A Comparison of Urological Consultations in a Private vs Academic Setting.

INTRODUCTION: This study aims to determine the differences between urological consulting service utilization in an academic setting compared to a private setting at a single institution during its transition from private to academic medical center. METHODS: A retrospective review of patients undergoing inpatient urology consultation from July 2014 to June 2019 was performed. Consults were weighted using patient-days to account for hospital census. RESULTS: A total of 1,882 inpatient urology consults were ordered, with 763 occurring prior to and 1,187 occurring after transition to academic medical center. Consults were placed more frequently in the academic than private setting (6.8 vs 4.5 consults/1,000 patient-days, P < .00001). The monthly consult rate in the private setting remained steady throughout the year, while the academic rate rose and then fell in accordance with the academic calendar, until statistically equaling the private rate in the final month of the academic year. Urgent consults were more likely to be ordered in the academic setting (7.1% vs 3.1%, P < .001), along with consults for urolithiasis (18.1% vs 12.6%, P < .001). Retention consults were more common in the private setting (23.7% vs 18.3%, P < .001). CONCLUSIONS: In this novel analysis, we demonstrated that significant differences exist between inpatient urological consult use in private and academic medical centers. Consults are ordered more frequently in academic hospitals until the end of the academic year, suggesting a learning curve for academic hospital medicine services. Recognition of these practice patterns identifies a potential opportunity to decrease the number of consultations through improved physician education.

The effect of day of discharge on hospital readmission after minimally invasive partial nephrectomy.

INTRODUCTION: To assess the association between postoperative discharge day after minimally invasive partial nephrectomy with 30-day readmission rates, and specifically compare postoperative day 1 to postoperative day 2 discharge. We hypothesized that discharge on earlier postoperative days would be associated with higher rates of readmission after partial nephrectomy. MATERIALS AND METHODS: The National Cancer Database was queried for patients undergoing minimally invasive partial nephrectomy for non-metastatic disease without chemo or radiation therapy from 2010-2014. Readmission rates were compared between postoperative discharge days. Multivariable logistic regression was used to analyze variables associated with 30-day readmission. RESULTS: A total of 19,300 patients undergoing minimally invasive partial nephrectomy were included, comprising patients discharged on postoperative day 0 (POD0) (n = 601, 3%), POD1 (n = 2,999, 16%), POD2 (n = 6,866, 36%), POD3 (n = 4,568, 24%), POD4 (n = 2,068, 11%), and POD5 or later (n = 2,198, 11%). Rates of 30-day readmission were similar between POD0, POD1 and POD2 discharges (1.8%, 1.9%, 2.2%, respectively), but were higher for discharges on POD3 or later (POD3 3.0%, POD4 4.9%, POD5 or greater 5.5%). On multivariable analysis, odds of 30-day readmission were similar between POD0 (OR 0.83 [95%CI 0.45-1.55], p = 0.56) and POD1 (OR 0.84 [95%CI 0.62-1.15], p = 0.28) compared to discharge on POD2. CONCLUSIONS: Patients discharged on POD2 are not readmitted any less frequently than patients discharged on POD0 or POD1. Implementing protocols with POD1 as the default discharge day after partial nephrectomy should be considered. Future studies designing and evaluating safe and acceptable implementation strategies for these protocols are necessary.

Does Moses technology improve the efficiency and outcomes of standard holmium laser lithotripsy? A systematic review and meta-analysis.

