Racial Differences in the Detection Rate of Bladder Cancer Using Blue Light Cystoscopy: Insights from a Multicenter Registry.

The use of blue light cystoscopy (BLC) has been shown to improve bladder tumor detection. However, data demonstrating the efficacy of BLC across different races are limited. Herein, we aim to evaluate heterogeneity in the characteristics of BLC for the detection of malignant lesions among various races. Clinicopathologic information was collected from patients enrolled in the multi-institutional Cysview® registry (2014-2021) who underwent transurethral resection or biopsy of bladder tumors. Outcome variables included sensitivity and negative and positive predictive values of BLC and white light cystoscopy (WLC) for the detection of malignant lesions among various races. Overall, 2379 separate lesions/tumors were identified from 1292 patients, of whom 1095 (85%) were Caucasian, 96 (7%) were African American, 51 (4%) were Asian, and 50 (4%) were Hispanic. The sensitivity of BLC was higher than that of WLC in the total cohort, as well as in the Caucasian and Asian subgroups. The addition of BLC to WLC increased the detection rate by 10% for any malignant lesion in the total cohort, with the greatest increase in Asian patients (18%). Additionally, the positive predictive value of BLC was highest in Asian patients (94%), while Hispanic patients had the highest negative predictive value (86%). Our study showed that regardless of race, BLC increases the detection of bladder cancer when combined with WLC.

Comparison of peritoneal interposition flaps and sealants for prevention of lymphocele after robotic radical prostatectomy and pelvic lymph node dissection: a systematic review, meta-analysis, Bayesian network meta-analysis, and meta-regression.

Lymphocele is one of the most common complications after radical prostatectomy. Multiple authors have proposed the use of vessel sealants or peritoneal interposition techniques as preventive interventions. This study aimed to aggregate and analyze the available literature on different interventions which seek to prevent lymphocele through a Bayesian Network. A systematic review was performed to identify prospective studies evaluating strategies for lymphocele prevention after robot assisted laparoscopic prostatectomy + pelvic lymph node dissection. Data was inputted into Review Manager 5.4 for pairwise meta-analysis. Data was then used to build a network in R Studio. These networks were used to model 200,000 Markov Chains via MonteCarlo sampling. The results are expressed as odds ratios (OR) with 95% credible intervals (CrI). Meta-regression was used to determine coefficient of change and adjust for pelvic lymph node dissection extent. Ten studies providing data from 2211 patients were included. 1097 patients received an intervention and 1114 patients served as controls. Interposition with fenestration had the lowest risk of developing a lymphocele (OR 0.14 [0.04, 0.50], p = 0.003). All interventions, except sealants or patches, had significant decreased odds of lymphocele rates. Meta-analysis of all the included studies showed a decreased risk of developing a lymphocele (OR 0.42 [0.33, 0.53], p < 0.00001) for the intervention group. Perivesical fixation and interposition with fenestration appear to be effective interventions for reducing the overall incidence of lymphocele.

Interruptions in bladder cancer care during the COVID-19 public health emergency.

BACKGROUND: Academic and community urology centers participating in a pragmatic clinical trial in non-muscle-invasive bladder cancer completed monthly surveys assessing restrictions in aspects of bladder cancer care due to the COVID-19 Public Health Emergency. Our objective was to describe pandemic-related restrictions on bladder cancer care. METHODS: We invited 32 sites participating in a multicenter pragmatic bladder cancer trial to complete monthly surveys distributed through REDCap beginning in May 2020. These surveys queried sites on whether they were experiencing restrictions in the use of elective surgery, transurethral resection of bladder tumors (TURBT), radical cystectomy, office cystoscopy, and intravesical bacillus Calmette-Guerin (BCG) availability. Responses were collated with descriptive statistics. RESULTS: Of 32 eligible sites, 21 sites had at least a 50% monthly response rate over the study period and were included in the analysis. Elective surgery was paused at 76% of sites in May 2020, 48% of sites in January 2021, and 52% of sites in January 2022. Over those same periods, coinciding with COVID-19 incidence waves, TURBT was restricted at 10%, 14%, and 14% of sites, respectively, radical cystectomy was restricted at 10%, 14%, and 19% of sites, respectively, and cystoscopy was restricted at 33%, 0%, and 10% of sites, respectively. CONCLUSIONS: Bladder cancer care was minimally restricted compared with more pronounced restrictions seen in general elective surgeries during the COVID-19 pandemic.

