Assessing artificial intelligence responses to common patient questions regarding inflatable penile prostheses using a publicly available natural language processing tool (ChatGPT).

INTRODUCTION: The evolving landscape of healthcare information dissemination has been dramatically influenced by the rise of artificial intelligence (AI) driven chatbots, providing patients with accessible and interactive platforms to obtain knowledge about medical procedures and conditions. Among the various surgical interventions in urology, inflatable penile prosthesis (IPP) is a common treatment for men with erectile dysfunction. As patients increasingly seek comprehensive resources to understand what this procedure entails, AI-based chat technologies, such as ChatGPT, have become more prominent. This study aimed to assess the capacity of ChatGPT to provide accurate and easily understandable responses to common questions regarding the IPP procedure. MATERIALS AND METHODS: Ten frequently asked questions (FAQ) about the IPP procedure were presented to the ChatGPT chatbot in separate conversational sessions without follow up questions or repetitions. An evidence-based approach was employed to assess the accuracy of the chatbot's responses. Responses were categorized as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification." RESULTS: Upon review, 70% of ChatGPT's answers to questions regarding the IPP procedure were rated as "excellent," not necessitating further clarification. Twenty percent were considered "satisfactory," requiring minimal clarification, notably on the omission of statistical data and the depth of discussion on certain topics. Ten percent of the responses were "unsatisfactory," requiring substantial clarification, including a failure to provide a definitive answer when necessary. CONCLUSIONS: This study reveals that ChatGPT has a substantial capability to produce evidence-based, understandable responses to a majority of common questions related to the IPP procedure. While there is room for improvement, ChatGPT can serve as an advantageous tool for patient education, enhancing preoperative understanding and contributing to informed decision-making during urological consultations for IPP.

Racial disparity in the utilization of immunotherapy for advanced prostate cancer.

PURPOSE: To identify whether there was a disparity in the utilization of immunotherapy in the treatment of black patients with metastatic castration resistant prostate cancer (mCRPC). METHODS: Using the National Cancer Database, we identified patients between 2010- 2015 with likely minimally/asymptomatic mCRPC. We analyzed annual trends for chemotherapy and immunotherapy use and compared utilization by demographic and clinical features. Multivariable analysis was performed to determine predictors of receiving immunotherapy vs chemotherapy. RESULTS: We identified 1301 patients with likely mCRPC. The majority were non Hispanic White (NHW - 63 %) and 23 % were non-Hispanic Black (NHB). Overall, there was increased utilization of immunotherapy in mCRPC from 2010 onwards, with the peak occurring in 2014 (4.6 %). Chemotherapy use increased significantly, peaking in 2014 to 26.1 %. However, the increased utilization of immunotherapy in the mCRPC was mainly seen in White patients: from 50 % to 74.2 % of the cohort. Conversely, there was a decrease in utilization of immunotherapy among Black mCPRC patients: from 50 % to 25.8 %. On multivariable analysis, there was no statistically significant difference between treatment types by race. CONCLUSION: FDA approval of Sipuleucel-T for mCRPC led to increased utilization of immunotherapy shortly thereafter, but this was mainly noted in white patients. Black patients comparatively did not exhibit increased utilization of this novel agent after 2010. Further studies are necessary to help understand barriers to access to new treatment in mCRPC and eliminate the burden of disease in minority populations."

The Development of an Artificial Intelligence Model Based Solely on Computer Tomography Successfully Predicts Which Patients Will Pass Obstructing Ureteral Calculi.

OBJECTIVE: To improve upon prior attempts to predict which patients will pass their obstructing ureteral stones, we developed a machine learning algorithm to predict the passage of obstructing ureteral stones using only the CT scan at a patient's initial presentation. METHODS: We obtained Institutional Review Board approval to conduct a retrospective study by extracting data from all patients with an obstructing 3-10 mm ureteral stone. We included patients with sufficient data to be categorized as having either passed or failed to pass an obstructing ureteral stone. We developed a 3D-convolutional neural network (CNN) model using a dynamic learning rate, the Adam optimizer, and early stopping with 10-fold cross-validation. Using this model, we calculated the area under the curve (AUC) and developed a model confusion matrix, which we compared with a model based only on the largest dimension of the stone. RESULTS: A total of 138 patients met inclusion criteria and had adequate images that could be preprocessed and included in the study. Seventy patients failed to pass their ureteral stones, and 68 patients passed their stones. For the 3D-CNN model, the mean AUC was 0.95 with an overall mean sensitivity of 95% and mean specificity of 77%, which outperformed the model based on stone-size. CONCLUSION: The 3D-CNN model predicts which patients will pass their obstructing ureteral stones based on CT scan alone and does not require any further measurements. This can provide useful clinical information which may help obviate the need for a delay in care for patients who inevitably require surgical intervention.