Introduction: Retrograde ureteroscopy with holmium laser lithotripsy (HLL) is a standard treatment for urolithiasis. Moses technology has been shown to improve fragmentation efficiency in vitro; however, it is still unclear how it performs clinically compared to standard HLL. We performed a systematic review and meta-analysis evaluating the differences in efficiency and outcomes between Moses mode and standard HLL. Material and methods: We searched the MEDLINE, EMBASE, and CENTRAL databases for randomized clinical trials and cohort studies comparing Moses mode and standard HLL in adults with urolithiasis. Outcomes of interest included operative (operation, fragmentation, and lasing times; total energy used; and ablation speed) and perioperative parameters (stone-free rate and overall complication rate). Results: The search identified six studies eligible for analysis. Compared to standard HLL, Moses was associated with significantly shorter average lasing time (mean difference [MD] -0.95, 95% confidence interval [CI] -1.22 to -0.69 minutes), faster stone ablation speed (MD 30.45, 95% CI 11.56-49.33 mm3/min), and higher energy used (MD 1.04, 95% CI 0.33-1.76 kJ). Moses and standard HLL were not significantly different in terms of operation (MD -9.89, 95% CI -25.14 to 5.37 minutes) and fragmentation times (MD -1.71, 95% CI -11.81 to 8.38 minutes), as well as stone-free (odds ratio [OR] 1.04, 95% CI 0.73-1.49) and overall complication rates (OR 0.68, 95% CI 0.39-1.17). Conclusions: While perioperative outcomes were equivalent between Moses and standard HLL, Moses was associated with faster lasing time and stone ablation speeds at the expense of higher energy usage.

Perioperative Aspirin Use Is Associated with Bleeding Complications during Robotic Partial Nephrectomy.

PURPOSE: Daily aspirin use following cardiovascular intervention is commonplace and creates concern regarding bleeding risk in patients undergoing surgery. Despite its cardio-protective role, aspirin is often discontinued 5-7 days prior to major surgery due to bleeding concerns. Single institution studies have investigated perioperative outcomes of aspirin use in robotic partial nephrectomy (RPN). We sought to evaluate the outcomes of perioperative aspirin (pASA) use during RPN in a multicenter setting. MATERIALS AND METHODS: We performed a retrospective evaluation of patients undergoing RPN at 5 high volume RPN institutions. We compared perioperative outcomes of patients taking pASA (81 mg) to those not on aspirin. We analyzed the association between pASA use and perioperative transfusion. RESULTS: Of 1,565 patients undergoing RPN, 228 (14.5%) patients continued pASA and were older (62.8 vs 56.8 years, p <0.001) with higher Charlson scores (mean 3 vs 2, p <0.001). pASA was associated with increased perioperative blood transfusions (11% vs 4%, p <0.001) and major complications (10% vs 3%, p <0.001). On multivariable analysis, pASA was associated with increased transfusion risk (OR 1.94, 1.10-3.45, 95% CI). CONCLUSIONS: In experienced hands, perioperative aspirin 81 mg use during RPN is reasonable and safe; however, there is a higher risk of blood transfusions and major complications. Future studies are needed to clarify the role of antiplatelet therapy in RPN patients requiring pASA for primary or secondary prevention of cardiovascular events.

Reducing Pseudoaneurysm and Urine Leak After Robotic Partial Nephrectomy: Results Using the Early Unclamping Technique.

OBJECTIVE: To present our experience using the early unclamping technique for robotic partial nephrectomy with particular attention to delayed complications, namely pseudoaneurysm and urine leak. We hypothesized that early hilar unclamping allows for improved control of end arteries and renorrhaphy after tumor resection, reducing overall delayed complications after partial nephrectomy with no increased risk of blood transfusion. METHODS: This single institution retrospective review of a prospectively maintained database includes patients undergoing robotic partial nephrectomy with early unclamping technique for presumed renal malignancy between 2009 and 2018. Patient demographics and perioperative parameters are described, particularly rates of pseudoaneurysm and urine leak. Results are compared to previously published partial nephrectomy studies using various clamping and renorrhaphy techniques. RESULTS: Four hundred and sixty three patients were included in the study. Mean operative time and warm ischemia time were 186 and 14.7 minutes, respectively. Mean estimated blood loss was 242 cc. Thirty-day postoperative complication rate was 14.7%, with 88% of these Clavien I-II. Urine leak occurred in 1 patient (0.2%) undergoing a simultaneous partial nephrectomy and pyelothitotomy for partial staghorn stone. Postoperative transfusion rate was 1.33% and our pseudoaneurysm rate was 0%. CONCLUSION: The early unclamping technique for robotic partial nephrectomy is reliable and safe, with low pseudoaneurysm and urine leak rates which compare favorably to other published techniques.

