Assessing the safety of minimally invasive partial nephrectomy in octogenarians.

As life expectancy continues to rise, there is a growing cohort of octogenarians that can have oncologic benefit from a partial nephrectomy. This study aims to analyze a large national dataset to compare the safety and outcomes in octogenarians receiving a nephrectomy. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was utilized. All subjects 80-89 years old who received a minimally invasive partial nephrectomy (CPT: 50543) or radical nephrectomy (CPT: 50545, 50546) from 2016 to 2020 were included. Baseline characteristics, comorbidities, and postoperative complications were compared. Chi-square analysis and student t-tests were used to analyze categorical and continuous variables, respectively. 1765 procedures were performed on octogenarians, of which 1299 (73.6%) received a radical nephrectomy and 466 (26.4%) received a partial nephrectomy. When comparing preoperative comorbidities, octogenarians undergoing partial nephrectomy had lower rates of dyspnea at exertion (7.3 vs. 10.6%, p = 0.04), COPD (2.8 vs. 5.9%, p = 0.01), and chronic steroid use (1.5 vs. 3.3%, p = 0.04). No statistically significant differences were seen in any minor (Clavien 1/2) or major post-operative complications (Clavien 3/4). Readmissions were higher in those who received a partial nephrectomy (10.5 vs. 6.5%, p = 0.01); however, there were no significant differences in reoperation (2.4 vs. 1.7%, p = 0.36) or mortality (1.3 vs. 1.8%, p = 0.48). Partial nephrectomy is a safe and feasible operation in octogenarians. Preoperative counseling and appropriate patient selection remain imperative.

Can men 75 and older safely receive a minimally invasive radical prostatectomy?

Men 75 and older presenting with localized prostate cancer have traditionally not been managed with surgery. Therefore, we compared the morbidity and operative outcomes of radical prostatectomy (RP) in men 75 and older to their younger counterparts. We utilized the American College of Surgeons National Surgical Quality Improvement Program database to gather subjects who received a minimally invasive RP (CPT: 55866) from 2016 to 2020. This cohort was then stratified by age to compare men 18-74 years old and men 75 and older. The preclinical profile, complications, and outcomes were analyzed. Chi-square and Mann-Whitney U test were used to analyze categorical and continuous variables, respectively. Of the 48,485 men identified, 2,009 (4.1%) were ≥ 75 years old. Within the 75 and older cohort, the median age was 76 (IQR: 75-78), the median BMI was 27.3 (IQR: 24.9-29.9), and 1,601 (79.7%) were Caucasian. Men 75 and older had higher rates of Clavien 3 (1.3% vs. 0.8%, p = 0.02) and Clavien 4 (7.8% vs. 5.0%, p < 0.001) complications. Reoperative rates (1.7% vs. 1.1%, p = 0.01), readmission rates (6.5% vs. 4.1%, p < 0.001), and mortality (0.4% vs. 0.1%, p < 0.001) were all higher in men 75 and older. Multivariate analysis shows older age to be a risk factor for readmission (OR 1.58, 95%CI 1.31-1.90). Complications and 30-day outcomes remain within an acceptable range to offer surgery in men 75 and older. Age alone should not disqualify men from receiving a RP, but appropriate patient selection and counseling are necessary.

National Utilization, Reimbursement, and Urban Versus Rural Trends of Extracorporeal Shockwave Lithotripsy and Ureteroscopic Laser Lithotripsy.

OBJECTIVE: To describe temporal utilization and reimbursement trends of extracorporeal shockwave lithotripsy (ESWL) and ureteroscopy (URS) with laser lithotripsy. METHODS: The Medicare Provider Utilization and Payment Database was queried for all ESWL and URS performed between 2013 and 2020 using Current Procedural Terminology codes: ESWL - 50590; URS - 52352, 52353, 52356. Cases that lacked rural or urban identification codes were excluded. A total of 347,174 ESWL and 401,899 URS cases were identified. Linear regression was performed with statistical significance set to 95% confidence intervals. RESULTS: There was a significant upward trend for URS utilization over the study period (R2 = 0.91, P <.001), but there was not a significant trend for ESWL utilization. In 2013, ESWL was used more frequently than URS, but by 2016, URS was used more frequently than ESWL. From 2013 to 2019, URS utilization increased by 241% and 168% by urban and rural urologists, respectively. URS was also associated with a slight increase in physician reimbursement over time (R2 = 0.87, P <.001), whereas there was no association between ESWL and physician reimbursement. For URS, rural and urban urologists were reimbursed an average of $312.07 (standard deviation [SD] $14.03) and $404.86 (SD $21.96), respectively. For ESWL, rural and urban urologists were reimbursed an average of $456.22 (SD $5.74) and $562.66 (SD $16.68), respectively. CONCLUSION: According to the Medicare database, URS has surpassed ESWL in utilization, especially by urban urologists. Physician reimbursement for ESWL remained higher than URS reimbursement, though URS reimbursement increased slightly in recent years.

