Assessing the readability and quality of online information about benign prostatic hyperplasia.

PURPOSE: Benign prostatic hyperplasia (BPH) affects nearly half of men in their fifties. Patients often search the Internet to better understand their diagnosis, but online health information is not well regulated and can be difficult for patients to comprehend. This study aims to evaluate not only readability, but also the quality of online information about BPH, as well as the effect of commercial bias on readability and quality. METHODS: Three search engines (Google, Bing, and DuckDuckGo) were used with broad search terms including "BPH," "BPH treatment," and "BPH surgery," to mimic a patient diagnosed with BPH seeking further information. 204 total websites were identified, of which 62 were unique websites. Among those unique websites, 23 were advertisements. Three readability formulas (Flesch-Kincaid Grade Level, Flesch-Kincaid Reading Ease, SMOG) were used to generate readability scores. DISCERN standardized questionnaire was used to evaluate website quality. RESULTS: Average reading level of online information about BPH was significantly higher than the recommended level by the American Medical Association (AMA) and United States Department of Health and Human Services (USDHHS). Advertisements had significantly easier readability than nonadvertisements. Average website quality was "excellent" for nonadvertisements, but only "fair" for advertisements. CONCLUSION: Although advertisements may hold optimal search result positions and have better readability than nonadvertisements, they have biased and lower quality information. It is important to guide patients to high quality online information of appropriate reading level. Continued efforts should be made to create and share with patients high quality resources with improved readability to facilitate comprehension and minimize misinformation.

Online interest in surgical treatment for benign prostatic hyperplasia using Google trends.

PURPOSE: Online health information-seeking behavior has increased over the past 15 years; however, little is known about the online interest for surgical treatment of men with benign prostatic hyperplasia. We used Google Trends to evaluate online interest for various surgical procedures for benign prostatic hyperplasia in the US and worldwide. METHODS: Transurethral resection of the prostate, photoselective vaporization of the prostate, Holmium laser enucleation of the prostate, Urolift, and Rezum were selected as search terms of interest within Google Trends. Google Trends normalizes the popularity of search terms on a 0-100 scale. ANOVA and the average rate of change in popularity scores were conducted from July 2015 to February 2019. RESULTS: From 2004 to 2019, online interest in transurethral resection of the prostate and photoselective vaporization of the prostate remained stable in the US and worldwide; meanwhile, there was an upward trend for Urolift and Rezum. There was a statistically significant increase in the online interest for Holmium laser enucleation of the prostate in the US and worldwide; however, the mean popularity score was significantly higher worldwide. CONCLUSIONS: A shift in online interest towards minimally invasive surgical therapies for benign prostatic hyperplasia was demonstrated in the US and worldwide and parallels clinical practice patterns, such as HoLEP and Urolift surgical volumes in Indiana and Australia, respectively. Google Trends can be used in real-time to gauge online interest for surgical procedures and help guide physician-patient counseling.

Ureteroscopic biopsy of upper tract urothelial carcinoma using a novel ureteroscopic biopsy forceps.

