Racial, ethnic, and socioeconomic disparities in rates of stage IV prostate cancer after USPSTF category "D" recommendation against prostate-specific antigen screening: a retrospective cohort study.

Background: In 2012 the United States Preventative Services Task Force (USPSTF) changed its prostate-specific antigen (PSA) screening recommendation to a category "D". The purpose of this study is to examine racial, ethnic, and socioeconomic differences in risk of presentation with metastatic prostate cancer (mPCa) at time of diagnosis before and after the 2012 USPSTF category "D" recommendation. Methods: This is a population-based cohort study. We identified patients with mPCa at diagnosis within the National Cancer Database from 2004-2017. Logistic regression models were used to examine associations of mPCa with age, race, ethnicity, geographic location, education level, income, and insurance status. Linear regression models assuming underlying binomial distribution were fitted to annual percentage of mPCa at diagnosis for years 2012-2017 to evaluate the post category "D" recommendation era. Results: From 2004 to 2017, 88,987 patients presented with mPCa. A higher percentage of mPCa was noted post-USPSTF category "D" recommendation, with a disproportionately greater increase observed among Hispanics and non-Hispanic Blacks [Δslope/year: Hispanics (0.0092), non-Hispanic Blacks (0.0073) and non-Hispanic Whites (0.0070)]. Insurance status impacts race/ethnicity differently: uninsured Hispanics were 3.66 times more likely to present with mPCa than insured Hispanics, while uninsured non-Hispanic Blacks were 2.62 times more likely to present with mPCa than insured non-Hispanic Blacks. Household income appears to be associated with differences in mPCa, particularly among non-Hispanic Blacks. Those earning <$30,000 were more likely to present with mPCa compared to higher income brackets. Conclusions: Since the USPSTF grade "D" recommendation against PSA screening, the percentage of mPCa at diagnosis has increased, with a higher rate of increase among Hispanic and non-Hispanic Blacks compared to non-Hispanic Whites.

Association of day of surgery and distance traveled with length of stay in patients undergoing robotic-assisted partial nephrectomy (RAPN) at a tertiary medical center.

The objective of this study is to analyze the association between surgical day of the week and distance traveled with prolonged length of stay (LOS) following robotic-assisted partial nephrectomy (RAPN). 563 consecutive RAPN performed by a single surgeon were evaluated. Early week RAPN was considered Monday through Wednesday, while late-week RAPN was defined as surgery performed Thursday through Friday. Distance traveled for RAPN was evaluated as greater than or less than 60 miles. The respective groups were compared to see if the surgical day of the week or distance traveled influenced the hospital stay or prolonged hospital stay (defined as hospital length of stay equal or greater than 3 days). Overall, 213 patients (38.0%) undergoing RAPN experienced a prolonged LOS. A total of 380 patients underwent early week RAPN compared to 183 late-week RAPN. Patients undergoing late-week RAPN were more likely to have a prolonged LOS compared to early week RAPN (n = 81, 44% vs. n = 133, 35%, respectively; p = 0.004). 229 patients traveled less than 60 miles, while 332 patients traveled more than 60 miles to receive RAPN. 135 patients (40.7%) traveling more than 60 miles experienced a prolonged stay compared to 78 patients (34.1%) traveling less than 60 miles, although this difference was not statistically significant (p = 0.128). Patients who underwent RAPN at the end of the week were more likely to have a prolonged LOS, while distance traveled for RAPN did not appear to affect likelihood of prolonged LOS.

Disposable Cystoscopes Do Not Decrease Post Renal Transplant Stent Removal Symptomatic Infection Rates.

