAP and initial PLCO trials showed no significant reduction in PCa mortality, the ERSPC demonstrated a 21% reduction at 13 years, with further benefits at extended follow-up. Differences in outcomes are attributed to variations in trial design, contamination, adherence rates, and PSA thresholds. Future studies are needed focus on optimizing screening intervals, targeting high-risk populations, and incorporating non-invasive diagnostic tools to improve screening efficacy and reduce associated harms.

Predictors of Timely and Delayed Urological Evaluation Following Referral for Elevated Prostate-specific Antigen in a Diverse, Urban, High-risk Population.

INTRODUCTION: This study aimed to evaluate predictors of timely urological evaluation among men referred for initial elevated PSA in a diverse, high-risk, urban community. METHODS: We conducted a retrospective cohort study of all men aged 50+ referred to urology within our healthcare network between January 2018 and December 2021 for initial elevated PSA. Time to initial urological evaluation was categorized as timely (within 4 months of referral), late (after 4 months), or absent (no urology evaluation). Demographic and clinical variables were abstracted. A multivariable multinomial logistic regression model was conducted to identify predictors of timely vs late vs absent urological evaluation controlling for age, referral year, household income, distance to care, and PSA at referral. RESULTS: A total of 1,335 men met inclusion criteria; 589 (44.1%), 210 (15.7%), and 536 (40.1%) had timely, late, and absent urological evaluation, respectively. The majority were non-Hispanic Black (46.7%), English-speaking (84.0%), and married (54.6%). Median time to initial urological evaluation differed significantly between timely and late groups (16 vs 210 days, P < .001). Multivariable logistic regression revealed the following to be significant predictors of timely urological evaluation: non-Hispanic Black (OR=1.59, P = .03), Hispanic (OR=2.07, P = .001), Spanish-speaking (OR=1.44, P = .03), or former-smokers (OR=1.31, P = .04). CONCLUSIONS: In our diverse community, men who are non-Hispanic White or English-speaking have a decreased odds of timely urological evaluation after a referral for elevated PSA in our diverse patient population. Our study underscores cohorts that may benefit from implementation of institutional safeguards such as patient navigation systems to facilitate and ensure appropriate follow-up upon referral for elevated PSA.

Moral Distress in Radiology: Frequency, Root Causes, and Countermeasures-Results of a National Survey.

BACKGROUND. A major cause of burnout is moral distress: when one knows the right course of action but institutional constraints make the right course impossible to pursue. OBJECTIVE. The purpose of this study was to assess the frequency and severity with which radiologists experience moral distress and to explore moral distress's root causes and countermeasures. METHODS. This study entailed a national survey that evaluated moral distress in radiology. The survey incorporated the validated Moral Distress Scale for Health Care Professionals, along with additional questions. After the scale was modified for applicability to radiology, respondents were asked to assess 16 clinical scenarios in terms of frequency and severity of moral distress. On May 10, 2022, the survey was sent by e-mail to 425 members of radiology practices included on a national radiology society's quality-and-safety LISTSERV. The Measure of Moral Distress for Health Care Professionals (MMD-HP) score was calculated for each respondent as a summary measure of distress across scenarios (maximum possible score, 256). RESULTS. After 12 surveys with incomplete data were excluded, the final analysis included 93 of 425 respondents (22%). A total of 91 of 93 respondents (98%) experienced at least some moral distress for at least one scenario. A total of 17 of 93 respondents (18%) had left a clinical position due to moral distress; 26 of 93 (28%) had considered leaving a clinical position due to moral distress but did not leave. The mean MMD-HP score was 73 ± 51 (SD) for those who had left, 89 ± 47 for those who had considered leaving but did not leave, and 39 ± 35 for those who had never considered leaving (p < .001). A total of 41 of 85 respondents (48%) thought that the COVID-19 pandemic had influenced their moral distress level. Across respondents, the three scenarios with highest moral distress were related to systemic causes (higher case volume than could be read safely, high case volume preventing teaching residents, and lack of administrative action or support). The countermeasure most commonly selected to alleviate moral distress was educating leadership about sources of moral distress (71%). CONCLUSION. Moral distress is prevalent in radiology, typically relates to systemic causes, and is a reported contributor to radiologists changing jobs. CLINICAL IMPACT. Urgent action by radiology practice leadership is required to address moral distress, as radiologists commonly practice in environments contradictory to their core values as physicians.

Assessment of Patient Understanding Prior to Urological Procedures.

