Performance of multiparametric prostate magnetic resonance imaging validated by targeted and systematic transperineal biopsies.

Objective: To measure the performance of multiparametric (mp) magnetic resonance imaging (MRI) to identify intraprostatic tumour deposits using a systematic and targeted MR-guided transperineal prostate biopsy technique. Materials and Methods: Patients underwent a combined systematic and targeted MR-guided transperineal biopsy procedure in the dorsal lithotomy position under general anaesthesia. Systematic biopsies were spaced 10 mm or less apart and additional biopsies targeted any Prostate Imaging-Reporting and Data System (PI-RADS) 3, 4 or 5 lesions identified on mpMRI. Cancer detection rates were calculated on a per patient and per lesion basis. Results: A total of 125 patients underwent the biopsy procedure. The positive predictive value (PPV) of mpMRI per patient was 59% for any cancer and 49% for Gleason score (GS) ≥ 7 cancer. The negative predictive value (NPV) of mpMRI per patient was 67% for any cancer and 88% for GS ≥ 7 cancer. On a per lesion basis, the PPV of PI-RADS 3 lesions for any and GS ≥ 7 cancer was 24% and 10%. For PI-RADS 4 lesions it was 42% and 32%. For PI-RADS 5 lesions, it was 76% and 70%. MpMRI failed to identify GS ≥ 7 cancer found on systematic biopsy in 22% of patients. Conclusion: Based on a combination of systematic and targeted transperineal prostate biopsies, mpMRI showed a high NPV and low PPV for GS ≥ 7 cancer on a per patient basis. The PPV of mpMRI on a per lesion basis increased with increasing PI-RADS score. However, there were a significant number of both false positive as well as false negative (mpMRI invisible) areas within the prostate that contained GS ≥ 7 cancer. Therefore, pathologic confirmation using both targeted and systematic mapping biopsy is necessary to accurately identify all intraprostatic tumour deposits.

Opioid-Limiting Pain Control After Transurethral Resection of the Prostate: A Randomized Controlled Trial.

OBJECTIVE: To assess whether a multimodal opioid-limiting protocol and patient education intervention can reduce postoperative opioid use following transurethral resection of the prostate. METHODS: This prospective, non-blinded, single-institution, randomized controlled trial (NCT04102566) assigned 50 patients undergoing a transurethral resection of the prostate to either a standard of care control (SOC) or multimodal experimental group (MMG). The intervention included adding ibuprofen to the postoperative pain regimen, promoting appropriate opioid use while hospitalized, an educational intervention, and discharging without opioid prescription. Data regarding demographics, operative data, opioid use, pain scores, and patient satisfaction were compared. RESULTS: A total of 47 patients were included, n = 23 (MMG) and n = 24 (SOC). Demographic and operative findings were similar. Statistical analysis for noninferiority demonstrated non-inferior inpatient pain control (mean pain score 2.5 MMG vs 2.4 SOC, P = 0.0003). The multimodal group used significantly fewer morphine milligram equivalents after discharge (0 vs 4.1, P = 0.04). Inpatient use was reduced but did not reach statistical significance (6.0 vs 9.8, P = 0.2). Mean satisfaction scores with pain control were similar (9.6 MMG vs 9.2 SOC, P = 0.32). No opioid prescriptions were requested after discharge. Adverse events and medication side effects were infrequent and largely similar between groups. CONCLUSION: Implementation of an opioid-limiting postoperative pain protocol and patient education resulted in no outpatient opioid use while maintaining patient satisfaction with pain control. Eliminating opioids following a common urologic procedure will decrease risk of opioid-related adverse events and have a positive downstream impact.

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.

Impact of catheter size on pain and continence following robotic prostatectomy.

