Primary Retroperitoneal Mucinous Cystadenocarcinoma: A Case Report.

Mucinous neoplasms are commonly seen in the ovaries and pancreas. Their occurrence in the retroperitoneum is uncommon. We present a case of a retroperitoneal mucinous cystadenocarcinoma in a 54-year-old female who presented with right flank pain. Imaging demonstrated an 8.6 × 7.9 cm mass at the anterior surface of the lower pole of the right kidney, suspicious for renal cell carcinoma. Serum tumor markers carbohydrate antigen 19-9 (CA 19-9) and cancer embryonic antigen (CEA) were within normal limits, and cancer antigen 125 (CA 125) was elevated. Surgical resection of the mass was performed. Intraoperatively, the mass was noted to lie in the retroperitoneum, unattached to the kidney. On gross examination, a 10.0 × 7.0 × 7.0 cm unilocular cystic structure with red-brown mucoid material was present. The inner lining was mostly smooth with areas of excrescences, covering less than 5% of the surface area. Microscopic examination showed cystic areas lined by mucinous epithelium with an underlying ovarian-type stroma. Solid areas showed features of a borderline papillary mucinous tumor with invasive carcinoma. A diagnosis of mucinous cystadenocarcinoma was made. Their occurrence in the retroperitoneum is unusual. Although rare, this entity should always be considered in the differential diagnosis of retroperitoneal cystic lesions.

National Implementation and Evaluation of a Virtual Subinternship in Urology.

OBJECTIVE: To conduct a nationwide evaluation of student and program director (PD) perspectives of virtual subinternships that took place during the COVID-19 pandemic. MATERIALS AND METHODS: In December 2020, we distributed anonymous surveys to all 534 urology residency applicants and 161 urology PDs at academic medical centers across the United States to evaluate virtual subinternships. Surveys assessed curriculum composition, goals, satisfaction, barriers, and future reusability. The primary outcome was overall satisfaction with the subinternship, evaluated on a 5-point Likert scale. RESULTS: The survey was completed by 174 students (33%) and 82 PDs (51%), including 81 students (47%) and 32 PDs (41%) who participated in virtual subinternships at 29 institutions. Overall, 77% of students and 78% of PDs rated the electives "excellent" or "very good." On ordinal logistic regression, higher student ratings were associated with duration ≥3 weeks (odds ratio [OR] 4.64, P = .003) and class size ≤4 students (OR 3.33, P = .015). Higher PD ratings were associated with full-time electives (OR 11.18, P = .019), class size ≤4 students (OR 13.99, P = .042), and utilization of the standardized Guidebook from the Society of Academic Urologists (OR 11.89, P = .038). The most commonly reported challenge to the subinternship's efficacy was lack of hands-on learning (87% of students and 81% of PDs). Looking forward, 45% of students and 66% of PDs recommended incorporating virtual components into future electives. CONCLUSION: The virtual subinternship was a coordinated nationwide initiative to provide urologic education to medical students during a pandemic. The most successful courses were structured with longer duration, full-time commitment, and small class size.

Can preoperative renal mass biopsy change clinical practice and reduce surgical intervention for small renal masses?

