Impact of surgical volume and resident involvement on patency rates after vasectomy reversal-A 14-year experience in an open access system.

OBJECTIVE: Evaluate the influence of fellowship training, resident participation, reconstruction type, and patient factors on outcomes after vasectomy reversals in a high volume, open access system. METHODS: Retrospective review of all vasectomy reversals performed at a single institution from January 1, 2002 to December 31, 2016 was conducted. Patient and spouse demographics, patient tobacco use and comorbidities, surgeon training and case volume, resident participation, reconstruction type, and postoperative patency were collected and analyzed. RESULTS: Five hundred and twenty-six vasectomy reversals were performed during the study period. Follow-up was available in 80.6% of the cohort and overall patency, regardless of reconstruction type was 88.7%. The mean time to reversal was 7.87 years (range of 0-34 years). The majority of cases included resident participation. Case volume was high with faculty and residents logging a mean of 37.0 and 38.7 (median 18 and 37) cases respectively. Bilateral vasovasostomy was the most common reconstruction type (83%) and demonstrated a significantly better patency rate (89%) than all other reconstructions (p=0.0008). Overall patency and patency by reconstruction type were not statistically different among faculty surgeons and were not impacted by fertility fellowship training, resident participation or post-graduate year. Multivariate analysis demonstrated that increased time to reversal and repeat reconstructions had a negative impact on patency (p=0.0023 and p=0.043, respectively). CONCLUSIONS: Surgeons with a high volume of vasectomy reversals have outcomes consistent with contemporary series regardless of fellowship training in fertility. Patency was better for bilateral vasovasostomies. Patency was not negatively impacted by tobacco use, comorbidities, resident participation, or post-graduate year.

Urology Individual Critical Task List: Creation and Validation of a Simulation Curriculum.

INTRODUCTION: Individual critical task lists (ICTLs) are skills identified by the U.S. Army for the maintenance of combat readiness in each military occupational specialty, including physicians. These lists vary by medical and surgical specialties and are being utilized by leaders to determine individual deployment capability. The lists for urologists include broader tasks that are not routinely performed in a urology practice. Our goal was to create a simulation curriculum to train urologists and to perform validation testing. MATERIALS AND METHODS: Urology staff and residents at a single military treatment facility underwent a simulation event of urology ICTLs: chest tube, needle decompression, intubation, cricothyroidotomy, and extended focused assessment with sonography for trauma. The simulation was broken down into a pretest, cognitive acquisition, in-person training with subject matter experts for skills acquisition, and a posttest. Content validity questionnaires were administered to participants after the training session. Cognitive acquisition consisted of a series of videos demonstrating task execution and in-person demonstration of tasks and clinical scenarios of when they would be needed. In-person simulation was performed on training mannequins and a sonography simulation trainer. RESULTS: There were a total of nine participants: three residents and six staff urologists, ranging from postgraduate year 2 to more than 10 years out of residency. The total simulation time was 120 min, including 30 min for pretest and viewing of videos. Knowledge-based questions improved from pretest to posttest significantly (mean of 1.2 to 0.1, P < .001). Confidence performing tasks improved significantly on all tasks (P ≤ .01). All participants felt the simulation to be beneficial and had more comfort with the tasks. CONCLUSIONS: The novel urology ICTL curriculum using simulation is a feasible and well-received way to keep competency on these tasks and maintain readiness. Face and content validity was established for the urology ICTL simulation curriculum, and the curriculum is exportable to equip urologists at other facilities for the urology ICTLs and for deployments, where life-saving interventions may be necessary from urologists that may be outside their ordinary scope of practice.

Automated Urinalysis for Evaluation of Microscopic Hematuria: Current Options and Revising the Gold Standard.

INTRODUCTION: Urinalysis is the defining test for microscopic hematuria and has traditionally been performed via microscopy. In recent years automated urinalysis machines, which use different technology to identify cells, have been widely adopted. There is little understanding of these machines in the urology community and how their use may affect evaluation of hematuria. METHODS: We compared commercially available automated urinalysis machines and reviewed the literature comparing these machines to microscopic urinalysis. We also reviewed local hospital practices regarding these systems. RESULTS: We identified 6 commercially available machines, almost all of which use flow cytometry as the mechanism to identify red blood cells. Review of the literature and local practice revealed differing definitions of normal range for red blood cells, most of which do not correlate with the American Urological Association definition of microscopic hematuria. There are also several methods for calibrating the machines in comparison to traditional microscopy. CONCLUSIONS: Use of automated urinalysis machines is widespread. However, these methods do not correspond exactly to traditional microscopy and use varying definitions of microscopic hematuria. These findings warrant additional investigation into the role of these devices in the definition of microscopic hematuria to prevent unneeded evaluations and to appropriately use health care resources.

Identifying bladder rupture following traumatic pelvic fracture: A machine learning approach.