Same-Day Discharge After Robot-Assisted Partial Nephrectomy: Is It Worth It?

Introduction and Objective: Robot-assisted partial nephrectomy (RAPN) has traditionally been performed as an inpatient procedure; however, recent studies have suggested the feasibility of same-day discharge (SDD) after RAPN. We aimed to evaluate the safety and cost-effectiveness of SDD for RAPN. Methods: A retrospective analysis was conducted on patients undergoing RAPN between January 2015 and July 2021. Comparison before and after the implementation of an SDD protocol was assessed through differences in postanesthesia care unit (PACU) time, length of stay, 30-day readmission rate, 30-day return to emergency department (ED) rates, unplanned office visits (OVs), and need for secondary procedures. A cost-efficacy model was generated to estimate the difference in expenditure between SDD and inpatient RAPN. Results: In total, 192 patients underwent RAPN with 74 being SDD and 118 being admitted postoperatively. After SDD protocol implementation, the percentage of patients discharged from the PACU increased from 0% to 76%. The safety profile of SDD was similar to the inpatient group, with no differences in readmission rates (1.4% vs 5.1%, p = 0.18) or return to ED (5.4% vs 9.3%, p = 0.33). Compared with inpatient RAPN, SDD was associated with increased time in PACU (375 vs 251 minutes, p < 0.001), resulting in an additional expenditure of $1,622 per patient. SDD patients were more likely to return for one or more unplanned OVs (17.6% vs 6.8%, p = 0.02). Overall, the total cost of SDD was significantly lower than inpatient RAPN ($5,222 per patient vs $8,425, p < 0.001). Conclusion: Despite a shorter postoperative monitoring period, SDD appears safe, with equivalent readmission rates, return to ED, and secondary procedures. SDD for RAPN saves ∼$3,000 per patient. In implementing an SDD protocol, clinicians should be cognizant of increased demands on PACU infrastructure and be willing to provide additional support in the office setting.

Post-cystoscopy infections and device malfunctions in reprocessed flexible cystoscopes in a national database.

INTRODUCTION: Flexible cystoscopes can be multi-use devices that visually inspect genitourinary structures such as the bladder and urethra. The objective of this study is to characterize the adverse events and associated device malfunctions of reusable flexible cystoscopes and to provide information on contamination and post-procedural infections. MATERIALS AND METHODS: The Manufacturer and User Facility Device Experience (MAUDE) database was queried for all adverse events and device malfunctions related to the use of flexible cystoscopes between January 2015 and December 2020. The MAUDE adverse event classification system was used to standardize the severity of complications and special focus was taken to identify clusters of events related to a single device. RESULTS: A total of 335 adverse events related to flexible cystoscopes were identified. Most adverse events associated with patient harm were caused by infection (n = 121), which included 19 cases of sepsis, one ICU admission, and one death. Among the infections, 29 cases showed growth of the same organism in both the device and patient. There were five infectious outbreaks identified and each outbreak was attributed to a single cystoscope. Other adverse events included mechanical malfunction (n = 6) and allergic reaction (n = 1). CONCLUSIONS: Our findings highlight the risk of post-procedural infection associated with flexible cystoscope contamination. Further studies are needed to characterize the prevalence and incidence of flexible cystoscope contamination and to develop strategies to prevent post-procedural infection.

Robotic distal ureterectomy and re-implant for obstructing metastatic melanoma - surgical considerations in the palliative setting.

Non-urothelial malignant ureteral obstruction (MUO) causes hydronephrosis, renal damage and infectious sequelae. The overall condition, symptoms, and plans for systemic therapy inform urologic intervention. In well-selected cases, there is a role for definitive reconstruction. We describe a robotic-assisted distal ureterectomy and reimplant for definitive repair of obstructive metastatic melanoma.

Medications Most Commonly Associated With Erectile Dysfunction: Evaluation of the Food and Drug Administration National Pharmacovigilance Database.