INTRODUCTION: The role of renal biopsy prior to surgical intervention for a renal mass remains controversial despite the fact that for all other urological organs except the testicle, biopsy inevitably precedes treatment as is true for all other specialties dealing with solid masses (e.g. thyroid, breast, colon, liver, etc.). Accordingly, we sought to determine the impact of a routine biopsy regimen on the course of patients with cT1a lesions in comparison with a contemporary series of cT1a individuals who went directly to treatment without a preoperative biopsy. METHODS: We analyzed a multi-institutional, prospectively maintained database of patients who underwent an office-based, ultrasound-guided, renal mass biopsy (RMB) for a cT1a renal mass (i.e. ≤4cm in largest dimension). Controls were selected from all patients in the database who had a cT1a renal lesion but did not undergo RMB. Both groups were analyzed for differences in treatment modality and surgical pathology results. RESULTS: A total of 72 RMB and 73 control patients were analyzed. The groups were similar in regards to their baseline characteristics. Overall RMB diagnostic rate was 75%. Surgical pathology revealed that excision of benign tumors was eight-fold less in the RMB cohort compared to the control group (3% vs. 23%; P < 0.001). Additionally, the rate of active surveillance in the RMB cohort was nearly three times higher at 35% vs. 14% for the controls (P < 0.001). Biopsy was concordant with surgical pathology in 97% of cases for primary histology (i.e. benign vs. malignant), 97% for histologic subtype, and 46% for low (I or II) vs. high (III or IV) grade. On multivariate analysis patients who underwent surgical intervention without preoperative RMB were 6.7 times more likely to have benign histopathology compared to patients who underwent preoperative RMB (OR 6.7, 95% CI = 0.714 - 63.626, P = 0.096). There were no procedural or post-procedural RMB complications. CONCLUSIONS: For patients with cT1a lesions, the implementation of routine office-based RMB led to a significant decrease in the rate of surgical intervention for benign tumors. This practice also resulted in a higher rate of active surveillance for the management of renal cortical neoplasms with benign histopathology compared to a control group.

Laser scanner for 3D reconstruction of a wound's edge and topology.

PURPOSE: Robotic systems have the potential to overcome inherent limitations of humans and offer substantial advantages to patients including reduction in surgery time. Our group has undertaken the challenge of developing autonomous wound closure system. One of the initial steps is to allow accurate assessment of wound skin topology and wound edge location. We present a vision-laser scanner to generate 3D point cloud for 3D reconstruction of wound's edge and topology. METHODS: When the laser range sensor measures Z coordinate, two encoders installed on the actuators of the gantry robot provide the precision values of X, Y coordinates simultaneously. The 3D point cloud of the wound skin is generated by recordings of X, Y and Z during scanning is performed over wound skin surface. To reduce the scanning time, we exploit a supplementary laser LED to project a regular laser spot on the wound skin surface, which can provide an additional measurement point by incorporating artificial neural network estimation approach. In the meantime, the point cloud of the wound edge can be extracted by detecting if the laser spot is located on the wound edge in the image from 2D camera. RESULTS: The mean absolute error (MAE) and standard deviation (σ) of wound edge are measured in MeshLab environment. The MAE (σ) in X (tangent), Y (tangent), and Z (normal) are 0.32 (0.22) mm, 0.37 (0.34) mm, and 0.61 (0.29) mm, respectively. The experimental results demonstrate that the vision-laser scanner attains high accuracy in determining wound edge location along the tangent of the wound skin. CONCLUSION: A vision-laser scanner is developed for 3D reconstruction of wound's edge and topology. The experimental tests on the different wound models revealed the effectiveness of the vision-laser scanner. The proposed scanner can generate 3D point cloud of the wound skin and its edge simultaneously, and thus significantly improve the accuracy of wound closure in clinical applications.

Feasibility and Utility of Mobile Applications for the Evaluation of Urology Residents' Surgical Competence.

OBJECTIVE: To provide real-time assessment and feedback on the competency of urology residents' surgical skill via mobile applications and examine their feasibility and utility. MATERIALS AND METHODS: Two mobile application-based systems (SIMPL and myTIPreport) were sequentially implemented for the case-by-case assessment of residents' performance of surgical skills at a single institution. Data was collected regarding residents' perception of their feedback pre- and post-implementation of the applications. Faculty were surveyed after their implementation to determine their feasibility and utility. RESULTS: 297 individual evaluations were completed with SIMPL and 822 with myTIPreport over four and eleven months respectively. Post-implementation, residents showed significantly improved perceptions regarding the quantity and personalization of surgical skill feedback (P = .043 and .005 respectively). A majority (75%) of the faculty found the mobile applications feasible to use, an improvement compared to prior methods of resident evaluation, and would recommend continued use. CONCLUSION: This study represents the first documented use of real-time surgical competency assessment in urology. The use of mobile applications to evaluate urology residents' surgical competency in clinical practice is both feasible and useful. Their use may allow for more individualized surgical skill teaching during training and for the verification of the surgical skills necessary to practice autonomously.