Robot-assisted partial nephrectomy for large renal masses: a multi-institutional series.

OBJECTIVES: To compare peri-operative outcomes after robot-assisted partial nephrectomy (RAPN) for cT2a (7 to <10 cm) to cT1 tumours. MATERIALS AND METHODS: Patients with a cT1a (n = 1 358, 76.4%), cT1b (n = 379, 21.3%) or cT2a (n = 41, 2.3%) renal mass were identified from a multi-institutional RAPN database. Intra- and postoperative outcomes were compared for cT2a masses vs cT1a and cT1b masses using multivariable regression models (linear, logistic, Poisson etc.), adjusting for operating surgeon and a modified R.E.N.A.L. nephrometry score that excluded the radius component. RESULTS: The median sizes for cT1a, cT1b and cT2a tumours were 2.5, 5.0 and 8.0 cm, respectively (P < 0.001) with modified R.E.N.A.L. nephrometry scores being 6.0, 6.5 and 7.0, respectively (cT1a, P < 0.001; cT1b, P = 0.105). RAPN for cT2a vs cT1a masses was associated with a 12% increase in operating time (P < 0.001), a 32% increase in estimated blood loss (P < 0.001), a 7% increase in ischaemia time (P = 0.008), a 3.93 higher odds of acute kidney injury at discharge (95% confidence interval [CI] 1.33, 8.76; P = 0.009) and a higher risk of recurrence (hazard ratio [HR] 10.9, 95% CI 1.31, 92.2; P = 0.027). RAPN for cT2a vs cT1b masses was associated with a 12% increase in blood loss (P = 0.036), a 5% increase in operating time (P = 0.062) and a marginally higher risk of recurrence (HR 11.2, 95% CI 0.77, 11.5; P = 0.059). RAPN for cT2a tumours was not associated with differences in complications (cT1a, P = 0.535; cT1b, P = 0.382), positive margins (cT1a, P = 0.972; cT1b, P = 0.681), length of stay (cT1a, P = 0.507; cT1b, P = 0.513) or renal function decline up to 24 months post-RAPN (cT1a, P = 0.124; cT1b, P = 0.467). CONCLUSION: For T2a tumours RAPN is a feasible treatment option in a select patient population when performed by experienced surgeons in institutions equipped to manage postoperative complications. Although RAPN was associated with greater blood loss and longer operating and ischaemia time in T2a tumours, it was not associated with greater complication or positive surgical margin rates compared with T1 tumours. Renal function preservation rates were equivalent for up to 24 months postoperatively; however, 12-month recurrence-free survival was significantly lower in the T2a group. Extended follow-up is required to further evaluate long-term survival.

Comparison of perioperative and functional outcomes of robotic partial nephrectomy for cT1a vs cT1b renal masses.

OBJECTIVE: To compare perioperative and functional outcomes of patients with cT1a or cT1b renal masses undergoing robotic partial nephrectomy (RPN) in a large multi-institutional study PATIENTS AND METHODS: The present retrospective Institutional Review Board-approved multi-institutional study utilised a prospectively maintained database to identify patients undergoing RPN by six surgeons for a solitary cT1a (n = 1 307) or cT1b (n = 377) renal mass from 2006 to 2016. Perioperative and renal function outcomes at discharge and at a median follow-up of 12.2 months were compared in univariable and multivariable regression analyses adjusting for surgeon performing the procedure and date of surgery. RESULTS: In univariable analysis, cT1b masses were associated with longer operative time (190.0 vs 159.0 min, P < 0.001), longer warm ischaemia time (18.8 vs 15.0 min, P < 0.001), higher estimated blood loss (150.0 vs 100.0 mL, P < 0.001), more intraoperative complications (5.6% vs 2.4%, P = 0.034), and more surgical postoperative complications (10.1% vs 5.7%, P =0.002). Results were similar in multivariable analysis with additional findings including more overall postoperative complications (odds ratio 1.55, P = 0.015) and longer length of stay (P < 0.001) associated with cT1b masses. There were no differences in the risk of progression of chronic kidney disease stage at 12.2 months, positive surgical margins, or major postoperative complications. CONCLUSIONS: Although our study shows a longer operative time, longer warm ischemia time, and higher complication rate for patients undergoing RPN for cT1b renal masses, the magnitude of these differences is small. RPN should be considered for cT1b lesions when anatomical and spatial location allow for a feasible procedure.