BACKGROUND: Erectile dysfunction (ED) is an adverse effect of many medications. AIM: We used a national pharmacovigilance database to assess which medications had the highest reported frequency of ED. METHODS: The Food and Drug Administration Adverse Event Reporting System (FAERS) was queried to identify medications with the highest frequency of ED adverse event reports from 2010 to 2020. Phosphodiesterase-5 inhibitors and testosterone were excluded because these medications are often used as treatments for men with ED. The 20 medications with the highest frequency of ED were included in the disproportionality analysis. OUTCOMES: Proportional Reporting Ratios (PRRs) and their 95% confidence intervals were calculated. RESULTS: The 20 medications accounted for 6,142 reports of ED. 5-α reductase inhibitors (5-ARIs) and neuropsychiatric medications accounted for 2,823 (46%) and 2,442 (40%) of these reports respectively. Seven medications showed significant levels of disproportionate reporting with finasteride and dutasteride having the highest PRRs: 110.03 (103.14-117.39) and 9.40 (7.83-11.05) respectively. The other medications are used in a wide variety of medical fields such as cardiology, dermatology, and immunology. CLINICAL IMPLICATIONS: Physicians should be familiar with these medications and understand their respective mechanisms of action, so that they may counsel patients appropriately and improve their quality of life. STRENGTHS AND LIMITATIONS: The strength of the study is its large sample size and that it captures pharmacologic trends on a national level. Quantitative and comparative "real-world" data is lacking for the most common medications associated with ED. The limitation is that the number of reported events does not establish causality and cannot be used to calculate ED incidence rates. CONCLUSION: In a national pharmacovigilance database, 5-ARIs and neuropsychiatric medications had the highest reports of ED adverse effects. There were many other medications used in a variety of medical fields that were also associated with ED. Kaplan-Marans E, Sandozi A, Martinez M, et al. Medications Most Commonly Associated With Erectile Dysfunction: Evaluation of the Food and Drug Administration National Pharmacovigilance Database. Sex Med 2022;10:100543.

Device-related complications during renal cryoablation: insights from the Manufacturer and User Facility Device Experience (MAUDE) database.

INTRODUCTION AND OBJECTIVES: Cryoablation offers a treatment option for small renal masses ideally suited ≤3 cm. In well-selected candidates, it is associated with less perioperative morbidity compared to more invasive options, such as partial or radical nephrectomy. However, little is known regarding device-related complications associated with the procedure. We provide an analysis of reports on renal cryoablation from the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database. METHODS: Reports on renal cryoablation submitted to the MAUDE database from 2015 through 6/2021 were analyzed. Cases not pertaining to renal cryoablation were excluded (n = 33). Reports were examined to identify patient morbidity related to a potential device malfunction, as well as manufacturer assessment. Complications were graded based on an established MAUDE complication-reporting stratification. Fisher's Exact test was utilized to analyze for associations between device-related adverse events and severity of post-treatment sequelae. RESULTS: Two hundred and thirty-nine unique cases were identified. Adverse events were related to issues with the needles or system (212 cases), technical error (12 cases), or complication related to patient or tumor complexity (14 cases). There were 187 (78.6%) minor complications (MAUDE 1-2) and 52 (21.4%) major complications (MAUDE 3-4). The manufacturer performed formal device review in 164 (68.6%) cases, accepting responsibility for malfunction in 41. Notable MAUDE 3 complications included 29 (12.1%) cases aborted due to instrument/system malfunction and 14 (5.9%) cases of hemorrhage requiring a subsequent procedure. All 3 reported patient deaths (MAUDE 4) appeared to be a consequence of poor baseline health. On statistical analysis, major complications were seen in a significantly higher proportion of non-device related adverse events compared to device related events (85.2% vs. 13.7%, P < .001). CONCLUSION: While renal cryoablation is associated with low overall perioperative morbidity, there is a diverse set of device-related and procedural complications reported in recent years. Device-related adverse events were often associated with minor complications, and major complications were often seen in higher risk patients with comorbidities, more complex tumors, and after technical error. These findings highlight the need for standardized reporting of complications, optimized patient selection and counseling to ensure the best outcomes.

Primary urethral melanoma treated sucessfully with wide excision and combination immunotherapy: Case report and review of literature.

We report the rare case of a primary malignant melanoma of the urethra. An 89-year-old African American woman who was referred to our urology clinic for intermittent gross hematuria and a palpable vaginal mass of two months duration. Cystoscopy revealed a 3 cm mass in the distal urethra and urethral meatus that was surgically resected by wide local excision. The histopathologic diagnosis was primary malignant melanoma of the urethra. The patient was subsequently treated with adjuvant EBRT and immunotherapy with nivolumab and ipilimumab. Post-treatment PET-CT showed good response to treatment and patient remained in remission at eight month follow up.