INTRODUCTION Continence and catheter related pain following prostatectomy are significant patient concerns, and it is unknown whether catheter size impacts these variables. In this study, patients undergoing prostatectomy were randomized to receive either a 16 French or 20 French catheter to assess the impact of catheter size on postoperative continence and pain. MATERIALS AND METHODS: Patients were prospectively randomized to receive either a 16 French or a 20 French latex catheter at the completion of prostatectomy. Subjects were asked on postoperative day 7 to report their average catheter-related pain and the amount of opioid medication used. International Prostate Symptom Score, Quality of Life score and pads per day were recorded 6 and 12 weeks postoperatively. RESULTS: Fifty-two patients were randomized. Seven were excluded: surgeon catheter preference (3) or withdrawal of consent (4). Demographic and pathologic data did not differ between groups (all p > 0.20). Catheter pain scores and postoperative opioid use were not different between groups (all p > 0.78). Postoperative subjective urinary symptom scores, and pads per day did not differ between groups at both 6 and 12 weeks (all p > 0.16). CONCLUSIONS: Catheter size did not impact postoperative urethral and bladder pain or continence prostatectomy. These data suggest that surgeon preference should guide catheter selection between 16-20 French. Future studies might investigate precise intraoperative anastomosis size measurement and the impact of catheter size on pain scores in a nonoperative population.

Intraperitoneal Rupture of a Synovial Sarcoma of the Kidney.

Primary renal synovial sarcoma is an aggressive, extremely rare disease. Nearly all reported cases are characterized by SYT-SSX gene translocation (X;18)(p11;q11). We describe the case of a 43-year-old woman who presented with an intraperitoneal rupture of this rare sarcoma followed by a right radical nephrectomy. Follow-up imaging 1 month after surgery revealed peritoneal carcinomatosis. She began systemic chemotherapy with doxorubicin and dacarbazine, progressed after 3 months, and is currently receiving single-agent ifosfamide. Only one instance of intraperitoneal rupture has been reported previously. This case report contributes to the characterization of this rare disease.

Robotic Pyeloplasty in Patients with Equivocal Diuretic Renogram.

INTRODUCTION: Previous studies examining patients with equivocal renal scans performed before robotic assisted pyeloplasty for ureteropelvic junction obstruction have shown conflicting results regarding outcomes. To address these conflicting reports we compared rates of symptom resolution and improvement in postoperative radiographic scans between patients at our institution presenting with equivocal vs obstructed preoperative diuretic renograms. METHODS: We conducted a retrospective review of 143 patients who underwent robotic assisted pyeloplasty by a single surgeon at our institution from 2001 to 2017. Patients with preoperative and postoperative diuretic renograms available were included in study. Patients were analyzed in equivocal preoperative imaging or obstructed preoperative imaging groups. RESULTS: A total of 102 patients were included in this study, 16 with equivocal diuretic renograms and 86 with obstructed diuretic renograms. Mean preoperative differential function was 34.9% in the obstructed group and 43.2% in the equivocal group (p=0.07). Postoperative symptom resolution was equivalent between equivocal and obstructed groups (87.5% vs 89.4%, p=0.69). However, improvement in diuretic renogram obstruction was significantly greater in obstructed compared with equivocal cases (84.7% vs 56.3%, p=0.01). CONCLUSIONS: Surgical management of patients with equivocal obstruction can be challenging. Patients with preoperative equivocal diuretic renograms are less likely to have radiographic improvement after robotic assisted pyeloplasty but do experience equivalent symptom resolution compared to patients with obstructed preoperative diuretic renograms. Symptom improvement rather than improvement in radiographic obstruction should be the primary focus when offering robotic assisted pyeloplasty to patients presenting with equivocal diuretic renograms.

Outcomes after Robotic-assisted Pyeloplasty in Patients Presenting with Pain Versus Nonpain Presenting Symptoms.

OBJECTIVE: To assess the impact of presenting symptom or incidental finding on symptomatic and radiographic outcomes after robotic-assisted pyeloplasty (RAP). METHODS: We retrospectively reviewed the records of 143 patients at our institution who received pyeloplasty from 2001-2017. Patients without both pre- and postoperative radiographic data were excluded. Patients were grouped by primary presenting symptom into either pain at presentation (pain) or nonpain primary presenting symptom, including incidental findings (nonpain). Primary outcomes were persistence of postoperative symptoms and improvement in diuretic renogram half-times. RESULTS: The study inclusion criteria was met by 105 patients. Pain was the most common presenting symptom (70.0%), followed by incidental finding (10.5%), infection (7.6%), hematuria (4.8%), hypertension (2.8%), elevated creatinine (2.8%), and nausea (1.0%). Patients with nonpain presentations were significantly more likely to have postoperative symptoms (P = .04), and less likely to improve on diuretic renogram (P = .03). Incidental presentation was found to be associated with greater likelihood of persistent postoperative symptoms compared with other presentations (36.3% vs 8.5%, P = .02). CONCLUSION: Ureteropelvic junction obstruction (UPJO) patients presenting with pain, experience better symptom and radiographic improvement following RAP compared with patients presenting without pain. Incidental UPJO was the most common nonpain presentation and is associated with less symptomatic and radiographic benefit after RAP. These findings will help reconstructive urologists counsel patients with UPJO regarding outcomes of RAP.