Staged Fowler-Stephens and Single-stage Laparoscopic Orchiopexy for Intra-abdominal Testes: Is There a Difference? A Single Institution Experience.

OBJECTIVE: To compare single-stage laparoscopic orchiopexy (SSLO) and staged Fowler-Stephens (SFS) procedures in the management of intra-abdominal undescended testes, and to analyze postoperative atrophy and malpositioning as end points. MATERIALS AND METHODS: A retrospective chart review identified laparoscopic orchiopexy patients with intra-abdominal testes between November 2006 and November 2014. Of 167 patients who had laparoscopic orchiopexy, 73 (85 testes) were identified as having laparoscopic orchiopexy. Baseline characteristics, as well as testicular scrotal position and size at follow-up, were recorded. Regression analysis was performed to compare outcomes between patients who underwent SFS and SSLO. RESULTS: Of the 85 laparoscopic orchiopexies, 35 underwent SFS and 50 had SSLO. Patient demographics were comparable in both groups. The median age at surgery was 12 months (5-151 months), and the average follow-up was 17.3 months. On follow-up, there were 0 recorded cases of SFS patients with abnormally positioned testes postoperatively, whereas there were 10 (20.0%) SSLO patients who had abnormally positioned testes (odds ratio: 0.05, 95% confidence interval: 0.01-0.44). Differences in atrophy rates were not significant. CONCLUSION: These results suggest that there may be no difference between the 2 approaches in terms of postoperative atrophy. However, the SFS appears to be more successful in securing a favorable scrotal position. Atrophy does not seem to be associated with other patient factors. Prospective, randomized studies are indicated to further explore outcome differences between the 2 approaches.

The Single Wire Ureteral Access Sheath, Both Safe and Economical.

Introduction. Novel disposable products for ureteroscopy are often inherently more expensive than conventional ones. For example, the Cook Flexor© Parallel™ (Flexor) access sheath is designed for ease and efficiency of gaining upper tract access with a solitary wire. We analyze the cost combinations, efficiency, and safety of disposable products utilized for upper tract access, including the Flexor and standard ureteral access sheath. Methods. We performed a retrospective review from January 2014 to October 2014 of patients undergoing URS for nephrolithiasis, who were prestented for various reasons (e.g., infection). Common combinations most utilized at our institution include "Classic," "Flexor," and "Standard." Total costs per technique were calculated. Patient characteristics, operative parameters, and outcomes were compared among the groups. Results. The most commonly used technique involved a standard ureteral sheath and was the most expensive ($294). The second most utilized and least expensive combination involved the Flexor, saving up to $80 per case (27%). All access sheaths were placed successfully and without complications. There were no significant differences in operative time, blood loss, or complications. Conclusions. In prestented patients within this study, the Flexor combination was the most economical. Although the savings appear modest, long-term impact on costs can be substantial.

Main Renal Artery Clamping With or Without Renal Vein Clamping During Robotic Partial Nephrectomy for Clinical T1 Renal Masses: Perioperative and Long-term Functional Outcomes.