OBJECTIVE: To evaluate patient understanding of risks, benefits, and alternatives (R/B/A) prior to urological procedures using the teachback method. METHODS: Using a preprocedural phone interview, patients recalled general knowledge and R/B/A of a scheduled procedure. A scoring system compared patient responses to a standardized R/B/A list to analyze the level of understanding, graded as incomplete (<25%), partial (25-75%), or complete (>75%). Following the interview, additional education was provided if understanding was inadequate, and patients were queried regarding their satisfaction. RESULTS: Patients (n = 99) comprised 46% women; 32% Spanish speaking; Mean age was 64 ± 10.9 years. Procedures included were: intravesical botulinum toxin injection (24), mid-urethral sling (9), colpocleisis (4), prostate biopsy (24), ureteroscopy (16), transurethral resection prostate (11), transurethral resection bladder tumor (11). Across all procedures, the average percent of risks identified was 12%, benefits 63%, and alternatives 35%. No patients had complete understanding, but most had partial (73.7%). Patients had significantly higher level of understanding if they were female (P = 0.02), underwent the same procedure previously (P < 0.01) or any surgery within a year (P = 0.02), and were undergoing an in-office procedures (P = 0.03). After the teachback interview, most patients (90%) were satisfied with their understanding. CONCLUSION: In our cohort, patient understanding was alarmingly incomplete and there was substantial benefit in pre-procedural interviews. Our findings highlight the need for improvement in patient education prior to surgery and offers a potential solution using a teachback-based telephone interview.

A Procedural Checklist for Transurethral Resection of Bladder Tumors (TURBT) Enhances Operative Dictation and Assesses Surgeon Accuracy of Tumor Characteristic Predictions.

BACKGROUND: A lack of standardization is pervasive in procedural application and reporting templates for TURBT with the use of a surgical checklist proposed as a means for quality improvement. OBJECTIVE: To introduce a TURBT checklist to assess surgeon prediction accuracy and the impact of standardized documentation on quality of resection and oncologic outcomes. METHODS: Nine critical elements of a high-quality TURBT identified by literature review were incorporated into a prospectively implemented checklist for operative reports. The checklist included both visualized and predicted tumor characteristics. A retrospective single-institution analysis compared quality of dictation pre- and post-checklist implementation. Surgeon predictions were compared to final pathology reports to determine rates of concordance. Kaplan-Meier curves examined the association of checklist use with recurrence free survival (RFS). RESULTS: 333 operative reports were included in this analysis, of which 107 (32.1%) were completed pre-checklist implementation. The average number of critical elements reported was 8.69 with checklist use compared to 4.99 without (p < 0.001). There was no significant difference in RFS between the pre- and post-checklist cohorts (log-rank test p = 0.53). Surgeons were least and most accurate in predicting low grade tumor (43.5%) and absence of muscle invasion (96.6%), respectively. CONCLUSIONS: Incorporation of a TURBT surgical checklist improves operative dictation and quality of reporting but did not directly impact RFS. With quality of initial resection a proven correlate to recurrence rates, checklist implementation to improve surgical performance and long-term oncologic outcomes reveals an interesting area of exploration highlighting the need for more standardized methodology when performing these procedures.

Gender Bias in YouTube Videos Describing Common Urology Conditions.

OBJECTIVE: To study implicit and explicit gender biases in YouTube videos describing common urologic conditions based on language patterns, speaker gender, and speaker profession. METHODS: Using a Boolean search, the top 30 videos for benign prostatic hyperplasia (BPH), kidney stones, urinary tract infections (UTIs), overactive bladder (OAB), erectile dysfunction (ED), and pelvic organ prolapse (POP) were retrieved. Using the Linguistic Inquiry and Word Count program (LIWC) software, video transcripts were analyzed for 16 word categories and compared by speaker gender and urology topic to assess for bias. RESULTS: OAB and POP had the least view counts and subscribers; kidney stone and ED videos had the most. Student education channels were more likely to feature male than female speakers (19 male vs. 6 female, P=0.01). A significant difference was noted between speaker gender in BPH (25 male vs. 4 female, P<0.001), OAB (4 male vs. 22 female, P<0.001), and POP (6 male vs. 23 female, P<0.001) videos. When examining linguistic patterns with the LIWC program, female speakers were more likely to mention personal concerns and use tentative words when speaking alone compared to males. CONCLUSIONS: Gender bias exists in YouTube videos concerning common urologic conditions. We must be mindful of how information is distributed in order to minimize the perpetuation of gender stereotypes that are common in medicine. Awareness of these patterns and biases should encourage Urologists to proactively consider how they present themselves and how they reference the conditions they present in social media outlets.

Trends in the use of administrative databases in urologic oncology: 2000-2019.