Inconsistency in the Definition of Urinary Tract Infection after Intravesical Botulinum Toxin A Injection: A Systematic Review.

PURPOSE: To more accurately examine the rate of urinary tract infection following onabotulinumtoxinA injection of the bladder we systematically reviewed the literature for definitions of urinary tract infection in studies of onabotulinumtoxinA injections. We assessed the studies for consistency with guideline statements defining urinary tract infections. MATERIALS AND METHODS: We systematically reviewed the literature by querying MEDLINE® and Embase®. We included original studies on adult patients with idiopathic overactive bladder and/or neurogenic detrusor overactivity who underwent cystoscopy with onabotulinumtoxinA injection and in whom urinary tract infection was a reported outcome. RESULTS: We identified 299 publications, of which 50 met study inclusion criteria. In 27 studies (54%) urinary tract infection diagnostic criteria were defined with a total of 10 definitions among these studies. None of the overactive bladder studies used a definition which met the EAU (European Association of Urology) criteria for urinary tract infection. Only 2 of the 10 studies on patients with neurogenic bladder used a urinary tract infection definition consistent with the NIDRR (National Institute on Disability and Rehabilitation Research) standards. CONCLUSIONS: Definitions of urinary tract infection are heterogeneous and frequently absent in the literature on onabotulinumtoxinA to treat overactive bladder and/or neurogenic bladder. Given the potential for post-procedure urinary symptoms in this setting, explicit criteria are imperative to establish the true urinary tract infection rate following treatment with onabotulinumtoxinA.

Evolution of the Ureteral Stent: The Pivotal Role of the Gibbons Ureteral Catheter.

OBJECTIVE: To review the pioneering contributions of Dr. Robert Gibbons of Virginia Mason Medical Center to the evolution and development of the modern ureteral stent. METHODS: We reviewed Dr. Gibbons' extensive work through primary sources, including interviews, projector slides, radiology images, stent prototypes, his personal writings, and archived documents. In addition, we performed a review of historical texts and manuscripts describing important innovations in the development of the ureteral stent. RESULTS: In 1972, motivated by a desire to provide his patients with a long-term alternative to open nephrostomy and inspired by Drs. David Davis and Paul Zimskind, who in 1967 had described the use of indwelling ureteral silicone tubing, Dr. Gibbons began to experiment with modifications to improve upon existing stents. To address distal migration, Dr. Gibbons added "wings" that collapsed as the stent was advanced and expanded once in proper position to secure the stent in place. Barium was embedded into the proximal tip to facilitate radiographic visualization. A flange was added to the distal end, preventing proximal migration and minimizing trigonal irritation, and a tail was attached to aid in stent removal. The result was the original Gibbons stent, the first commercially available ureteral stent, and the establishment of Current Procedural Terminology code 52332, still used today. CONCLUSION: The ureteral stent is a fundamental component of urologic practice. In developing the Gibbons stent, Dr. Gibbons played a pivotal role in addressing the challenge of internal urinary diversion particularly for those who needed long-term management. Urologists and the patients they serve owe Dr. Gibbons and other surgeon-inventors a debt of gratitude for their innovative work.

Increasing Adherence to an AUA Guideline: A Durable Impact on Immediate Postoperative Mitomycin C Use.