Safe transition to opioid-free pathway after robotic-assisted laparoscopic prostatectomy.

To determine whether local anesthetic infiltration and non-narcotic pain medications can safely reduce or eliminate opioid use following robotic-assisted laparoscopic prostatectomy while maintaining adequate pain control. After initiation of this quality-improvement project, patients undergoing robotic-assisted laparoscopic prostatectomy had surgeon-administered local anesthesia around all incisions into each successive layer from peritoneum to skin, with the majority infiltrated into the transversus abdominis muscle plane and posterior rectus sheath of the midline extraction incision. Post-operatively patients received scheduled acetaminophen plus ketorolac, renal function permitting. A retrospective review was performed for all cases over 19 months, spanning project implementation. 157 cases (76 in opioid-free pathway, 81 in standard pathway) were included. Five patients (6.6%) in the opioid-free pathway required post-operative opioids while inpatient, versus 61 (75.3%) in the standard pathway, p < .001. Mean patient-reported pain score on each post-operative day was lower in the opioid-free pathway compared to the standard pathway [day 0: 2.4 (SD 2.6) vs. 3.9 (SD 2.7), p < .001; day 1: 1.4 [SD 1.6] vs. 3.3 (SD 2.2), p < .001; day 2 0.9 (SD 1.5) vs. 2.6 (SD 1.9), p < .001]. Fewer post-operative complications were seen in the opioid-free pathway versus standard [0 vs. 5 (6.2%), p = 0.028], and there was no statistically significant difference in number of emergency room visits or readmissions within 3 weeks of surgery. The use of surgeon-administered local anesthetic plus scheduled non-narcotic analgesics can safely and significantly reduce opioid use after robotic-assisted laparoscopic prostatectomy while improving pain control.

Comparative analysis of 1152 African-American and European-American men with prostate cancer identifies distinct genomic and immunological differences.

Racial disparities in prostate cancer have not been well characterized on a genomic level. Here we show the results of a multi-institutional retrospective analysis of 1,152 patients (596 African-American men (AAM) and 556 European-American men (EAM)) who underwent radical prostatectomy. Comparative analyses between the race groups were conducted at the clinical, genomic, pathway, molecular subtype, and prognostic levels. The EAM group had increased ERG (P < 0.001) and ETS (P = 0.02) expression, decreased SPINK1 expression (P < 0.001), and basal-like (P < 0.001) molecular subtypes. After adjusting for confounders, the AAM group was associated with higher expression of CRYBB2, GSTM3, and inflammation genes (IL33, IFNG, CCL4, CD3, ICOSLG), and lower expression of mismatch repair genes (MSH2, MSH6) (p < 0.001 for all). At the pathway level, the AAM group had higher expression of genes sets related to the immune response, apoptosis, hypoxia, and reactive oxygen species. EAM group was associated with higher levels of fatty acid metabolism, DNA repair, and WNT/beta-catenin signaling. Based on cell lines data, AAM were predicted to have higher potential response to DNA damage. In conclusion, biological characteristics of prostate tumor were substantially different in AAM when compared to EAM.

Durability of Digital Flexible Ureteroscope in University Hospital and Ambulatory Surgical Center: Is It Time to Rethink?