INTRODUCTION AND OBJECTIVE: Administrative databases (AD) provide investigators with nationally representative study populations to answer research questions using large sample sizes. We aimed to quantify the trends and incidence of AD use in published manuscripts in urologic oncology. We examined 6 commonly used databases: National Cancer Database, surveillance, epidemiology, and end results database (SEER), SEER-Medicare, Nationwide Inpatient Sample, National Surgical Quality Improvement Program, and Premier Healthcare Database. METHODS: A literature review, powered by PubMed and DistillerSR, aggregated manuscripts that used the aforementioned databases to study a genitourinary malignancy between July 1, 2000 through June 30, 2019. Included publications were categorized by database used, corresponding author department affiliation, organ, journal, year, and contribution - defined as temporal treatment trends, outcomes and survival, comparative effectiveness research, or cost-effectiveness. RESULTS: There were 2,265 publications across 302 journals that met the inclusion criteria. Between 2000 and 2019 the compound annual growth rate of these publications was 18.7%. SEER use grew at a rate of 14.6% annually. National Cancer Database use grew 28.2% annually. Prostate cancer comprised the majority of publications (51.3%), followed by kidney (23.1%) and bladder (22.5%) cancer. Journals publishing these manuscripts had a median impact factor of 3.28 (IQR = 1.84-5.74) in 2019. Urologists published 52.5% of AD manuscripts over the study period. CONCLUSIONS: Our results show substantial growth in the use of ADs for the study of urologic oncology. Given the broad use of ADs, investigators and specialty societies should advocate for continued improvement in the data captured by them.

The Feasibility and Efficacy of a Multi-Institutional Urology Boot Camp for Incoming Urology Residents.

OBJECTIVES: To determine the feasibility and perceived usefulness of a pre-residency urology boot camp for first and second year urology residents. METHODS: First and second year urology residents attended a multi-institutional boot camp in July 2019, which consisted of lectures, a hands-on practical, patient simulation session, and networking social event. Attendees completed a pre-course survey where they rated their comfort level in managing interpersonal, post-operative, and urology-specific scenarios on a Likert scale of 0-5. Participants completed follow-up surveys immediately and 6 months after the course regarding confidence in managing the same scenarios and the impact of boot camp on their training. RESULTS: 6 urology PGY1s (55%) and 5 PGY2s (45%) from 4 institutions attended the boot camp. On the precourse survey, PGY2s had higher average comfort scores compared to PGY1s for all post-operative scenarios besides hypotension but just 2 urology-specific scenarios, difficult Foley troubleshooting (4 vs 3, P < .01) and obstructing urolithiasis with urosepsis (3.6 vs 2.2, P = .05). Immediately after the course, 10 of 11 (91%) residents reported feeling better prepared to handle all scenarios. All participants reported they would recommend this training to other urology residents. Six months later, the majority of respondents reported using knowledge learned in boot camp on a daily basis. All agreed that it was a useful networking experience, and 63% had since contacted other residents they met at the course. CONCLUSION: A pre-residency boot camp is both feasible and valuable for first- and second-year urology residents for gaining practical medical knowledge and professional networking.

Conventional semen analysis and advanced sperm function tests in diagnosis and management of varicocele.

Clinical varicoceles are a common cause of male infertility and affect sperm parameters as measured in a conventional semen analysis. Varicocelectomy has been shown in prospective studies to improve semen parameters in men with a clinical varicocele. Clinical varicoceles are also a well-known source of oxidative stress which may affect the quality of spermatozoa. Spermatozoa are particularly susceptible to oxidative stress due to a limited capacity for DNA repair. The susceptibility of spermatozoa to oxidative stress is modulated by a balance between ROS and antioxidants, which can be quantified by various laboratory assays. Varicocelectomy has been consistently shown to reduce both ROS and sperm DNA fragmentation, and various assays should be utilised in the diagnosis and treatment of infertile men with a clinical varicocele.

Acute Cerebrovascular Events With COVID-19 Infection.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) has been associated with an increased incidence of thrombotic events, including stroke. However, characteristics and outcomes of COVID-19 patients with stroke are not well known. METHODS: We conducted a retrospective observational study of risk factors, stroke characteristics, and short-term outcomes in a large health system in New York City. We included consecutively admitted patients with acute cerebrovascular events from March 1, 2020 through April 30, 2020. Data were stratified by COVID-19 status, and demographic variables, medical comorbidities, stroke characteristics, imaging results, and in-hospital outcomes were examined. Among COVID-19-positive patients, we also summarized laboratory test results. RESULTS: Of 277 patients with stroke, 105 (38.0%) were COVID-19-positive. Compared with COVID-19-negative patients, COVID-19-positive patients were more likely to have a cryptogenic (51.8% versus 22.3%, P<0.0001) stroke cause and were more likely to suffer ischemic stroke in the temporal (P=0.02), parietal (P=0.002), occipital (P=0.002), and cerebellar (P=0.028) regions. In COVID-19-positive patients, mean coagulation markers were slightly elevated (prothrombin time 15.4±3.6 seconds, partial thromboplastin time 38.6±24.5 seconds, and international normalized ratio 1.4±1.3). Outcomes were worse among COVID-19-positive patients, including longer length of stay (P<0.0001), greater percentage requiring intensive care unit care (P=0.017), and greater rate of neurological worsening during admission (P<0.0001); additionally, more COVID-19-positive patients suffered in-hospital death (33% versus 12.9%, P<0.0001). CONCLUSIONS: Baseline characteristics in patients with stroke were similar comparing those with and without COVID-19. However, COVID-19-positive patients were more likely to experience stroke in a lobar location, more commonly had a cryptogenic cause, and had worse outcomes.