Molecular biomarkers in the context of focal therapy for prostate cancer: recommendations of a Delphi Consensus from the Focal Therapy Society.

BACKGROUND: Focal therapy (FT) for prostate cancer (PCa) is promising. However, long-term oncological results are awaited and there is no consensus on follow-up strategies. Molecular biomarkers (MB) may be useful in selecting, treating and following up men undergoing FT, though there is limited evidence in this field to guide practice. We aimed to conduct a consensus meeting, endorsed by the Focal Therapy Society, amongst a large group of experts, to understand the potential utility of MB in FT for localized PCa. METHODS: A 38-item questionnaire was built following a literature search. The authors then performed three rounds of a Delphi Consensus using DelphiManager, using the GRADE grid scoring system, followed by a face-to-face expert meeting. Three areas of interest were identified and covered concerning MB for FT, 1) the current/present role; 2) the potential/future role; 3) the recommended features for future studies. Consensus was defined using a 70% agreement threshold. RESULTS: Of 95 invited experts, 42 (44.2%) completed the three Delphi rounds. Twenty-four items reached a consensus and they were then approved at the meeting involving (N.=15) experts. Fourteen items reached a consensus on uncertainty, or they did not reach a consensus. They were re-discussed, resulting in a consensus (N.=3), a consensus on a partial agreement (N.=1), and a consensus on uncertainty (N.=10). A final list of statements were derived from the approved and discussed items, with the addition of three generated statements, to provide guidance regarding MB in the context of FT for localized PCa. Research efforts in this field should be considered a priority. CONCLUSIONS: The present study detailed an initial consensus on the use of MB in FT for PCa. This is until evidence becomes available on the subject.

Representation in Figures Depicting Penile Pathology in Urologic Textbooks.

OBJECTIVE: To investigate whether penile pathologies are presented diversely in urologic textbooks and identify areas where more diverse presentation is warranted. METHODS: Photographic depictions of penile pathologies in 9 urologic textbooks were assigned a Fitzpatrick skin phototype and constitutive skin color. Fitzpatrick skin phototypes ranged from I to VI, and constitutive skin colors were light, fair, medium, and dark. Fitzpatrick skin phototypes I-III were deemed nonskin of color, and IV-VI considered skin of color. Figures were classified based on pathology presented: infectious benign or sexually transmitted infection (STI), noninfectious benign, or malignant. Chi-square and odds ratios were used to compare skin color ranges across pathologic categories and determine where a figure depicting skin color would most likely be encountered. RESULTS: Within 116 figures meeting inclusion criteria, 15 (51.7%) infectious/STI pathologies displayed skin of color, while 10 (27.8%) noninfectious benign and 7 (13.7%) malignant pathologies displayed skin of color. Within 85 diagnostic images, 15 (51.7%) images of infections/STIs, 10 (28.6%) noninfectious benign, and 4 (19.0%) malignant pathologies presented skin of color (P < 0.01). Overall, images of patients with skin of color were more likely depictions of infections/STIs than any other pathology (P < .001, OR = 2.26). CONCLUSION: There is a lack of depictions of malignant and noninfectious benign penile pathology on the skin of color. This may contribute to continued disparities in the diagnosis and treatment of penile pathologies.

Aquablation, Prostatic Urethral Lift, and Transurethral Water Vapor Therapy: A Comparison of Device-Related Adverse Events in a National Registry.

Purpose: Aquablation, prostatic urethral lift (PUL), and transurethral water vapor therapy (TWVT) have demonstrated efficacy for the treatment of benign prostatic hyperplasia (BPH). Our objective was to describe device malfunctions and complications to help guide procedural selection and performance. Materials and Methods: The Manufacturer and User Facility Device Experience (MAUDE) database was examined for reports related to the use of these three procedures for the treatment of BPH between January 1, 2015, and July 1, 2020. Reports were evaluated for device malfunctions and surgical complications using a previously described externally validated classification system developed for the MAUDE database. Chi square analysis was used for statistical comparison between groups. Results: A total of 391 adverse events were reported: aquablation (n = 102), PUL (n = 132), and TWVT (n = 157). There were 79 (78%) severe or life-threatening adverse events for aquablation vs 69 (52%) for PUL vs 24 (15%) for TWVT (p < 0.001). There were 4 cases of rectal perforation with aquablation and 25 cases of the PUL implants needing to be removed or causing a problem with a later procedure. Blood transfusion frequencies were aquablation-32 (31%), PUL-21 (16%), and TWVT-1 (1%). The most common device malfunctions were: aquablation-motion error (n = 8), handpiece fracture/attachment malfunction (n = 8); PUL-device misfire (n = 27), needle fragmentation (n = 21); TWVT-unresolvable error message (n = 19). Conclusions: In a national database, aquablation and PUL had noteworthy complications or device-related malfunctions such as rectal perforation and the improper placement or failed deployment of the PUL implants. Both patients and providers should be aware of potential risks when selecting these novel BPH treatments.