Introduction and Objectives: Published literature on damages to a digital flexible ureteroscope (DFU) examines a limited number of ureteroscopes and shows wide variation in its durability. The aim of this study was to compare the primary damage location, causes of DFU damages, and the durability of Karl Storz Flex-Xc digital ureteroscope between University Hospital (UH) and Ambulatory Care Surgery Center (ASC). We also evaluated the available literature on the durability of DFU. Methods: Each damaged DFU prospectively underwent a manufacturer's evaluation to determine the reason for return and primary site of damage. Hospital data on the number of ureteroscopic procedures and damaged DFUs over 3 years were retrospectively reviewed. The possible reason for the damage was classified as either intraoperative or between the procedures. The durability of DFUs, type, and cause of damage were compared between the UH and nonteaching ASC. A chi-square test was utilized for categorical variables. When cell frequencies were <5, Fisher's exact test was used. Results: During the study period, 1211 ureteroscopies were performed and 143 ureteroscopes were returned to the manufacturer. The mean number of uses was 7.45 at the UH and 16.5 at the ASC. The location and cause of damage were similar at both locations. The most common locations of primary damage were at the angle cover (70.6%) and instrument channel (19.2%). Most damage occurred during the handling of the ureteroscopes between surgical procedures (78%). On review of the literature, we found that DFUs were 6 times more durable in a nonteaching hospital. Conclusions: The DFU was more than two times as durable in the ASC as in the UH. Most incidents occurred during handling between surgical procedures. Future research is needed to examine the impact of training and certification of support staff on durability of DFUs.

Robotic Pyelolithotomy for the Intact Removal of a Complete Staghorn Calculus: A Feasible Approach Even After a Previous Open Pyelolithotomy.

OBJECTIVE: To describe the steps and technique of a robotic pyelolithotomy for complete removal of a left staghorn stone after a previous open pyelolithotomy. METHODS: The patient is placed in a left modified flank position with 4 laparoscopic ports placed: 12mm port for camera paramedian to the left of the midline, 8mm robotic port left lower quadrant at the level of the umbilicus, 8mm robotic port midclavicular line 2 finger breaths below the costal margin, 12mm Airseal assistant port paramedian infraumbilical. The white line of Toldt was incised and the colon was mobilized medially. Anterior Gerota's fascia was opened and tacked to the lateral abdominal wall exposing renal pelvis and parenchyma. An intraoperative ultrasound confirmed the underlying stone. A V-shaped Gil-Vernet pyelolithotomy incision was made and Prograsp forceps were used to manipulate the stone out of the renal pelvis. The collecting system was inspected and irrigated using the robotic lens. The pyelotomy was closed with 4-0 Monocryl suture on a TF needle in 2 lengths of suture, superiorly and inferiorly. Gerota's fascia was closed over the renal pelvis and the kidney was re-retroperitonealized by tacking the colon to the white line of Toldt. The specimen was retrieved through a mini-Pfannenstiel incision via a specimen bag. The patient was discharged on postoperative day 1 and seen in clinic 5 weeks later for stent removal. CONCLUSIONS: Robotic pyelolithotomy is a minimally invasive alternative that can be offered to patients with complete staghorn stones even after major open stone surgery. However case selection for this approach relies on the stone burden primarily in a dilated renal pelvis with limited calyceal projections. It is imperative to review preoperative imaging to understand the calyceal anatomy and the rotation required to free the stone from the collecting system.

Lowering positive margin rates at radical prostatectomy by color coding of biopsy specimens to permit individualized preservation of the neurovascular bundles: is it feasible? a pilot investigation

ABSTRACT Objective: To evaluate whether color-coding of prostate core biopsy specimens aids in preservation of the neurovascular bundles from an oncological perspective. Materials and Methods: MRI guided transrectal ultrasound and biopsy of the prostate were performed in 51 consecutive patients suspected of being at high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor. Results: Of the 51 patients undergoing prostate biopsy, 30 (58.8%) were found to have cancer of the prostate: grade group 1 in 13.7%, 2 in 25.5%, 3 in 7.8%, 4 in 7.8% and 5 in 3.9% of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. Five patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic extension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy. Conclusion: Color-coding of prostate biopsy core specimens may assist in tailoring the approach for preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modification of the prostate biopsy protocol is valuable in larger groups of patients.

Lowering positive margin rates at radical prostatectomy by color coding of biopsy specimens to permit individualized preservation of the neurovascular bundles: is it feasible? a pilot investigation.