OBJECTIVE: To compare renal function outcome between a contemporary cohort of propensity score-matched patients undergoing main renal artery clamping (MAC) alone and those undergoing main renal artery clamping with renal vein clamping (MVAC) during robotic partial nephrectomy. MATERIALS AND METHODS: Patients with a solitary T1 renal mass undergoing robotic partial nephrectomy were propensity score-matched on American Society of Anesthesiologists score, RENAL Nephrometry score, tumor size, tumor laterality, and operating surgeon to provide 66 patients undergoing MAC and 66 patients undergoing MVAC for analysis. Demographic and tumor-specific characteristics in addition to perioperative and renal function outcomes at discharge and 9 months were compared. RESULTS: No differences in any baseline characteristics including age (P = .847), baseline estimated glomerular filtration rate (eGFR) (P = .358), RENAL Nephrometry score (P = .617), and tumor size (P = .551) were identified. Warm ischemia time was longer in patients undergoing MVAC than in patients undergoing MAC (21.0 minutes vs 15.0, P <.001), with no differences in estimated blood loss (P = .413), length of hospitalization (P = .112), and postoperative complications (overall [P = .251], by Clavien-Dindo classification [P = .119]). No differences in the percent change in eGFR (P = .866) or acute kidney injury (P = .493) at discharge and no differences in the percent change in eGFR (P = .401) or progression to chronic kidney disease (P = .594) at 9 months were identified. CONCLUSION: Compared with MAC, clamping of the renal vein in addition to the main renal artery does not appear to adversely affect postoperative renal function. Future studies comparing MAC with MVAC partial nephrectomy in patients with baseline chronic kidney disease, a solitary kidney and complex tumors with prolonged warm ischemia time are necessary.

Testicular Mass in Late Adolescence: Not Always Malignant.

We present a rare case of cystic dysplasia of the testes in an adolescent boy who presented with testicular pain and found to have a palpable intratesticular mass. Ultrasound revealed an avascular cystic dilation of the testicle. Usually, a palpable intratesticular mass is malignant unless proven otherwise. However, on computed tomography scan, he was found to have agenesis of the ipsilateral kidney and dilation of the ipsilateral seminal vesicle. These findings were consistent with a congenital abnormality, suggesting that the testicular finding was likely cystic dysplasia of the testes, with low malignant potential. Thus, the patient did not undergo radical orchiectomy.

Giant Fungating Basal Cell Carcinoma of the Scrotum.

We present an unusual case of basal cell carcinoma (BCC) arising from a non-sun-exposed area. The patient was 69-year-old male with an enlarging giant fungating mass protruding from his scrotum for which he did not seek medical treatment until recently. The mass did not involve the scrotum or epididymis and was confirmed on ultrasound. The patient underwent wide surgical excision and was diagnosed with BCC of the scrotum. Scrotal BCC appears to be more aggressive and more likely to metastasize compared with lesions arising from other areas of the body.

Non-grafted Vaginal Depth Augmentation for Transgender Atresia, Our Experience and Survey of Related Procedures.

INTRODUCTION: Neovaginal atresia especially following male-to-female transgender vaginoplasty is a distressing concern. A pelvic space must be re-created. Traditionally, an epithelial or mucosal lining is employed to cover the space. However, in our series of 18 patients, a non-grafted approach has been equally efficacious, as previously described by others. AIM: To follow the outcome of male-to-female transsexuals undergoing secondary depth enhancement without use of graft or flap. METHODS: Patient selection included two operated on elsewhere, one of whom had a lower abdominal skin graft, and the remainder done here using an inverted penile skin flap supplemented by a scrotal graft extension as needed. The time lag from primary to revision surgery varied from 5 months to 23 years, average 3.7 years. The fascial plane of Denonvilliers was reopened and packed for 7 days to facilitate maintenance of a pelvic space. Patients are requested to perform serial self-dilations with a stent set indefinitely to maintain patency and procure additional depth. Immuno-histochemistry staining was performed to demonstrate estrogen receptor (ER) presence in male genital skin. Estrogen cream may be utilized to facilitate wound healing. Main outcome measures were post-operative depth results and Female Sexual Function Index (FSFI) scores. Several attempts were made to contact all patients for completion of a FSFI. Ten out of 18 responded. RESULTS: Following revision of the pelvic space, static depths increased two-fold on average, from 2.4 in. (6.2 cm) to 5.0 in. (12.7 cm). The FSFI domain scores (of desire, arousal, lubrication, orgasm, satisfaction, and pain) were all mid-range or above. Full scale FSFI scores (compilation score) averaged 23.4 (range limits 2-36). Histologic staining showed the presence of ER in genital skin of all genetic males tested regardless of estrogen usage and perceived gender. CONCLUSIONS: Given adequate development of the rectal-vesical space and preservation of that space with self-dilation, epithelialization will ensue providing sexual gratification for patient and partner (as per patient). LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Urology Patients and the Internet: Socioeconomic Status and Language Skills Significantly Impact Use.