INTRODUCTION: We sought to assess the adequacy of surgical specimens obtained utilizing the BIGopsy (Cook Medical, Bloomington, IN, USA) biopsy forceps both ex vivo and in vivo and compare them to traditional 3Fr biopsy forceps in patients with suspected upper tract urothelial carcinoma. MATERIALS AND METHODS: Patients undergoing nephroureterectomy for suspected upper tract transitional cell carcinoma were recruited. Surgical specimens, immediately after extirpation were examined and alternatively biopsied ex vivo with the BIGopsy and 3Fr biopsy forceps. We then retrospectively reviewed our most recent experience with ureteroscopic biopsy. The biopsy device, size, depth, grade, stage, pathologic diagnosis and subjective biopsy quality were assessed. RESULTS: Three ex vivo nephroureterectomy specimens were evaluated. The average biopsy size from the 3Fr biopsy forceps was 3.5 +/- 2.8 mm2 and for the BIGopsy was 31.2 +/- 34.6 mm2. Subjectively, the BIGopsy specimens revealed less distortion and fragmentation and were easier to interpret by the pathologist. Sixteen patients underwent 19 ureteroscopic procedures. The mean size in maximal diameter (mm +/- SD) of the biopsies in each group were; 3Fr 1.2 +/- 0.4, BIGopsy 3.4 +/- 2.0, nitinol basket 4.9 +/- 4.0 and laser 11 +/- 8.5. Lamina propria was identified in 3/13 (23%) biopsies with 3Fr biopsy forceps, 6/11 (55%) biopsies with the BIGopsy forceps, 6/8 (75%) biopsies with the nitinol basket and 2/2 (100%) biopsies with the holmium laser. Six patients underwent biopsies with both the BIGopsy and 3Fr biopsy forceps. A definitive diagnosis was made in 2/6 cases with the 3Fr biopsy forceps compared with all 6/6 cases with the BIGopsy biopsy forceps. Grade and stage matched final surgical grade and stage in 3/3 cases biopsied with the BIGopsy. CONCLUSION: For lesions with stalks, the holmium laser and basket biopsy provided larger specimens than either of the forceps. For flat or sessile lesions, the BIGopsy biopsy forceps provided larger, deeper less distorted specimens than the 3Fr biopsy forceps and correlated well with ultimate grade and stage. Improved biopsy quality may translate into improved ability to diagnose both benign and malignant ureteral and renal pelvic mucosal lesions endoscopically.

Assessing the Content and Readability of Robotic and Laparoscopic Sacrocolpopexy Information Online.

IMPORTANCE: Apical pelvic organ prolapse is a common condition that affects women. Currently, sacrocolpopexy is considered the criterion standard surgical treatment, with an increasing preference for minimally invasive techniques. OBJECTIVE: In this study, the content and readability of select internet pages describing robotic and laparoscopic sacrocolpopexy were evaluated. STUDY DESIGN: Using an online key word planner, the phrases "robotic sacrocolpopexy" and "laparoscopic sacrocolpopexy" were determined to be the most popular search terms. These terms were systematically browsed in incognito mode in 3 of the most popular web search engines: Google, Yahoo, and Bing. Links that were nontext primary, duplicate, irrelevant, and non-English were excluded. The Flesch-Kincaid Grade Level and Flesch-Kincaid Reading Ease indices were used to assess readability. RESULTS: The average readability of all sites was 12.9, requiring at least a 12th-grade reading level, which is significantly higher than the recommended American Medical Association/National Institutes of Health (AMA/NIH) level of sixth-grade or below. One hundred percent of all analyzed sites were above this recommended sixth-grade reading level. There was no significant difference between mean grade level or reading ease score from the type of web source (P = 0.32 and 0.34, respectively), approach of surgery (P = 0.91, 0.70), or specialty (P = 0.48, 0.36). CONCLUSIONS: Almost all websites require at least a high school education to properly comprehend, regardless of source or specialty. It is important that health care providers be aware of available information, so they may direct patients to specific resources that are personally validated or provide in-office materials at an appropriate reading level.

A case of epididymoorchitis without testicular infarction presenting with reversal of diastolic testicular flow on Doppler ultrasonography.

An acute scrotum is a common clinical scenario prompting urologic involvement. Scrotal ultrasonography with Doppler is the main imaging modality utilized for the evaluation of an acute scrotum and can help distinguish testicular torsion from epididymoorchitis, two common causes of testicular pain. Testicular infarction is a rare but potential complication of epididymoorchitis. We report a case of epididymoorchitis presenting with reversal of testicular diastolic flow concerning for impending testicular infarction but with a non-ischemic testis on scrotal exploration and repeat scrotal ultrasonography post-operatively.

Opioid Prescribing Practices of U.S. Urology Trainees after Urological Surgery.

