Manual Dexterity Predictors of Artificial Urinary Sphincter Success.

OBJECTIVE: To determine better in-office measures for artificial urinary sphincter outcomes, we investigated the ability of preoperative timed peg-transfer, pinch strength, grip strength, and Disabilities of the Arm Shoulder and Hand Outcome questionnaire in predicting postoperative satisfaction, confidence, and ease of use of artificial urinary sphincter placement for stress urinary incontinence. MATERIALS AND METHODS: A timed 9-hole peg test, pinch and grip strength assessment, and upper extremity questionnaire were administered during the preoperative visit before sphincter placement. In addition to standard preoperative workup, short-form International Consultation of Incontinence Questionnaire and physician handshake were recorded. Activation occurred 6 weeks after surgery along with assessment of adequacy of pump placement. Three months from surgery a repeat incontinence questionnaire and a survey measuring satisfaction, difficulty of use, and confidence were given. Correlation between preoperative assessment variables and the postoperative questionnaire was assessed. RESULTS: Thirty-nine patients were included. Average age and body mass index were 68.8 years and 28.8 kg/m2, respectively. Prior prostatectomy accounted for 92.3% of patients, and 46.2% had prior pelvic radiation. Postoperatively, 59.0% of patients were very satisfied; 64.1% of patients reported no difficulty of use; 53.8% felt confidence within 1 day; and 66.7% had much better bladder control. Average pad improvement count was 5.3. Pinch test was associated with satisfaction (P = .011) while peg test was associated with confidence (P = .049). Handshake and upper extremity questionnaire were not significant. CONCLUSION: The pinch and 9-hole peg transfer tests are cost-effective and easily performed adjuncts that could be used during artificial urinary sphincter evaluation for patients with unclear manual functional status.

Contemporary Trends of Systemic Neoadjuvant and Adjuvant Intravesical Chemotherapy in Patients With Upper Tract Urothelial Carcinomas Undergoing Minimally Invasive or Open Radical Nephroureterectomy: Analysis of US Claims on Perioperative Outcomes and Health Care Costs.

INTRODUCTION: New evidence indicates that minimally invasive surgery (MIS) (laparoscopic or robotic-assisted [LNU, RANU]) reaches oncologic equivalence compared with Open Radical Nephroureterectomy (ORNU) for high-risk upper-tract urothelial carcinoma (UTUC). Recently, European Association of Urology (EAU) Guidelines suggested implementing neoadjuvant chemotherapy (NAC) to standard treatment to improve oncologic outcomes of high-risk UTUC. We aimed (1) To explore contemporary trends of MIS for RNU in the United States and to compare perioperative outcomes and costs with that of ORNU. (2) To determine the trends of NAC and postoperative intravesical chemotherapy (PIC) administration for high-risk UTUC and to assess their contribution to perioperative outcomes and costs. PATIENTS AND METHODS: The Optum Clinformatics Data Mart de-identified database was queried from 2003 to 2018 to retrospectively examine patients who had undergone LNU/RANU or ORNU with or without NAC and PIC. We evaluated temporal adoption trends, complications, and health care cost analyses. We obtained descriptive statistics and utilized multivariable regression modeling to assess outcomes. RESULTS: A total of n = 492 ORNU and n = 1618 LNU/RANU procedures were reviewed. The MIS approach was associated with a statistically significant lower risk of intraoperative complications (adjusted Odds Ratio [aOR], 0.48, 95% CI:0.24-0.96), risk of hospitalization costs (aOR: 0.62, 95% CI:0.49-0.78), and shorter hospital stay (aOR: 0.20, 95% CI:0.15-0.26) when compared to ORNU. Overall, adoption of NAC and PIC accounted for only n = 81 and n < 37 cases respectively. The implementation of NAC and higher number of cycles were associated with an increased probability of any complication rate (aOR: 2.06, 95% CI:1.26-3.36) and hospital costs (aOR: 2.12, 95% CI:1.33-3.38). CONCLUSION: MIS has become the approach of choice for RNU in the US. Although recommended by guidelines, neither NAC nor postoperative bladder instillation of chemotherapy has been routinely incorporated into the clinical practice of patients with UTUC.

Removing Race from eGFR calculations: Implications for Urologic Care.

Equations estimating the glomerular filtration rate are important clinical tools in detecting and managing kidney disease. Urologists extensively use these equations in clinical decision making. For example, the estimated glomerular function rate is used when considering the type of urinary diversion following cystectomy, selecting systemic chemotherapy in managing urologic cancers, and deciding the type of cross-sectional imaging in diagnosing or staging urologic conditions. However, these equations, while widely accepted, are imprecise and adjust for race which is a social, not a biologic construct. The recent killings of unarmed Black Americans in the US have amplified the discussion of racism in healthcare and has prompted institutions to reconsider the role of race in estimation of glomerular filtration rate equations and raced-based medicine. Urologist should be aware of the consequences of removing race from these equations, potential alternatives, and how these changes may affect Black patients receiving urologic care.