Changing the Status Quo: Developing a Virtual Sub-Internship in the Era of COVID-19.

PROBLEM: Subinternships are integral to medical education as tools for teaching and assessing fourth-year medical students. Social distancing due to COVID-19 has precluded the ability to offer in-person subinternships - negatively impacting medical education and creating uncertainty surrounding the residency match. With no precedent for the development and implementation of virtual subinternships, the Society of Academic Urologists (SAU) developed an innovative and standardized curriculum for the Virtual Subinternship in Urology (vSIU). METHODS: The vSIU committee's mandate was to create a standardized curriculum for teaching foundational urology and assessing student performance. Thirty-three members from 23 institutions were divided into working groups and given 3 weeks to develop 10 modules based on urologic subspecialties, Accreditation Council for Graduate Medical Education core competencies, technical skills training and student assessment. Working groups were encouraged to develop innovative learning approaches. The final curriculum was assembled into the "vSIU Guidebook." RESULTS: The vSIU Guidebook contains 212 pages - 64 pages core content and 2 appendices (patient cases and evaluations). It outlines a detailed 4-week curriculum with a sufficient volume of resources to offer a completely adaptable virtual course with the same rigor as a traditional subinternship. Modules contain curated teaching resources including journal articles, lectures, surgical videos and simulated clinical scenarios. Innovative learning tools include reflective writing, mentorship guidelines, videoconference-based didactics, surgical simulcasting and virtual technical skills training. The guidebook was disseminated to program directors nationally. NEXT STEPS: The vSIU is the first virtual subinternship in any specialty to be standardized and offered nationally, and it was implemented by at least 19 urology programs. This curriculum serves as a template for other specialties looking to develop virtual programs and feedback from educators and students will allow the curriculum to evolve. As the pandemic continues to challenge our paradigm, this rapid and innovative response exemplifies that the medical community will continue to meet the needs of an ever-changing educational landscape.

Prognostic Molecular Signatures for Metastatic Potential in Clinically Low-Risk Stage I and II Clear Cell Renal Cell Carcinomas.

Introduction: For patients with localized node-negative (Stage I and II) clear cell renal cell carcinomas (ccRCC), current clinicopathological staging has limited predictive capability because of their low risk. Analyzing molecular signatures at the time of nephrectomy can aid in understanding future metastatic potential. Objective: Develop a molecular signature that can stratify patients who have clinically low risk ccRCC, but have high risk genetic changes driving an aggressive metastatic phenotype. Patients, Materials, and Methods: Presented is the differential expression of mRNA and miRNA in 44 Stage I and Stage II patients, 21 who developed metastasis within 5 years of nephrectomy, compared to 23 patients who remained disease free for more than 5 years. Extracted RNA from nephrectomy specimens preserved in FFPE blocks was sequenced using RNAseq. MiRNA expression was performed using the TaqMan OpenArray qPCR protocol. Results: One hundred thirty one genes and 2 miRNA were differentially expressed between the two groups. Canonical correlation (CC) analysis was applied and four CCs (CC32, CC20, CC9, and CC7) have an AUC > 0.65 in our dataset with similar predictive power in the TCGA-KIRC dataset. Gene set enrichment showed CC9 as kidney development/adhesion, CC20 as oxidative phosphorylation pathway, CC32 as RNA binding/spindle and CC7 as immune response. In a multivariate Cox model, the four CCs were able to identify high/low risk groups for metastases in the TCGA-KIRC (p < 0.05) with odds ratios of CC32 = 5.7, CC20 = 4.4, CC9 = 3.6, and CC7 = 2.7. Conclusion: These results identify molecular signatures for more aggressive tumors in clinically low risk ccRCC patients who have a higher potential of metastasis than would be expected.

Laparoscopic Partial Nephrectomy.