OBJECTIVE: To evaluate whether color-coding of prostate core biopsy specimens aids in preservation of the neurovascular bundles from an oncological perspective. MATERIALS AND METHODS: MRI guided transrectal ultrasound and biopsy of the prostate were performed in 51 consecutive patients suspected of being at high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor. RESULTS: Of the 51 patients undergoing prostate biopsy, 30 (58.8%) were found to have cancer of the prostate: grade group 1 in 13.7%, 2 in 25.5%, 3 in 7.8%, 4 in 7.8% and 5 in 3.9% of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. Five patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic extension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy. CONCLUSION: Color-coding of prostate biopsy core specimens may assist in tailoring the approach for preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modification of the prostate biopsy protocol is valuable in larger groups of patients.

Perinephric Fat Stranding Is Associated with Elevated Creatinine Among Patients with Acutely Obstructing Ureterolithiasis.

INTRODUCTION: Pyelovenous/pyelolymphatic backflow from acute ureteral obstruction, manifesting radiologically as perinephric fat stranding (PFS), may result in elevated serum creatinine. Among patients with acutely obstructing ureterolithiasis, we evaluated the relationship between degree of PFS and changes in serum creatinine from baseline. METHODS: Our tertiary care center's radiology dictation system (Fluency Discovery, M Modal) was queried for noncontrast abdominopelvic CT studies obtained in the Emergency Department for patients with obstructing ureteral calculi from 7/2015 to 4/2016. A single radiologist blinded to clinical data reviewed all CT scans and coded stone size, location, severity of hydronephrosis, and degree of PFS (none, mild, moderate, severe). For patients who met imaging criteria, a retrospective chart review was performed. RESULTS: We evaluated 148 patients with mean age of 46 years (SD 14.6), 56.0% (n = 83) were male. On univariate analysis, moderate-severe perinephric stranding was associated with elevated creatinine from baseline (OR 2.93, p = 0.03). Mean creatinine increased as the severity of stranding increased (none Cr = 0.978 mg/dL, mild Cr = 0.983 mg/dL, moderate Cr = 1.165 mg/dL, severe Cr = 1.370 mg/dL; p < 0.01). An increase in creatinine from baseline was not associated with greater severity of hydronephrosis (OR 0.504, p = 0.189). There was no association between degree of PFS and severity of hydronephrosis, positive urine culture, stone location, or symptom duration (p > 0.05). On regression analysis controlling for positive urine culture and degree of hydronephrosis, there remained an association between elevated serum creatinine from baseline and moderate-severe PFS (OR 9.0, p = 0.01). CONCLUSIONS: Among patients with acute obstructive ureterolithiasis, moderate-severe PFS was associated with elevated serum creatinine from baseline. This elevated creatinine was not explained by the obstructed kidney alone, as there was no association between the severity of hydronephrosis and increased creatinine. Pyelovenous/pyelolymphatic backflow resulting in PFS may be a contributing factor to elevated serum creatinine in this setting.

Five Supernumerary Renal Arteries Originating From the Aorta Associated With Ureteropelvic Junction Extrinsic Compression.

A 65-year-old woman presented with recurrent urinary tract infections. A computed tomography of the abdomen and pelvis shows a dilated and malrotated right renal pelvis consistent with a ureteropelvic junction obstruction as well as multiple renal arteries arising from the aorta. A computed tomography angiography revealed 5 separate renal arteries originating from the aorta with a single renal artery crossing over and obstructing the right renal pelvis. On Lasix renogram, the affected kidney contributes 45% of total renal function. The patient remained asymptomatic (absent of hematuria, flank pain, infection) and opted for active surveillance.

Perineal urethrostomy: Still Essential in the Armamentarium for Transurethral Surgery.

A 69-year-old morbidly obese man presented with hematuria caused by a large anterior wall bladder tumor. The mass was inaccessible for resection by standard means due to the patient's obesity and phallic length. A perineal urethrostomy was required to enable complete resection. This age-old technique is revisited for the benefit of this generation's urologists.

Quantification of risk factors in 500 patients with postoperative urinary retention.