A biofeedback-guided programme or pelvic floor muscle electric stimulation can improve early recovery of urinary continence after radical prostatectomy: A meta-analysis and systematic review.

PURPOSE: Urinary incontinence (UI) after radical prostatectomy (RP) is an early side effect after catheter removal. This systematic review and meta-analysis were conducted to compare different forms of non-invasive treatments for post-RP UI and to analyse whether the addition of biofeedback (BF) and/or pelvic floor muscle electric stimulation (PFES) to PF muscle exercise (PFME) alone can improve results in terms of continence recovery rate. MATERIALS AND METHODS: A literature search was performed following the PRISMA guidelines. We performed a cumulative meta-analysis to explore the trend in the effect sizes across subgroups during a 12-months follow-up. RESULTS: Twenty-six articles were selected. At baseline after RP and catheter removal, mean pad weight varied extremely. At 1- and 3-months intervals, mean difference in pad weight recovery from baseline was significantly higher using guided programs (BF, PFES or both) than using PFME alone (3-months: PFME 111.09 g (95%CI 77.59-144.59), BF 213.81 g (95%CI -80.51-508-13), PFES 306.88 g (95%CI 158.11-455.66), BF + PFES 266.31 g (95%CI 22.69-302.93); P < .01), while at 6- and 12-months differences were similar (P > .04). At 1- and 3-months intervals, event rate (ER) of continence recovery was significantly higher using guided programs than using PFME alone (3-months: PFME 0.40 (95%CI 0.30-0.49), BF 0.49 (95%CI 0.31-0.67), PFES 0.57 (95%CI 0.46-0.69), BF + PFES 0.75 (95%CI 0.60-0.91); P < .01), while at 6- and 12-months ERs were similar. CONCLUSIONS: Regarding non-invasive treatment of UI secondary to RP, the addition of guided programs using BF or/and PFES demonstrated to improve continence recovery rate, particularly in the first 3-month interval, when compared with the use of PFME alone.

Safety and Feasibility of Outpatient Surgery in Benign Prostatic Hyperplasia: a Systematic Review and Meta-Analysis.

Purpose: Most of the endourologic procedures along the urinary tract have been widely practiced as outpatient operations, including surgery for benign prostatic hyperplasia (BPH). This systematic review and meta-analysis was conducted to assess safety and feasibility of outpatient surgery for patients suffering from symptomatic BPH candidate for endoscopic disobstruction. Materials and Methods: PubMed, Web of Science, Cochrane, and Embase were searched up until March 30, 2020. Methodological index for nonrandomized studies (MINORS) tool was utilized to assess the quality of included studies, and a pooled measure of failure rate (FR) or event rate (ER) estimate was calculated. Further sensitivity analysis, subgroup analysis, and meta-regression were conducted to investigate contribution of moderators to heterogeneity. Results: Twenty studies with a total of 1626 patients treated according to outpatient criteria for endoscopic BPH surgery were included. In total, 18 studies reporting data on immediate hospital readmission and/or inability to discharge after endoscopic procedure presented FR estimates ranging from 1.7% to 51.1%. Pooled FR estimate was 7.8% (95% confidence interval [CI]: 5.2-10.3); Heterogeneity: Q = 76.85; degree of freedom = 17, p < 0.001; I2 = 75.12%. Subgroup analysis according to surgical technique revealed difference among the three approaches with pooled FR of 3% (95% CI: 1-4.9), 7.1% (95% CI: 3.9-10.4), and 11.8% (95% CI: 7-16.7) for transurethral resection of the prostate, Green-light, and holmium laser vaporesection, respectively (p < 0.001). At meta-regression analysis, none of the retrieved covariates was able to significantly influence the cumulative outcomes reported. ER for postoperative complications and early outpatient visit showed a pooled estimate of 18.6% (95% CI: 13.2-23.9) and 7.7% (95% CI: 4.3-11), respectively. Conclusions: Our analysis revealed how transurethral procedures for BPH on an outpatient setting are overall reliable and safe. Of note, there were significant outcome differences between groups with regard to type of surgical procedure, perioperative prostate volume, and discharge protocol suggesting the need for further prospective analysis to better elucidate the best strategy in such outpatient conduct.

Resolution of bilateral testicular masses after viral infection.