Renal cell carcinoma has historically been managed by radical nephrectomy, but as knowledge of the disease has advanced, nephron sparing surgery has become the norm in appropriately selected tumors. Laparoscopic partial nephrectomy (LPN) has been shown to have comparable oncologic outcomes and a shorter convalescence period compared to the traditional open partial nephrectomy. Dissemination of techniques has led to significantly increased use of minimally invasive nephron sparing surgery, and LPN remains a cost-effective and efficacious method for approaching small renal masses.

Primary renal Ewing Sarcoma masquerading as Wilms in an adolescent female.

Primary renal Ewing's sarcoma (ES) of the kidney represents a rare oncologic entity belonging to the collection of small round cell tumors, which typically feature osseous presentations. Renal ES is an aggressive disease entity with high metastatic potential, either at time of presentation or following initial extirpative therapy. Herein, we report the case of a 14-year-old female who initially presented with intermittent gross painless hematuria and a large left renal mass identified on ultrasound and confirmed on follow up MRI. Following partial nephrectomy (PN), patient was diagnosed with primary renal ES and subsequently underwent completion nephrectomy and chemotherapy.

Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis.

PURPOSE: The primary rationale for antimicrobial prophylaxis (AP) is to decrease the incidence of surgical site infection (SSI) and other preventable periprocedural infections, with the secondary goal of reducing antibiotic overuse. This Best Practice Statement (BPS) updates the prior American Urological Association (AUA) BPS and creates a comprehensive and user-friendly reference for clinicians caring for adult patients who are undergoing urologic procedures. MATERIALS AND METHODS: Recommendations are based on a review of English language peer-reviewed literature from 2006 through October 2018 and were made by consensus by a multidisciplinary panel. The search parameters included timing, re-dosing, and duration of AP across urologic procedures where there was the possibility of SSI. Excluded from the search were the management of infections outside the genitourinary (GU) tract and pediatric procedures. RESULTS: Single-dose AP is recommended for most urologic cases and antimicrobials should only be used when medically necessary, for the shortest duration possible, and not beyond case completion. Surgeons are the most accurate discerners of an SSI, and should use standard definitions to make better calculations of patient risk. The risk classification developed is dependent on the likelihood of developing SSI, and not the associated consequences of SSI. CONCLUSIONS: The AUA developed a multi-disciplinary BPS to guide clinicians on the proper usage of AP across urologic procedures and wound classifications. It is recommended that the lowest dose of antimicrobials be administered to decrease the risk of infection and to minimize the risk of drug-resistant organisms.

Weighted Gleason Grade Group (WGGG): A new prostate cancer biopsy reporting system with prognostic potential.

INTRODUCTION: Presently, prostate biopsy (PBx) results report the highest Gleason Grade Group (GGG) as a single metric that gauges the overall clinical aggressiveness of cancer and dictates treatment. We hypothesized a PBx showing multiple cores of cancer with more volume cancer per core would represent more aggressive disease. We propose the Weighted Gleason Grade Group (WGGG), a novel scoring system that synthesizes all histopathologic data and cancer volume into a single numeric value representing the entire PBx, allowing for improved prediction of adverse pathology and risk of biochemical recurrence (BCR) following radical prostatectomy (RP). METHODS: We studied 171 men who underwent RP after standard PBx. The WGGG was calculated by summing each positive core using the formula: GGG + (GGG x %Ca/core). RP pathology was evaluated for extraprostatic extension (EPE), positive surgical margins (PSM), seminal vesicle invasion (SVI), and lymph node involvement (LNI), and patients were followed for BCR. We compared GGG vs. WGGG receiver operating characteristic curves for each outcome, and determined the predictive capability of GGG and WGGG to identify patients with BCR. Categorized WGGG groups were created based on risk of BCR using classification and regression tree analysis. We then sought to externally validate WGGG in a cohort of 389 patients in a separate institutional dataset. RESULTS: In the development cohort, area under the curves (AUCs) for the WGGG vs. GGG were significantly higher for predicting EPE (0.784 vs. 0.690, P = 0.002), SVI (AUC 0.823 vs. 0.721, P = .014), LNI (AUC 0.862 vs. 0.823, P = 0.039), and PSM (AUC 0.638 vs. 0.575, P = 0.031. Analysis of the validation cohort showed similar findings for EPE (AUC 0.764 vs. 0.729, P = 0.13), SVI (AUC 0.819 vs. 0.749, P = 0.01), LNI (AUC 0.939 vs. 0.867, P = 0.02), and PSM (AUC 0.624 vs. 0.547, P = 0.04). Patients with WGGG >30 (high-risk group) demonstrated ∼50% failure at 2 years in both cohorts. CONCLUSIONS: The WGGG, by providing a metric reflecting the entirety of the PBx, is more informative than conventional single GGG alone in identifying adverse pathologic outcomes and risk of BCR following RP. This superior discriminatory capability has been achieved without any consideration of other commonly available clinical disease characteristics.