Post-Operative Order Set Decreases Opioid Prescriptions and Increases Efficiency.

BACKGROUND: Opioid addiction remains a public health crisis. We aimed to create an electronic medical record (EMR) based protocol to decrease post-operative prescribing of opioid medications and streamline the ordering process while maintaining adequate pain control. METHODS: An order set was created to minimize opioid prescriptions. The post-operative prescribing practices for minor urologic procedures (MUOs) over 6-week periods at three time points were compared: one period before and two periods after implementation of the order set. RESULTS: 72 MUOs were performed in the pre-implementation, 52 in post-implementation, and 60 in the long-term period. Opioid medications were prescribed for 66 patients (91.7%) pre-implementation, 23 patients (44.2%) post-implementation, and 45 patients (75.0%) at the long-term time point (P < .0001 and P = .015 respectively). The mean morphine milligram equivalent (MME) prescribed was 81.52 units before implementation, 38.74 units after, and 24.21 units at the long-term time point (P = .0002 and P < .0001 respectively). DISCUSSION: The integration of a post-operative prescribing order set into our EMR substantially decreased opioid prescribing after MUO while streamlining the ordering process to improve efficiency.

Is a restaging TURBT necessary in high-risk NMIBC if the initial TURBT was performed with blue light?

OBJECTIVES: To evaluate whether a restaging transurethral resection of bladder tumor (TURBT) is necessary in high-risk nonmuscle invasive bladder cancer (NMIBC) if the initial TURBT was performed using blue light (BL) technology. METHODS AND MATERIALS: Using the multi-institutional Cysview registry between 2014 and 2021, all consecutive adult patients with known NMIBC (Ta and T1 disease) who underwent TURBT followed by a restaging TURBT within 8 weeks were reviewed. Patients were stratified according to their initial TURBT, BL vs. white light (WL), and compared to determine rates of residual disease and upstaging. Univariate analysis was performed using Mann-Whitney U and chi-square tests, with P < 0.05 considered significant. RESULTS: Overall, 115 patients had TURBT for NMIBC followed by a restaging TURBT within 8 weeks and were included in the analysis. Patients who underwent BL compared to WL for their initial TURBT had higher rates of benign pathology on restaging TURBT, although this was not statistically significant (47% vs. 30%; P = 0.08). Of patients with residual tumors on restaging TURBT, there were no differences in rates of Ta (22% vs. 26.5%; P = 0.62), T1 (22% vs. 26.5%; P = 0.62), or CIS (5.5% vs. 13%; P = 0.49) when the initial TURBT was done using BL compared to WL. Rates of upstaging to muscle invasive disease were also not different when initial TURBT was performed using BL compared to WL (3% vs. 4%; P = 0.78). CONCLUSIONS: TURBT using BL does not reduce rates of residual disease or risk of upstaging on restaging TURBT in Ta or T1 disease. Thus, a restaging TURBT is still necessary even if initial TURBT was performed using BL.

Reference-Free Adaptive Filtering of Extracellular Neural Signals Recording in Ultra-High Field Magnetic Resonance Imaging Scanners: Removal of Periodic Interferences.

This paper focuses on the removal of periodic artifacts from neural signals recorded in rats in ultra-high field (UHF) MRI scanners, using a reference free adaptive feedforward method. Recording extracellular neural signals in the UHF environment is motivated by the desire to combine neural recording and UHF functional magnetic resonance imaging (fMRI) to better understand brain function. However, the neural signals are found to have extremely high noise artifacts of a periodic nature due to electromagnetic interference and due to small oscillatory motions. In particular, noise at 60 Hz and several harmonics of 60 Hz, sinusoidal noise from a pump, and low frequency breathing motion artifacts are observed. Due to significant overlap between the noise frequencies and the neural frequency region of interest, band pass filters cannot be effectively utilized in this application. Hence, this paper develops adaptive least squares feedforward cancellation filters to remove the periodic artifacts. The interference fundamental frequency is identified precisely using an implementation of k-means in an iterative approach. The paper includes significant animal data from rats recorded in an IACUC-approved procedure in 9.4T and 16.4T MRI machines. For breathing artifacts filtered from 4 rats, the mean signal cancellation values at the harmonic interference frequencies are 5.18, 12.97, and 20.87 dB/Hz for a sliding template subtraction, a single-stage impulse reference method, and the cascaded adaptive filtering approach respectively. For pump artifacts filtered from 2 chronically implanted rats, mean signal cancellation values are 2.85, 9.52 and 12.06 dB/Hz respectively. The experimental results show that periodic noise is very effectively removed by the developed cascaded adaptive least squares feedforward algorithm.