We present a case of viral-associated orchitis with bilateral testicular masses initially concerning for malignancy on scrotal ultrasound. In this case, patient underwent observation after discussing management options. Literature search revealed two cases of benign testicular mass after viral infection that was managed with radical orchiectomy. The previously documented case allowed for appropriate counseling to delay surgical intervention and allow for spontaneous resolution of the viral-induced testicular masses.

Sudden PSA rise to ≥20 ng/ml and prostate cancer diagnosis in the United States: A population-based study.

PURPOSE: While prostate-specific antigen (PSA) screening protocols vary, many clinicians have anecdotes of screened men with low PSA levels that rise significantly and are associated with high-risk prostate cancer (PC). We sought to better understand the frequency of high-risk cases that appear suddenly in a screened population. METHODS: We utilized data from a Commercial and Medicare advantage claims database to identify all US men ages 50 and above undergoing PSA screening who then had a sudden interval rise in PSA (e.g., PSA ≥ 20) and diagnosis of PC. We determined associations with age, race, screening intensity, and baseline PSA levels. RESULTS: In all, 526,120 men met entry criteria with an average age of 60.7 and follow-up of 5.6 years. As the baseline PSA increased, the rate of high-risk PC increased from 2/10,000 persons among men with the lowest baseline PSA (<1 ng/ml) to 14/10,000 person-years among men with a baseline PSA < 5 ng/ml. Moreover, as a man's age at baseline PSA increased, the rate of high-risk PC also increased. In contrast, the incidence of high-risk PC did not vary significantly by race/ethnicity. More screening PSAs and shorter intervals between PSA screenings were associated with a lower incidence of high-risk PC. CONCLUSIONS: The incidence of high-risk PC in a screened population is low (<0.1%). Our findings suggest that systematic screening cannot eliminate all PC deaths and provide an estimate for the risk of the rapid development of high-risk cancers that is comparable to that observed in active surveillance populations.

Nephron-sparing management of Xanthogranulomatous pyelonephritis presenting as spontaneous renal hemorrhage: a case report and literature review.

BACKGROUND: Xanthogranulomatous pyelonephritis (XGP) is an uncommon infectious disease of the kidney known to mimic other renal maladies. A rare presentation of this uncommon disease is spontaneous renal hemorrhage (SRH). CASE PRESENTATION: We report a case of XGP in a 58 year old woman who presented with abdominal pain, hematuria, and radiating left flank pain. CT scan was felt to be consistent with perirenal hemorrhage abutting a fat-containing renal mass. The patient was eventually taken to surgery for left partial nephrectomy. Pathology report returned as XGP, and the patient has no complications from this disease process at 8 month follow up. CONCLUSION: Our search of the literature shows XGP presenting as SRH to be a rare clinical entity. Furthermore, this is the first such case managed with a nephron-sparing approach. The "great imitator" XGP should be added to the differential for patients presenting with spontaneous renal hemorrhage.

Longitudinal Rupture of Distal Corpus Cavernosum With Concomitant Urethral Injury: An Uncommon Result of a Common Mechanism.

Fracture of the penis is a well-recognized yet relatively uncommon urologic event. Forceful, blunt trauma with lateral bending of the penis in an erect state typically results in a transverse rupture of the tunica albuginea of the corpus cavernosum. Longitudinal tears of the corpus cavernosum are by themselves considered infrequent. We present a rare case of a patient with longitudinal rupture of the distal corpus cavernosum with concomitant extension to the corpus spongiosum causing partial urethral disruption as a result of trauma during sexual intercourse.

Impact of Cystectomy With Urinary Diversion Upon Tracked Receipt of Opioid Prescriptions Among Patients With Interstitial Cystitis/Bladder Pain Syndrome.

OBJECTIVE: To compare opioid requirements before and after cystectomy for end-stage Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) using a statewide tracking system. METHODS: Narcotic prescriptions were captured using the North Carolina Controlled Substance Reporting System for patients at a single institute undergoing cystectomy with urinary diversion (CWUD) for refractory, end-stage IC/BPS between 2010 and 2017. Values were documented for the year before and the year after surgery (excluding 30 days postoperatively to account for surgical pain) and converted to morphine equivalents (ME). Values were compared using Student t test. RESULTS: Following CWUD, there was a mean decrease in opioid receipt per patient of 6535 ME/year (P = .321). 8/26 (31%) had not filled any opiate prescriptions for the preceding 3 months at time of manuscript writing. CONCLUSION: In certain patients with end-stage, refractory IC/BPS, CWUD can help reduce opioid requirements.

Factors Associated with Trial Outcomes in the Management of Nephrolithiasis: A Legal Database Review.