Implementation of multiparametric magnetic resonance imaging technology for evaluation of patients with suspicion for prostate cancer in the clinical practice setting.

OBJECTIVES: To investigate the impact of implementing magnetic resonance imaging (MRI) and ultrasonography fusion technology on biopsy and prostate cancer (PCa) detection rates in men presenting with clinical suspicion for PCa in the clinical practice setting. PATIENTS AND METHODS: We performed a review of 1 808 consecutive men referred for elevated prostate-specific antigen (PSA) level between 2011 and 2014. The study population was divided into two groups based on whether MRI was used as a risk stratification tool. Univariable and multivariable analyses of biopsy rates and overall and clinically significant PCa detection rates between groups were performed. RESULTS: The MRI and PSA-only groups consisted of 1 020 and 788 patients, respectively. A total of 465 patients (45.6%) in the MRI group and 442 (56.1%) in the PSA-only group underwent biopsy, corresponding to an 18.7% decrease in the proportion of patients receiving biopsy in the MRI group (P < 0.001). Overall PCa (56.8% vs 40.7%; P < 0.001) and clinically significant PCa detection (47.3% vs 31.0%; P < 0.001) was significantly higher in the MRI vs the PSA-only group. In logistic regression analyses, the odds of overall PCa detection (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.29-2.35; P < 0.001) and clinically significant PCa detection (OR 2.04, 95% CI 1.48-2.80; P < 0.001) were higher in the MRI than in the PSA-only group after adjusting for clinically relevant PCa variables. CONCLUSION: Among men presenting with clinical suspicion for PCa, addition of MRI increases detection of clinically significant cancers while reducing prostate biopsy rates when implemented in a clinical practice setting.

Multi-institutional Evaluation of Producing and Testing a Novel 3D-Printed Laparoscopic Trainer.

OBJECTIVE: To create, distribute, and evaluate the efficacy of a portable, cost-effective 3D-printed laparoscopic trainer for surgical skills development. METHODS: The UCI Trainer (UCiT) laparoscopic simulator was developed via computer-aided designs (CAD), which were used to 3D-print the UCiT. Once assembled, a tablet computer with a rear-facing camera was attached for video and optics. Four institutions were sent the UCiT CAD files with a 3D-printer and instructions for UCiT assembly. For a comparison of the UCiT to a standard trainer, peg transfer and intracorporeal knot tying skills were accessed. These tasks were scored, and participants were asked to rate their experience with the trainers. Lastly, a questionnaire was given to individuals who 3D-printed and assembled the UCiT. RESULTS: We recruited 25 urologists; none had any 3D-printing experience. The cost of printing each trainer was $26.50 USD. Each institution used the Apple iPad for optics. Six of eight participants assembled the UCiT in < 45 minutes, and rated assembly as somewhat easy. On objective scoring, participants performed tasks equally well on the UCiT vs the conventional trainer. On subjective scoring, the conventional trainer provided a significantly better experience vs the UCiT; however, all reported that the UCiT was useful for surgical education. CONCLUSION: The UCiT is a low cost, portable training tool that is easy to assemble and use. UCiT provided a platform whereby participants performed laparoscopic tasks equal to performing the same tasks on the more expensive, nonportable standard trainer.