INTRODUCTION: We surveyed U.S. urology trainees to determine current prescribing practices after common endourological procedures. METHODS: An institutional review board approved, 22-item survey was distributed to all U.S. urology residents through the Society of Academic Urologists. The survey was divided into demographics including American Urological Association section, prescribing patterns after ureteroscopy, shockwave lithotripsy, percutaneous nephrolithotomy and transurethral prostate procedures, as well as attitudes surrounding opioid prescription. RESULTS: A total of 148 U.S. urology residents completed the survey (response rate 13%). All American Urological Association sections were represented, including Northeastern (12.8%), New England (8.1%), New York (6.1%), Mid-Atlantic (3.4%), Southeastern (19.6%), North Central (29.05%), South Central (10.1%) and Western (10.8%). By procedure, 72.3% of respondents prescribe opioids after ureteroscopy, 37.8% after shockwave lithotripsy, 93.9% after percutaneous nephrolithotomy, and 53.4% after transurethral prostate procedures. By procedure, the average number of tablets prescribed, were 7.5 (range 0-30) for ureteroscopy, 4.2 (0-20) for shockwave lithotripsy, 14.1 (0-40) for percutaneous nephrolithotomy and 6.7 (0-30) for transurethral prostate procedures. The average number of tablets prescribed by region varied significantly for ureteroscopy, percutaneous nephrolithotomy and transurethral prostate procedures (all p <0.0001), but did not vary significantly for shockwave lithotripsy (p=0.067). CONCLUSIONS: Opioid prescribing practices among U.S. urology residents for common urological procedures varied by regional American Urological Association section, and attitudes surrounding opioid dispensing influenced prescription patterns. While attitudes regarding opioid prescriptions after urological surgery are improving, residents may benefit from additional training, best practice policies and/or society guidelines.

Comparison of Transabdominal and Transrectal Ultrasound for Sizing of the Prostate.

OBJECTIVE: To compare the accuracy of prostate sizing between pelvic abdominal (PUS) and transrectal (TRUS) ultrasound in a large, diverse cohort of men at our institution. Prostate volume plays a vital role in all types of prostate disease. American Urological Association guidelines (2018) for surgical management of benign prostatic hyperplasia now include consideration of prostate volume measurement prior to surgical intervention. Ultrasound is a quick and radiation-free imaging modality. METHODS: We performed a single-center, retrospective study of 299 patients with prostate sizing between January 1, 2012 and August 31, 2017. Prostate volume was derived from ellipsoid volume calculation using dimensions measured on ultrasound. PUS and TRUS were compared by calculating the Pearson correlation coefficient and intraclass correlation coefficient, and agreement between modalities assessed using the Bland Altman analysis. This analysis was done for the whole sample population as well as for specific groupings according to body mass index, prostate size, and time between exams. RESULTS: A total of 236 patients had PUS followed by TRUS and met study inclusion criteria. Median age was 63, median prostate specific antigen value prior to PUS was 7.6 ng/mL, and only 20% were white. Mean volume differences between the two modalities for the data (volPUS - volTRUS) were (-0.3 ± 1.1) cm3. Bland-Altman analysis showed agreement between PUS and TRUS only for prostates ≤ 30 cm3. CONCLUSION: For prostates less than 30 cc, we found that PUS is interchangeable with TRUS in estimating prostate volume. However, for larger prostates where size may alter surgical management, we would recommend TRUS or cross-sectional imaging.

Robotic dismembered pyeloplasty surgical simulation using a 3D-printed silicone-based model: development, face validation and crowdsourced learning outcomes assessment.

Ureteropelvic junction obstruction (UPJO) is an uncommonly encountered pathology, posing a challenge for resident training. We describe the development and face validation of a robotic pyeloplasty simulation using a 3D-printed silicone-based model of UPJO for surgical training, in combination with crowdsourced scoring to objectively assess performance and learning outcomes. The organs were created using 3D modeling software and printed using a silicone-based material by Lazarus 3D, LLC. They were secured in a laparoscopic box trainer and the robotic system was docked. Eight residents and three faculty each performed two robotic-assisted right dismembered pyeloplasties on separate occaisions. Face validity was evaluated on a 5-point Likert scale. Crowd-Sourced Assessment of Technical Skills (C-SATS Inc.) scored surgical performance using the Global Evaluative Assessment of Robotic Skills (GEARS) criteria, based on video review of each simulation. All participants completed the simulation twice with fully patent anastomoses. Average time to complete the first and second trials was 44.4 min and 43.2 min, respectively. The average GEARS score was 17.1 and 17.6 for the first and second trials respectively. Participants improved on average in all 5 GEARS categories, with significant improvement in depth perception (p = 0.006). The model received mean scores (out of 5) of 4.36 for aesthetics, 4.18 for overall feel, 3.55 for realism, 4.72 for usability, and 4.72 for suturability. Residents had a significant increase in confidence between initial and final surveys on a 5-point Likert Scale: 1.63 vs. 2.38 (p = 0.03). Using 3D-printed silicone-based models, participants completed robotic-assisted dismembered pyeloplasties for training and skill acquisition. We demonstrated face validity of the simulation, which was also found to improve participant speed and significantly improve resident confidence. Crowdsourced assessment demonstrated significant improvement in depth perception.