INTRODUCTION: An Institutional Quality and Safety Initiative to reduce postoperative urinary retention (POUR) and improve patient safety indicators (PSIs) was undertaken after a nurse driven protocol for catheter removal lead to an increase in POUR. The aim of this study was to identify the number of risk factors present in patients with POUR while examining the prevalence of those risk factors individually. MATERIALS AND METHODS: A retrospective review of our institution's surgical database was performed to identify 500 consecutive cases of POUR between July 1, 2013 and July 1, 2014. POUR was defined as the inability to void postoperatively with bladder scan volumes greater than 450 mL and subsequent need for catheterization with an output greater than 450 mL. These records were individually reviewed for 15 known independent risk factors for urinary retention. Patients with incomplete records or preoperative baseline urinary retention requiring catheterization were excluded. RESULTS: Of the 500 consecutive patients with POUR, 288 (57.6%) were male and 212 (42.4%) were female. At the time of voiding trial, all 500 patients with POUR (100%) had at least one perioperative risk factor identified and over 75% had six or more (mean 6.88, median 7, range 1-12). CONCLUSIONS: Multiple perioperative risk factors are present in the vast majority of patients with POUR. Many of the risk factors are modifiable and represent an opportunity for intervention. This could ultimately lead to a risk profile which could be used to optimize timing of postoperative voiding trials, thus improving patient care (improve PSIs and patient comfort, reduce trauma) while maintaining low rates of CAUTI.

Intentional Omission of Ureteral Stents During Robotic-assisted Intracorporeal Ureteroenteric Anastomosis: Is It Safe and Feasible?

OBJECTIVE: To describe the surgical technique we used to perform a stentless intracorporeal ureteroenteric anastomosis and to determine the outcomes in this initial series. METHODS: We performed a retrospective review of a prospective database of all patients undergoing robotic-assisted intracorporeal urinary diversion with stentless ureteroenteric anastomosis between March 2014 and July 2016. Diversions were performed at the time of either robotic-assisted laparoscopic cystectomy for bladder cancer or urinary diversion for other indications. RESULTS: A total of 10 patients underwent implantation of 20 ureters into the intestine via a robotic-assisted approach with intentional omission of stents. Median body mass index was 29.57 (first quartile 23.68, third quartile 34.69). Median American Society of Anesthesiologists score was 3 (range 2-3). Seven patients had intracorporeal ileal conduit reconstruction and 3 patients had an intracorporeal neobladder creation. There were no patients who developed a stricture of the ureter nor did any patient develop a leak at the ureteroenteric anastomosis. All patients had normal serum creatinine at least 4 weeks after surgery, and all patients had follow-up computed tomography of the kidneys, which were normal. The median follow-up was 8 months (first quartile = 3 months, third quartile = 17 months). CONCLUSION: Robotic intracorporeal urinary diversion with intentional omission of ureteral stents is a safe and feasible option when establishing continuity of the genitourinary and gastrointestinal tracts.

Renal fungus ball: a challenging clinical problem.

INTRODUCTION: We describe a case of renal pelvi-ureteric fungus ball managed with placement of two nephrostomy tubes and amphotericin B irrigation through a nephrostomy tube with the other to free drain. CASE REPORT: A 46-year-old man with uncontrolled Type 2 diabetes mellitus was referred to the urology clinic for workup of recurrent urinary tract infection. Urine culture grew Candida albicans. The patient was started on oral fluconazole therapy. Cystoscopy and cystogram revealed a grade 3 left vesicoureteral reflux and right retrograde pyelogram revealed a filling defect in the right renal pelvis extending into the proximal ureter with severe hydroureteronephrosis. Two nephrostomy tubes were placed (mid-pole and lower pole) to ensure that the system was not obstructed. Amphotericin B (50 mg/1000 ml normal saline) irrigation was then instilled through the mid-pole nephrostomy tube at a rate of 30 ml/h with the lower pole nephrostomy tube to free drain. An antegrade nephrostogram was performed after 5 days of amphotericin B instillation, showing complete resolution of the fungus ball. The patient is awaiting definitive minimally invasive management of the distal ureteral narrowing. COMMENTS: Renal and pelvi-ureteric fungus ball is a challenging clinical entity. It must be addressed promptly and efficiently to be successful. We describe a minimally invasive approach that was tolerated well and resulted in complete clearance of the fungus ball in a relatively short time frame.