OBJECTIVE: To evaluate the effect of disposable cystoscopes on the rate of symptomatic urinary tract infections (UTI) following post-renal transplant cystoscopic stent removal. METHODS: We performed a retrospective study of post-renal transplant cystoscopic stent removals in our outpatient clinic from March 2019 to March 2022. Our clinic converted to disposable cystoscopes in October 2021. All outpatient, phone, and portal encounters were reviewed for 30 days following the procedure. The primary outcome was the number of post-procedural symptomatic UTI within 30 days of the procedure. Symptomatic UTI was defined as fever, dysuria, or hematuria accompanied by a positive urine culture. RESULTS: A total of 323 patients had post-transplant stent removals including 123 with reusable scopes and 200 with disposable scopes. Around 1.6% (2/123) of patients with a reusable cystoscope experienced symptomatic UTI's. They had positive urine cultures for Escherichia coli and Klebsiella. 2.0% (4/200) of patients with a disposable cystoscopy had a symptomatic UTI. The 3 types of positive urine cultures they experienced were E Coli, Klebsiella, and Enterococcus. CONCLUSION: The conversion from reusable to disposable cystoscopes did not decrease symptomatic UTI following renal transplant stent removal.

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy.

Objective: We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre- and peri-operative variables associated with length of stay (LOS) greater than 3 days and readmission within 30 days. Methods: Records from 2008 to 2018 for "laparoscopy, surgical; partial nephrectomy" for prolonged LOS and readmission cohorts were compiled. Univariate analysis with Chi-square, t-tests, and multivariable logistic regression analysis with odds ratios (ORs), p-values, and 95% confidence intervals assessed statistical associations. Results: Totally, 20 306 records for LOS greater than 3 days and 15 854 for readmission within 30 days were available. Univariate and multivariable analysis exhibited similar results. For LOS greater than 3 days, undergoing non-elective surgery (OR=5.247), transfusion of greater than four units within 72 h prior to surgery (OR=5.072), pre-operative renal failure or dialysis (OR=2.941), and poor pre-operative functional status (OR=2.540) exhibited the strongest statistically significant associations. For hospital readmission within 30 days, loss in body weight greater than 10% in 6 months prior to surgery (OR=2.227) and bleeding disorders (OR=2.081) exhibited strongest statistically significant associations. Conclusion: Multiple pre- and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data. Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection, optimization strategies, and patient education.

Prospective evaluation of the effect of adherent perinephric fat on outcomes of robotic assisted partial nephrectomy following elimination of the learning curve

ABSTRACT Purpose: To prospectively evaluate the association of adherent perinephric fat (APF) on perioperative outcomes of robotic-assisted partial nephrectomy (RAPN) following elimination of the surgical learning curve. Materials and Methods: 305 consecutive RAPNs performed by a single experienced surgeon were analyzed. The first 100 RAPNs were considered the learning curve and therefore excluded. APF was defined as the necessity of subcapsular renal dissection to mobilize the tumor from surrounding perinephric fat. Perioperative outcomes were evaluated including operative time, warm ischemia time (WIT), postoperative complications, length of stay, margins, ischemia, and complications score (MIC), estimated blood loss (EBL), and change in pre-operative to postoperative day 1 (POD 1) laboratory values. After correction for multiple comparisons, P values ≤0.0045 were considered statistically significant but associations with P values ≤0.05 were also mentioned in the study results. Results: Fifty-eight (28.3%) patients had APF. Patients with APF had longer operative times compared to those without APF (median, 213 vs. 192 minutes, P <0.001). There was some evidence of higher increase in change in creatinine from preoperative to POD 1 among those with APF compared to those without APF, although this was not statistically significant (median, 0.2 vs. 0.1mg/dL, P=0.03). There were no other statistically significant associations between presence of APF and perioperative outcomes. Conclusions: APF is associated with increased operative time but no change in other perioperative outcomes. Surgeon experience does not affect perioperative outcomes associated with APF.