INTRODUCTION: Bladder rupture following blunt pelvic trauma is rare though can have significant sequelae. We sought to determine whether machine learning could help predict the presence of bladder injury using certain factors at the time of presentation of blunt pelvic trauma. MATERIALS AND METHODS: Adult patients at a Level I trauma center with blunt trauma pelvic fractures from January 1, 2005 to December 31, 2017 were identified. Patients with admission urinalysis data, fracture ICD 9 codes, and mechanism of injury available in the trauma registry were included. Patients with bladder rupture and pelvic fracture were compared to those with pelvic fracture alone. The classification of results was performed using the MATLAB Classification Learner Tool. The classification performances were tested by machine learning algorithms in the domains of Decision Tree, Logistic Regression, Naïve Bayes, Support Vector Machine (SVM), Nearest Neighbor (KNN), and Ensemble classifiers. RESULTS: Of the 3063 eligible pelvic fracture patients identified, 208 (6.8%) had concomitant bladder ruptures. Twenty machine learning algorithms were then tested based on pelvic fracture ICD-9 code, admission urinalysis, and mechanism of injury. The best classification results were obtained using the Gaussian Naïve Bayes and Kernel Naïve Bayes classifiers, both with accuracy of 97.8%, specificity of 99%, sensitivity of 83%, and area under the curve (AUC) of the ROC curve of 0.99. CONCLUSION: Machine learning algorithms can be used to help predict with a high level of accuracy the presence of bladder rupture with blunt pelvic trauma using readily available information at the time of presentation. This has the potential to improve selection of patients for additional imaging, while also more appropriately allocating hospital resources and reducing patient risks.

Malignant Solitary Fibrous Tumor of the Renal Vein Presenting as a Giant Renal Artery Aneurysm: A Case Report and Review of Literature.

OBJECTIVES: To discuss an unusual presentation of solitary fibrous tumor (SFT) as well as the first description of SFT originating from the renal vein. CASE REPORT: In this article, we report the case of a 56-year-old man who presented with nonspecific epigastric pain and was found on computed tomography to have a large 10-cm renal artery aneurysm with evidence of contained rupture, segmental ischemia of the kidney, and suggestion of renal vein thrombosis. This was treated by a multidisciplinary team of urologists, vascular surgeons, and interventional radiologists with both renal artery coil embolization and radical nephrectomy. The thrombosis was found on pathologic review to be a malignant SFT originating from the renal vein with likely erosion into the renal artery. CONCLUSION: This report describes the first case of SFT originating from the renal vein and demonstrates the potential for mimicry as a giant renal artery aneurysm.

Head-to-Head Comparison of Three Virtual-Reality Robotic Surgery Simulators.

BACKGROUND AND OBJECTIVES: There are several different commercially available virtual-reality robotic simulators, but very little comparative data. We compared the face and content validity of 3 robotic surgery simulators and their pricing and availability. METHODS: Fifteen participants completed one task on each of the following: dV-Trainer (dVT; Mimic Technologies, Inc., Seattle, Washington, USA), da Vinci Skills Simulator (dVSS; Intuitive Surgical Inc., Sunnyvale, California, USA), and RobotiX Mentor (RM; 3D Systems, Rock Hill, South Carolina, USA). Participants completed previously validated face and content validity questionnaires and a demographics questionnaire. Statistical analysis was then performed on the scores. RESULTS: Participants had a mean age of 29.6 (range, 25-41) years. Most were surgical trainees, having performed a mean of 8.6 robotic primary surgeries. For face validity, ANOVA showed a significant difference favoring the dVSS over the dVT (P = .001), and no significant difference between the RM, dVSS, and dVT. Content validity revealed similar results, with a significant difference between the dVSS and dVT (P = .021), a trend toward a difference between the RM and dVT (P = .092), and no difference between the dVSS and RM (P = .99). CONCLUSION: All simulators demonstrated evidence of face and content validity, with significantly higher scores for the dVSS; it is also the least costly ($80,000 for the simulator), although it is frequently unavailable because of intra-operative use. The dVT and RM have similar face and content validity, are slightly more expensive, and are readily available.

Clinical and Pathologic Features of Hispanic Endometrial Cancer Patients With Loss of Mismatch Repair Expression.

OBJECTIVES: Approximately 3% to 5% of endometrial cancers (EC) are associated with Lynch syndrome (LS). The clinical characteristics and prevalence of LS have not been well studied in the US Hispanic population. Hispanics are the largest and fastest growing ethnic minority group in the United States. We sought to characterize the demographics, tumor characteristics, and prevalence of loss of mismatch repair (MMR) protein expression in a large Hispanic population with EC. METHODS: From January 1, 2005, to August 1, 2012, 83 women of Hispanic ethnicity diagnosed with EC 50 years and younger were identified. Clinical and pathologic data were abstracted from the electronic medical record. Tumor studies included immunohistochemistry of MLH1, MSH2, MSH6, and PMS2 and methylation of the MLH1 promoter. RESULTS: Ninety-five percent of patients were overweight or obese. The mean body mass index was 40.1 kg/m, 75% had irregular menses, 36% had diabetes, 46% were nulliparous, and 95% had endometrioid histology. Thirteen patients (15.7%) had tumor MMR deficiency due to a presumed germline mutation (9 MSH6, 3 MSH2, and 1 MLH1). The pattern of MMR protein loss was consistent with the expected binding properties of the MMR heterodimer complexes. No significant difference was found in clinical or pathological variables between patients with and without MMR deficient tumors. CONCLUSIONS: The prevalence of molecular findings consistent with LS was at least as high as other populations of varied geography, race, and ethnicity. We found no reliable factors to include body mass index, family history, synchronous tumors, or pathologic tumor features to serve as triage markers for which ECs should be screened for MMR protein loss. Our findings support a recommendation for universal screening of ECs utilizing 2-antibody testing with MLH1 promoter methylation testing as indicated up to 60 years or older. Our recommendations should be generalizable to other Hispanic populations in the Southern United States.