Testicular pure seminoma in a septuagenarian with a left-ventricular assist device.

The left ventricular assist device (LVAD) is an implanted mechanical pump that supports circulatory function for patients with advanced heart failure. LVAD survival has continuously improved over the last decade with an increasing number of patients requiring non-cardiac surgeries. We discuss a 77-year-old, LVAD-dependent male with an enlarging, indurated right testicular mass. Radical inguinal orchiectomy confirmed pure seminoma. The case highlights perioperative considerations in this unique cohort of patients.

Implementation and Impact of a Risk-Stratified Prostate Cancer Screening Algorithm as a Clinical Decision Support Tool in a Primary Care Network.

BACKGROUND: Implementation methods of risk-stratified cancer screening guidance throughout a health care system remains understudied. OBJECTIVE: Conduct a preliminary analysis of the implementation of a risk-stratified prostate cancer screening algorithm in a single health care system. DESIGN: Comparison of men seen pre-implementation (2/1/2016-2/1/2017) vs. post-implementation (2/2/2017-2/21/2018). PARTICIPANTS: Men, aged 40-75 years, without a history of prostate cancer, who were seen by a primary care provider. INTERVENTIONS: The algorithm was integrated into two components in the electronic health record (EHR): in Health Maintenance as a personalized screening reminder and in tailored messages to providers that accompanied prostate-specific antigen (PSA) results. MAIN MEASURES: Primary outcomes: percent of men who met screening algorithm criteria; percent of men with a PSA result. Logistic repeated measures mixed models were used to test for differences in the proportion of individuals that met screening criteria in the pre- and post-implementation periods with age, race, family history, and PSA level included as covariates. KEY RESULTS: During the pre- and post-implementation periods, 49,053 and 49,980 men, respectively, were seen across 26 clinics (20.6% African American). The proportion of men who met screening algorithm criteria increased from 49.3% (pre-implementation) to 68.0% (post-implementation) (p < 0.001); this increase was observed across all races, age groups, and primary care clinics. Importantly, the percent of men who had a PSA did not change: 55.3% pre-implementation, 55.0% post-implementation. The adjusted odds of meeting algorithm-based screening was 6.5-times higher in the post-implementation period than in the pre-implementation period (95% confidence interval, 5.97 to 7.05). CONCLUSIONS: In this preliminary analysis, following implementation of an EHR-based algorithm, we observed a rapid change in practice with an increase in screening in higher-risk groups balanced with a decrease in screening in low-risk groups. Future efforts will evaluate costs and downstream outcomes of this strategy.

Retained Urethral Foley Catheter: A Rare Cause of Total Incontinence After Transurethral Resection of the Prostate.

Background: Surgical therapy for benign prostatic obstruction is indicated after failure of medical therapy or in the presence of secondary side effects. Transurethral resection of the prostate (TURP) is the most well-established intervention. Urinary incontinence is the most distressing complication after TURP and may occur secondary to transient stress incontinence, unmasked neurogenic dysfunction, or iatrogenic injury to the external sphincter. Case Presentation: We present a 71-year-old man with total incontinence after TURP from a retained urethral Foley catheter after attempted self-extraction. Conclusion: The transected catheter was removed under general anesthesia with a larger grasper through a rigid cystoscope.

Rethinking the need for overnight admission after robotic-assisted laparoscopic prostatectomy.

Robotic-assisted laparoscopic prostatectomy (RALP) is the gold standard for the surgical management of localized prostate cancer (PCa). Multi-institutional series have demonstrated complications and readmissions in less than 5% of patients and most are now discharged within 24 h of surgery. Recently, several high-volume surgeons demonstrated the safety of same-day discharge (SDD) after RALP. The main benefits include lower costs and reduced exposure to nosocomial infections and hospital errors. The leading arguments for criticism include potential suboptimal postoperative care and the risk of missing a catastrophic event. In recent years, important advances have further strengthened the argument for SDD including more structured perioperative care, integration of single-port robotic systems, and new challenges presented by the coronavirus 2019 (COVID-19) pandemic. Here, we provide further evidence demonstrating the safety of SDD in a multi-institutional cohort of patients and review the main arguments supporting the expanded use of this approach.