Urologic oncology workforce diversity: A first step in reducing cancer disparities.

Urologic cancer disparities based on race/ethnicity and gender are well-documented across the cancer continuum. Patients cared for by physicians of similar race/ethnicity and gender report better communication, patient satisfaction, and care adherence which has the potential to translate into better health outcomes. We believe that ensuring a diverse Urologic Oncology workforce is an important first step toward eliminating cancer disparities due to the downstream effects of improved communication between concordant patient-physician dyads. In this essay, we review the demographics of the Urologic cancer patient population and Urologic Oncology workforce; describe current evidence supporting healthcare workforce diversity, especially related to race and gender-based concordant patient-physician relationships; and make recommendations for individual and institutional strategies to develop and support a diverse workforce in Urologic Oncology.

Utility of Blue Light Cystoscopy for Post-bacillus Calmette-Guérin Bladder Cancer Recurrence Detection: Implications for Clinical Trial Recruitment and Study Comparisons.

PURPOSE: The utility of blue light cystoscopy (BLC) in patients receiving bacillus Calmette-Guérin (BCG) during post-treatment cystoscopy is not well understood. Our objective was to determine if BLC improves recurrence detection in patients with non-muscle invasive bladder cancer (NMIBC) undergoing BCG. MATERIALS AND METHODS: Using the prospective multi-institutional Cysview® Registry (2014-2019), patients with NMIBC who received BCG within 1 year prior to BLC were identified. Primary outcomes were recurrences and whether lesions were detected on white light cystoscopy (WLC), BLC or both. We calculated the percentage of cystoscopies with recurrences that were missed with WLC alone. The cystoscopy-level BLC false-positive rate was the proportion of cystoscopies with biopsies only due to BLC suspicious lesions without recurrence. RESULTS: Of 1,703 BLCs, 282 cystoscopies were in the analytic cohort. The overall recurrence rate was 45.0% (127). With only WLC, 13% (16/127) of recurrences would have been missed as 5.7% (16/282) of cystoscopies performed had recurrence only identified with BLC. Among 16 patients with recurrence missed with WLC, 88% (14) had carcinoma in situ. The cystoscopy-level BLC false-positive rate was 5% (15). CONCLUSIONS: BLC helped detect recurrences after recent BCG that would have been missed with WLC alone. Providers should consider BLC for high-risk patients undergoing BCG and should discuss the risk of false-positives with these patients. As clinical trials of novel therapies for BCG-unresponsive disease increase and there are no clear guidelines on BLC use for post-treatment cystoscopies, it is important to consider how variable BLC use could affect enrollment in and comparisons of these studies.

Role of blue-light cystoscopy in detecting invasive bladder tumours: data from a multi-institutional registry.

OBJECTIVES: To evaluate the role of blue-light cystoscopy (BLC) in detecting invasive tumours that were not visible on white-light cystoscopy (WLC). PATIENTS AND METHODS: Using the multi-institutional Cysview registry database, patients who had at least one white-light negative (WL-)/blue-light positive (BL+) lesion with invasive pathology (≥T1) as highest stage tumour were identified. All WL-/BL+ lesions and all invasive tumours in the database were used as denominators. Relevant baseline and outcome data were collected. RESULTS: Of the 3514 lesions (1257 unique patients), 818 (23.2%) lesions were WL-/BL+, of those, 55 (7%) lesions were invasive (48 T1, seven T2; 47 unique patients) including 28/55 (51%) de novo invasive lesions (26 unique patients). In all, 21/47 (45%) patients had WL-/BL+ concommitant carcinoma in situ and/or another T1 lesions. Of 22 patients with a WL-/BL+ lesion who underwent radical cystectomy (RC), high-risk pathological features leading to RC was only visible on BLC in 18 (82%) patients. At time of RC, 11/22 (50%) patients had pathological upstaging including four (18%) with node-positive disease. CONCLUSIONS: A considerable proportion of invasive lesions are only detectable by BLC and the rate of pathological upstaging is significant. Our present findings suggest an additional benefit of BLC in the detection of invasive bladder tumours that has implications for treatment approach.