Voiding Chain Cystourethography: Assessing A Historical Test's Role in Selection for Urethrolysis

Objective To analyze the benefit of voiding chain cystourethrography (VCC) [placing a radiographic opaque chain into the urethra and bladder and asking the patient to void under fluoroscopy] in the urodynamic evaluation of female bladder outlet obstruction (BOO). Materials and Methods Females with post anti-incontinence operation voiding dysfunction who underwent urodynamic evaluation augmented with VCC and later had urethrolysis were identified. Six diagnostic criteria for obstruction were applied to each patient: (1) VCC ( obstructed: chain was angulated and could not be voiding out) (2) Video urodynamic study (VUDS) (detrusor contraction combined with radiographic obstruction) (3) maximum flow (Qmax) ≤ 15 cc/sec, detrusor pressure (pDet)@ Qmax ≥ 20 cm H20 (4) Qmax ≤ 11 cc/sec, pDet@ Qmax ≥ 25 cm H20 (5) Qmax ≤ 12 cc/sec, pDet@ Qmax ≥ 25 cm H20 (6) Blaivas-Groutz (B-G) nomogram. Urethrolysis results were reviewed. Agreement in assessment of BOO criteria was assessed by estimating the proportion of pair-wise agreements along with an exact binomial 95% confidence interval (CI) and by estimating kappa along with a 95% CI. Results Twenty-one patients were identified. Twenty of the 22 urethrolyses (91%) were clinically successful. Diagnosis of BOO was most common for VCC (86%) and then B-G Nomogram (67%). Agreement with the VCC was relatively poor for each of the five other methods (14%-62%) with the video urodynamic study (VUDS) being the best. Three patients with successful urethrolysis were diagnosed only by the VCC. All of kappa values regarding agreement with the VCC were low; the highest value of 0.15 was observed for VUDS. Conclusion VCC may augment selection criteria for urethrolysis. .

Magnetic resonance imaging to detect vesico-symphyseal fistula following robotic prostatectomy

Pubic complications following radical prostatectomy are rare. Osteitis pubis typically presents with symptoms related to irritation of the pubic rami including pain with ambulation and adduction of the leg. A 60-year-old male with prostatic adenocarcinoma underwent uneventful robotic assisted laparoscopic prostatectomy. The patient noted the onset of severe pubic pain exacerbated by ambulation approximately one month post-surgery. An abdominal/pelvic CT scan was negative for acute pathology. Due to continued discomfort, a multiplanar MRI of the pelvis was performed with and without intravenous contrast material (20 ml Omniscan). The MRI demonstrated irregularity of the bladder base and proximal urethra with a fistulous tract extending anteriorly in direct communication with the pubic symphysis joint space. Vague periarticular marrow edema-like signal and enhancement at the pubic symphysis was thought to represent osteitis pubis. The patient's symptoms resolved after one month of urethral catheter drainage, intravenous antibiotics, and anti-inflammatory therapy.

Erosion of inferior vena caval filter noted during robotic assisted laparoscopic partial nephrectomy

Inferior Vena Cava (IVC) filters are mechanical devices implanted to provide prophylaxis against pulmonary emboli in patients for whom standard anticoagulation is either inadequate or contraindicated. A 67-year-old female with a 10-year-old indwelling IVC filter underwent robotic assisted laparoscopic partial nephrectomy for a right upper pole renal mass. Renal hilum dissection was complicated by adhesions secondary to eroded IVC filter struts. IVC filter erosion is a well-described phoenomena in both the radiologic and surgical literature. As many as 25% of filters are noted to be radiographically eroded; however, the incidence of clinically significant erosion is much less. Given the placement of endovascularly delivered IVC filters in close proximity to many urologic operative fields, it is important for urologists to be aware of the potential of eroded devices when pursuing para-caval dissections.

Orthotopic ureterocele masquerading as a bladder tumor in a woman with pelvic pain

Single system orthotopic ureteroceles often present in adulthood are associated with characteristic radiographic findings. We present the case of a 54 year old woman with 8 months of urgency/frequency and pelvic pain that has the cystoscopic appearance of a bladder tumor. Cystoscopic images, radiographs and intraoperative photos demonstrate the work-up, evaluation, and treatment of this unique single system orthotopic ureterocele containing a calculus. This patient demonstrates the need for cystoscopy accompanied by upper tract imaging in patients with new onset pelvic pain, urgency/frequency, and frequent urinary tract infections.