INTRODUCTION: In this quality initiative we assessed whether providing surgeons with the American Urological Association guideline regarding intravesical mitomycin C at the time of surgery scheduling impacts compliance. Furthermore, we examined the durability of the intervention and the influence of surgeon volume on guideline adherence. METHODS: All patients (105) undergoing transurethral bladder tumor resection from July 2015 to February 2016 at Virginia Mason Medical Center were included prospectively. At the scheduling of surgery urologists were provided with a preoperative tool that included the relevant guideline. Mitomycin C use during the study period was compared to historical and subsequent year's use. Additionally, we stratified results by high and low volume resectionists. RESULTS: Before this study mitomycin C was used in 17.1% (25 of 146) of all resections. During the intervention period its use nearly tripled to 43% (28 of 65), an increase of 25.9%. The year after the intervention its use decreased to 32.7% (36 of 110). Durability was strongest for high volume surgeons and trended toward significance for low volume surgeons. CONCLUSIONS: Providing surgeons with a copy of the guideline at the time of surgery scheduling resulted in a threefold increase in guideline compliance. This change is durable and most impactful for higher volume surgeons. We believe this model can be used to ensure adherence and consideration for many guidelines.

A decision aid versus shared decision making for prostate cancer screening: results of a randomized, controlled trial.

INTRODUCTION: Shared decision making (SDM) is widely encouraged by both the American Urological Association and Choosing Wisely for prostate cancer screening. Implementation of SDM is challenging secondary to time constraints and competing patient priorities. One strategy to mitigate the difficulties in implementing SDM is to utilize a decision aid (DA). Here we evaluate whether a DA improves a patient's prostate cancer knowledge and affects prostate-specific antigen (PSA) screening rates. MATERIALS AND METHODS: Patients were randomized to usual care (UC), DA, or DA + SDM. Perception of quality of care was measured using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Outcomes were stratified by long term provider relationship (LTPR, > 3 years) versus short term provider relationship (STPR, < 3 years). Knowledge of prostate cancer screening and the decision regarding screening were assessed. Groups were compared using ANOVA and logistic regression models. RESULTS: A total of 329 patients were randomized. Patients in the DA + SDM arm were significantly more likely to report discussing the implication of screening (33% DA + SDM, 22% UC, 16% DA, p = 0.0292) and answered significantly more knowledge questions correctly compared to the UC arm (5.03 versus 4.46, p = 0.046). However, those in the DA arm were significantly less likely to report that they always felt encouraged to discuss all health concerns (72% DA, 78% DA + SDM, 87% UC, p = 0.0285). Interestingly, STPR patients in the DA arm were significantly more likely to undergo PSA-based prostate cancer screening (41%) than the UC arm (8%, p = 0.019). This effect was not observed in the LTPR group. CONCLUSIONS: Providing patients a DA without a personal interaction resulted in a greater chance of undergoing PSA-based screening without improving knowledge about screening or understanding of the consequences of this decision. This effect was exacerbated by a shorter term provider relationship. With complex issues such as the decision to pursue PSA-based prostate cancer screening, tools cannot substitute for direct interaction with a trusted provider.

Urologic Dermatology: a Review.

PURPOSE OF REVIEW: Genital dermatology represents a challenge to many providers. Though dermatologic lesions involving the genitalia may present to any of a number of practices, ranging from primary care to urology, gynecology, and dermatology, few training programs provide significant training regarding the diagnosis and management of genital dermatologic lesions. The purpose of this review is to provide urologists with an overview of common genital dermatological lesions that may be encountered in a clinic. The review also provides a guide to how to approach these conditions. RECENT FINDINGS: This manuscript summarizes the most common categories of genital dermatologic lesions, starting with normal variants and progressing to a review of contagious conditions, premalignant lesions, and malignant lesions. In cases in which a lesion does not definitively belong to one of these categories, an algorithmic approach to making a diagnosis may be helpful to narrow the differential diagnosis. The most common benign genital growths include cysts, syringomas, seborrheic keratosis, pearly papules, and Fordyce spots. Contagious lesions, such as herpes, syphilis, scabies, or molluscum contagiosum, should be treated immediately before complications or transmission can occur. Inflammatory genital lesions are very diverse in etiology and presentation but are the most common genital lesions in urological clinical practice. This category of lesions can be approached by dividing them into non-erythematous and erythematous (scaling and non-scaling) lesions. Given the potential evolution of the challenging category of premalignant genital lesions, proper recognition and early biopsy play an important role. Premalignant lesions can be broadly classified into two categories: those not related to HPV infection and those that are related to HPV, including erythroplasia of Queyrat (EQ), Bowen's disease, Bowenoid papulosis, vulvar intraepithelial neoplasia (VIN), and giant condyloma. Herein, contemporary nomenclature and proper evaluation and management of premalignant lesions are reviewed which provide safe and efficacious outcomes for patients. Finally, malignant genital lesions, though rare, must be recognized early and addressed correctly. Squamous cell carcinoma represents 95% of penile and approximately 90% of vulvar and vaginal malignancies, and diagnosis and management can be challenging and require proper referral to an oncologist. Genital dermatology is a challenging field marked by diagnostic difficulty and management challenges. This manuscript provides an overview of genitourinary dermatologic lesions in an effort to provide clinicians with a framework with which to approach the evaluation of these various conditions that will facilitate proper consideration of the differential diagnoses and help the urologist distinguish between normal, benign, premalignant, and malignant lesions.