Optimal Urine Culture Diagnostic Stewardship Practice-Results from an Expert Modified-Delphi Procedure.

BACKGROUND: Urine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship. METHODS: A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed. RESULTS: One hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions. CONCLUSIONS: These 18 guidance statements can optimize use of urine cultures for better patient outcomes.

Association of Residents' Medical School Reputation and Urology Residency Program Ranking.

INTRODUCTION: The Urology Residency Match process is a highly competitive application process that evaluates coursework performance, standardized examination scores, research productivity, quality of letter of recommendations, and participation in away rotations. With recent changes to medical school grading metrics, lack of in-person interviews, and examination scorings, less objective metrics are available to stratify applicants. We characterized the association of urology residents' medical school and urology residency program rankings. METHODS: Using publicly available resources, all urology residents from 2016 to 2022 were identified. Their medical school and urology residency rankings were determined from 2022 US News and World Reports and Doximity urology residency reputation. Ordinal logistic regression modeling was used to determine the association between medical school and residency rankings. RESULTS: A total of 2,306 successfully matched residents were identified from 2016 to 2022. There was positive association between urology program and medical school ranking (P < .001). Within each urology program tier over the last 7 years, there was no significant change over time in the proportions of urology residents by medical school rankings (P >0.05). A consistent proportion of matched residents from higher ranked medical schools matched into top ranked urology programs, while a consistent proportion of applicants from lower ranked medical schools matched into lower ranked urology programs across each application cycle from 2016 to 2022 (P < .05). CONCLUSIONS: We observed that over the last 7 years trainees from higher ranked medical schools were more commonly represented in top urology programs while lower ranked urology programs were overrepresented by residents from lower ranked medical schools.

The stem rust fungus Puccinia graminis f. sp. tritici induces centromeric small RNAs during late infection that are associated with genome-wide DNA methylation.

BACKGROUND: Silencing of transposable elements (TEs) is essential for maintaining genome stability. Plants use small RNAs (sRNAs) to direct DNA methylation to TEs (RNA-directed DNA methylation; RdDM). Similar mechanisms of epigenetic silencing in the fungal kingdom have remained elusive. RESULTS: We use sRNA sequencing and methylation data to gain insight into epigenetics in the dikaryotic fungus Puccinia graminis f. sp. tritici (Pgt), which causes the devastating stem rust disease on wheat. We use Hi-C data to define the Pgt centromeres and show that they are repeat-rich regions (~250 kb) that are highly diverse in sequence between haplotypes and, like in plants, are enriched for young TEs. DNA cytosine methylation is particularly active at centromeres but also associated with genome-wide control of young TE insertions. Strikingly, over 90% of Pgt sRNAs and several RNAi genes are differentially expressed during infection. Pgt induces waves of functionally diversified sRNAs during infection. The early wave sRNAs are predominantly 21 nts with a 5' uracil derived from genes. In contrast, the late wave sRNAs are mainly 22-nt sRNAs with a 5' adenine and are strongly induced from centromeric regions. TEs that overlap with late wave sRNAs are more likely to be methylated, both inside and outside the centromeres, and methylated TEs exhibit a silencing effect on nearby genes. CONCLUSIONS: We conclude that rust fungi use an epigenetic silencing pathway that might have similarity with RdDM in plants. The Pgt RNAi machinery and sRNAs are under tight temporal control throughout infection and might ensure genome stability during sporulation.

Approaches to Non-Muscle-Invasive Bladder Cancer.

PURPOSE OF REVIEW: Non-muscle-invasive bladder cancer (NMIBC) is a heterogenous malignancy with high recurrence and progression rates, which necessitate uniform recommendations for diagnosis and management. Herein, we review the literature, with an emphasis on guidelines and contemporary diagnostic techniques and interventions. RECENT FINDINGS: Guidelines around the world have adopted a schema which risk-stratify cases at diagnosis, to offer evidence-based treatment and surveillance recommendations. Enhanced endoscopic technologies can improve detection of NMIBC and reduce recurrence. The present Bacillus Calmette-Guerin (BCG) shortage in the USA has led to new strategies to prioritize the most high-risk cases. The entity of BCG-unresponsive high-risk NMIBC remains a challenge to manage, with multiple novel treatments under investigation; fortunately, new therapies have been approved, such as immune checkpoint inhibitors, and others are showing tremendous promise. The standardization of NMIBC management, with evolving detection techniques and therapeutics, offers great potential to improve patient outcomes and survivorship.