INTRODUCTION: Patient Internet use and resources are likely multifactorial. We assess how socioeconomic factors and language skills affect Internet use by patients. METHODS: We prospectively surveyed 116 patients with a bilingual questionnaire before they underwent urological surgery from July to September 2013. We obtained institutional review board approval for this study. Patients were surveyed for demographic data, English abilities, Internet use, anxiety level and understanding of the surgery. RESULTS: Patients with low English abilities were significantly more likely to have lower incomes and education (p <0.05). In addition, patients with low English abilities were significantly more likely neither to have Internet access nor to have used it to research their surgery. On multivariate analysis those with low confidence in English were 2.8 times more likely not to have used the Internet to research their surgery when controlling for age. Increased age remained statistically associated with a lower likelihood of using the Internet even when controlling for all demographic data. Lastly, patients with low confidence in English were significantly less likely to report increased anxiety before surgery (OR 0.147) when controlling for all demographic data including ethnicity. CONCLUSIONS: In our community those patients with low confidence in their English abilities are less likely to have access to, and use, the Internet before undergoing surgery. Older patients also use the Internet less often. Urologists should be aware of this potential language and age gap. Those with low English skills should likely be provided with additional counseling.

Reducing robotic prostatectomy costs by minimizing instrumentation.

INTRODUCTION AND OBJECTIVE: Since the introduction of robotic surgery for radical prostatectomy, the cost-benefit of this technology has been under scrutiny. While robotic surgery professes to offer multiple advantages, including reduced blood loss, reduced length of stay, and expedient recovery, the associated costs tend to be significantly higher, secondary to the fixed cost of the robot as well as the variable costs associated with instrumentation. This study provides a simple framework for the careful consideration of costs during the selection of equipment and materials. MATERIALS AND METHODS: Two experienced robotic surgeons at our institution as well as several at other institutions were queried about their preferred instrument usage for robot-assisted prostatectomy. Costs of instruments and materials were obtained and clustered by type and price. A minimal set of instruments was identified and compared against alternative instrumentation. A retrospective review of 125 patients who underwent robotically assisted laparoscopic prostatectomy for prostate cancer at our institution was performed to compare estimated blood loss (EBL), operative times, and intraoperative complications for both surgeons. Our surgeons now conceptualize instrument costs as proportional changes to the cost of the baseline minimal combination. RESULTS: Robotic costs at our institution were reduced by eliminating an energy source like the Ligasure or vessel sealer, exploiting instrument versatility, and utilizing inexpensive tools such as Hem-o-lok clips. Such modifications reduced surgeon 1's cost of instrumentation to ∼40% less compared with surgeon 2 and up to 32% less than instrumentation used by surgeons at other institutions. Surgeon 1's combination may not be optimal for all robotic surgeons; however, it establishes a minimally viable toolbox for our institution through a rudimentary cost analysis. A similar analysis may aid others in better conceptualizing long-term costs not as nominal, often unwieldy prices, but as percent changes in spending. With regard to intraoperative outcomes, the use of a minimally viable toolbox did not result in increased EBL, operative time, or intraoperative complications. CONCLUSION: Simple changes to surgeon preference and creative utilization of instruments can eliminate 40% of costs incurred on robotic instruments alone. Moreover, EBL, operative times, and intraoperative complications are not compromised as a result of cost reduction. Our process of identifying such improvements is straightforward and may be replicated by other robotic surgeons. Further prospective multicenter trials should be initiated to assess other methods of cost reduction.