Surgical solution to an intracorporeal nickel allergy.

A previously healthy 30-year-old man with a symptomatic varicocele underwent gonadal vein embolization using nickel vascular plugs. He developed a painful hypersensitivity to his nickel plugs and elected to pursue laparoscopic excision and proximal gonadal vein ligation. In the operating room, the gonadal vein was isolated from the ureter, and ligated proximal to the cephalad plug and distal to the caudal coil. His pain is completely resolved 5 months after surgery. Metal allergies are well documented in orthopedics and cardiology implants, but there are a limited number of case reports of metal allergies after varicocele embolization. Interestingly, nickel is the most common type of metal hypersensitivity.

Negative reinforcement impairs overnight memory consolidation.

Post-learning sleep is beneficial for human memory. However, it may be that not all memories benefit equally from sleep. Here, we manipulated a spatial learning task using monetary reward and performance feedback, asking whether enhancing the salience of the task would augment overnight memory consolidation and alter its incorporation into dreaming. Contrary to our hypothesis, we found that the addition of reward impaired overnight consolidation of spatial memory. Our findings seemingly contradict prior reports that enhancing the reward value of learned information augments sleep-dependent memory processing. Given that the reward followed a negative reinforcement paradigm, consolidation may have been impaired via a stress-related mechanism.

The calm mouse: an animal model of stress reduction.

Chronic stress is associated with negative health outcomes and is linked with neuroendocrine changes, deleterious effects on innate and adaptive immunity, and central nervous system neuropathology. Although stress management is commonly advocated clinically, there is insufficient mechanistic understanding of how decreasing stress affects disease pathogenesis. Therefore, we have developed a "calm mouse model" with caging enhancements designed to reduce murine stress. Male BALB/c mice were divided into four groups: control (Cntl), standard caging; calm (Calm), large caging to reduce animal density, a cardboard nest box for shelter, paper nesting material to promote innate nesting behavior, and a polycarbonate tube to mimic tunneling; control exercise (Cntl Ex), standard caging with a running wheel, known to reduce stress; and calm exercise (Calm Ex), calm caging with a running wheel. Calm, Cntl Ex and Calm Ex animals exhibited significantly less corticosterone production than Cntl animals. We also observed changes in spleen mass, and in vitro splenocyte studies demonstrated that Calm Ex animals had innate and adaptive immune responses that were more sensitive to acute handling stress than those in Cntl. Calm animals gained greater body mass than Cntl, although they had similar food intake, and we also observed changes in body composition, using magnetic resonance imaging. Together, our results suggest that the Calm mouse model represents a promising approach to studying the biological effects of stress reduction in the context of health and in conjunction with existing disease models.

An intermediate dose of LCMV clone 13 causes prolonged morbidity that is maintained by CD4+ T cells.

Wasting is a sign of various underlying disorders and is a common feature of cancer, sepsis, and AIDS. We have developed an in vivo model to study the various stages of wasting following infection of mice with lymphocytic choriomeningitis virus cl-13. Using this model we have identified four distinct stages of wasting and have discovered that all stages occur in the different groups of mice regardless of whether the virus is cleared or persists. However, the degree and extent of wasting vary between groups of mice, depending upon the dose of virus administered. Blocking IFNγ or TNFα, which are believed to take part in the wasting process, did not affect the wasting state. Finally, we found that CD4+ T cells control the maintenance stage of wasting. We believe this model will be useful in studying the regulation of wasting during a persistent viral infection, hopefully leading to improved therapies to ameliorate the disorder.