The Citizen Psychologist Curriculum-Preparing psychologists for public service: The 2018 American Psychological Association Presidential Initiative.

This article describes a curriculum developed as part of the American Psychological Association President Jessica Henderson Daniel's, 2018 Presidential Initiative-The Citizen Psychologist. The curriculum is designed to prepare the next generation of Citizen Psychologists to provide the broadest sense of service as leaders in their communities and in public service psychology. The curriculum prepares the learner to bring psychological knowledge, science, and expertise to bear on existing challenges to improve community well-being locally, nationally, and globally. This includes addressing the services needs of various vulnerable populations such as veterans, prisoners, the seriously mentally ill, those with substance abuse problems, children, and older adults. Competency-based curricula are presented in a series of modules, each dedicated to a level of education and training from high school through lifelong learning. Each module presents learning outcomes, activities, and resources designed to develop level-specific competencies. Steps for implementation and recommendations at the local and national level are provided. Implications of incorporating the Citizen Psychologist curriculum in education and training programs are discussed including encouraging students to explore volunteer and career opportunities in public service psychology. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Innovative Approaches to Battling Resident Burnout in a Urology Residency Program.

INTRODUCTION: Data suggest many U.S. physicians experience burnout, affecting up to 65% of U.S. urology resident physicians. We implemented a multifaceted Urology Resident Wellness Curriculum and measured its effect on burnout reported among our trainees. METHODS: We created a 5-pronged Resident Wellness Curriculum: 1) faculty-sponsored Resident Wellness Fund, 2) social groups between 1 faculty and 2-3 trainees, 3) one-on-one structured mentorship, 4) resident-organized social outings using the Resident Wellness Fund, and 5) wellness education. We administered 2 validated burnout questionnaires, the Maslach Burnout Index-Human Services Survey and the Expanded Mayo Physician Well Being Index, to our resident physicians at 4 time points, immediately before and following curriculum implementation. At study conclusion, resident physicians were asked to rank the most meaningful interventions. RESULTS: At 4 timepoints over 3 academic years, 54 completed instruments were collected from 32 unique resident physicians. Initial Maslach Burnout Index survey data indicated high levels of Depersonalization and Emotional Exhaustion with moderate levels of Personal Accomplishment. Over the study period, there was improvement in Depersonalization from high to moderate (28% decrease, p=0.04), improvement in Emotional Exhaustion from high to moderate (20% decrease, p=0.15) and preserved moderate Personal Accomplishment. The average Physician Well Being Index score decreased by 52% (p=0.006), demonstrating decreased levels of distress. Resident-organized social outings were ranked as the most meaningful intervention, with 63% of participants ranking it first. CONCLUSIONS: Rates of urology resident physician burnout were observed to be high at baseline, but improved significantly after introduction of a purposeful Resident Wellness Curriculum.

Assessing Contemporary Trends in Female Speakership within Urologic Oncology.

OBJECTIVE: To evaluate multidisciplinary female representation at urologic oncology conferences, we reviewed speakership trends at contemporary Society of Urologic Oncology (SUO) and American Society of Clinical Oncology Genitourinary Symposium (GU-ASCO) annual meetings. METHODS: Meeting programs from SUO and GU-ASCO from 2015 to 2019 were analyzed. Biographical information was determined by querying institutional websites and social/professional media platforms. Statistical analyses were performed to assess for differences and relationships between male and female authorship based on gender, specialty, professional, and educational factors. RESULTS: We identified 1102 speakers at genitourinary oncology conferences. Overall, 222 (20%) were female. There was no significant difference between female speakership rates at SUO and GU-ASCO. The overall proportion of female speakers increased over time, but not when analyzing each individual subspecialty conference separately. Several professional and educational differences were noted between genders. Female speakers were more likely to be medical oncologists (P <.001), have more recent years of graduation (2001 vs 1996, P <.001), hold an additional advanced degree (OR 2.09, P = .005), and speak in sessions where other women served as chair (OR 1.42, P = .044). Conversely, female speakers had lower odds of delivering a plenary or keynote address (OR 0.28, P = .015). CONCLUSION: We identified a significantly positive trend towards increased female representation within contemporary genitourinary conferences over time; these trends did not remain significant when analyzing each meeting separately. Several important disparities between men and women speakers were identified. Our data suggests that inclusion of women in planning committees may help reduce gender bias and promote diversity within urologic oncology.