The Effect of Holmium Laser Fiber Bending Radius on Power Delivery During Flexible Ureteroscopy.

Introduction: Flexible ureteroscopy is a mainstay of upper urinary tract stone treatment. Holmium laser lithotripsy is a particularly common and notable technique for the dusting and fragmenting of renal stones. During ureteroscopy, optical fibers are subject to sharp bends in pursuit of stones, particularly those at the lower pole. Following from principles of fiber optics, subjecting these fibers to sharp bending angle has the potential to reduce the efficiency of power transmission at the fiber tip. Due to the potential implications this hypothesis could have on endourological practice and research, we aimed to explore the potential impact of fiber bending on end-fiber power output. Materials and Methods: Using a highly sensitive oscilloscope and a urological holmium laser, we assessed the end-fiber power output under a variety of bending conditions. To ensure maximal confidence in our results, the maximal bending conditions explored substantially exceeded any condition, which could occur during ureteroscopic surgery. Results: We found evidence that bending radius alone has a clinically insignificant impact on the light power transmission in the fiber. At certain bending conditions, we observed a clinically unimportant but statistically significant reduction in power transmission. This was verified using two commonly used delivery fiber types exposed to 8-second bursts for each bending condition.

Robotic-Assisted Ureteral Re-implantation: A Case Series.

INTRODUCTION: Minimally invasive surgical techniques are currently used for numerous urologic disorders and generally offer decreased morbidity and equivalent outcomes compared with open surgery. There is a relative paucity of data on robot-assisted ureteral re-implantation (RAUR) in adult patients for benign stricture disease. PATIENTS AND METHODS: We retrospectively reviewed our recent experience with mid-/distal ureteral reconstruction at a single tertiary-care center. From 2010 to 2012, 13 consecutive patients presenting with benign obstruction of mid-/distal ureters were managed with RAUR. RESULTS: In all cases the operative procedure was undertaken with six-port transperitoneal access, and all procedures were completed robotically. All ureters (left, n=5; right, n=7; bilateral, n=1) were re-implanted in a standard Bricker fashion into the dome of the bladder with (n=8) or without (n=6) a psoas hitch. Catheters were removed 4-11 days postoperatively, and all cystograms were negative for leak. Stents were removed 14-48 days after surgery. All were negative for hydronephrosis. Average follow-up was 10 (range, 2-20) months. There were two grade 1, two grade 2, two grade 3, and no grade 4 or 5 complications in 3 patients. CONCLUSIONS: RAUR is a safe and effective procedure. Extensive laparoscopic lysis of adhesions represents the primary challenge to an otherwise straightforward minimally invasive surgery. At our institution, RAUR has replaced open ureteral re-implantation as the preferred treatment for benign mid-/distal ureteral stricture disease.

Spontaneous rupture of a renal artery aneurysm presenting as gross hematuria.

Renal artery aneurysms (RAAs) are localized dilations of the renal artery and/or its branches. They are being found with increasing frequency as a result of unrelated abdominal imaging or on workup for hypertension. They are rarely symptomatic; however, they can be a cause of life-threatening hematuria. Discussed is the case of a previously healthy 46-year-old man presenting with flank pain and gross hematuria. It is imperative for the practicing urologist to be aware of the appropriate evaluation and management of RAAs.

Fluoroscopy-guided percutaneous renal access.

Percutaneous renal surgery is dependent upon appropriate access to the targeted portion of the collecting system. Obtaining a well-positioned nephrostomy tract improves the urologist's ability to both obtain the desired surgical outcome and minimize attendant morbidities. The two primary methods of obtaining fluoroscopic-guided percutaneous renal access-"bull's eye" targeting and triangulation-are reviewed. The authors' preferred techniques are outlined, technical refinements are noted, and recent modifications and future directions are reviewed.