INTRODUCTION: Domestically the estimated annual cost of medical malpractice is $55.6 billion. As surgical providers in a high risk subspecialty, urologists are at particularly high risk. Interventions for nephrolithiasis are especially common in practice, and understanding the risks associated with high volume procedures is critical for quality improvement and cost containment. METHODS: Using the Westlaw legal database we identified all legal briefs with the search terms "medical malpractice" and "kidney stone" or "nephrolithiasis" for dates between January 2000 and December 2015. Each case was evaluated for alleged cause of malpractice, resulting injury and indemnity payments. RESULTS: The initial search yielded 55 cases, which was decreased to 29 after exclusions. Most cases (15, 52%) were decided in favor of the defendant, while the remaining suits led to indemnity payments, including 6 cases that were settled and 8 with verdicts for the plaintiff. Of named defendants 75% were urologists. The mean settlement amount was $158,400 while the mean indemnity payment for verdicts decided in favor of the plaintiff was $124,400. The most commonly alleged breach of duty was negligent performance in surgery (15 cases), followed by negligent postoperative care (6 cases), and failure to diagnose and treat (5 cases). The most commonly claimed damage was death (13 cases). CONCLUSIONS: Malpractice cases related to the management of nephrolithiasis most commonly involve allegations of negligent performance in surgery, negligent postoperative care, or failure to diagnose or treat. Urologists account for 75% of named defendants and should be aware of factors that increase the risk of litigation.

Optic nerve inflammation and demyelination in a rodent model of nonarteritic anterior ischemic optic neuropathy.

PURPOSE: Optic nerve (ON) ischemia associated with nonarteric anterior ischemic optic neuropathy (NAION) results in axon and myelin damage. Myelin damage activates the intraneural Ras homolog A (RhoA), contributing to axonal regeneration failure. We hypothesized that increasing extrinsic macrophage activity after ON infarct would scavenge degenerate myelin and improve postischemic ON recovery. We used the cytokine granulocyte-macrophage colony-stimulating factor (GM-CSF) to upregulate ON macrophage activity, and evaluated GM-CSF's effects after ON ischemia in the NAION rodent model (rAION). METHODS: Following rAION induction, GM-CSF was administered via intraventricular injection. Retinal ganglion cell (RGC) stereologic analysis was performed 1 month postinduction. The retinae and optic nerve laminae of vehicle- and GM-CSF-treated animals were examined immunohistochemically and ultrastructurally using transmission electron microscopy (TEM). RhoA activity was analyzed using a rhotekin affinity immunoanalysis and densitometry. Isolated ONs were analyzed functionally ex vivo by compound action potential (CAP) analysis. RESULTS: Rodent NAION produces ON postinfarct demyelination and myelin damage, functionally demonstrable by CAP analysis and ultrastructurally by TEM. Granulocyte-macrophage colony-stimulating factor increased intraneural inflammation, activating and recruiting endogenous microglia, with only a moderate amount of exogenous macrophage recruitment. Treatment with GM-CSF reduced postinfarct intraneural RhoA activity, but did not neuroprotect RGCs after rAION. CONCLUSIONS: Sudden ON ischemia results in previously unrecognized axonal demyelination, which may have a clinically important role in NAION-related functional defects and recovery. Granulocyte-macrophage colony-stimulating factor is not neuroprotective when administered directly to the optic nerve following ON ischemia, and does not improve axonal regeneration. It dramatically increases ON-microglial activation and recruitment.

Cellular inflammation in nonarteritic anterior ischemic optic neuropathy and its primate model.

OBJECTIVE: To correlate potential inflammatory responses in nonarteritic anterior ischemic optic neuropathy (NAION) with a lesion possessing many physiologic and histologic similarities from a model of nonhuman primate NAION (pNAION). METHODS: Using immunohistochemistry and confocal microscopic analysis, we evaluated the relative numbers of inflammatory cell types in the single available clinical specimen of early NAION (21 days after event). We correlated this with the temporal inflammatory response occurring in optic nerve tissue at different times following pNAION induction. RESULTS: In pNAION, there is a previously unsuspected infiltration of polymorphonuclear leukocytes occurring almost immediately after infarct induction, followed by invasion of ED1+ extrinsic macrophages, which peaks 5 weeks after infarct. Intrinsic microglia accumulate up to 70 days after induction in the area of primary axonal loss. The analyzed human NAION specimen was similar to 21-day pNAION tissue, with extrinsic macrophages and intrinsic microglial cells in the region of focal axon loss. CONCLUSIONS: Cellular inflammation plays a major early role following white-matter (optic nerve) infarct, with both polymorphonuclear leukocyte and macrophage function involved in debris elimination and tissue remodeling. The optic nerve in NAION and its primate model are associated with early cellular inflammation, previously unsuspected, that may contribute to postinfarct optic nerve damage.