The reporting quality of randomized controlled trials and experimental animal studies for urethroplasty.

OBJECTIVES: To assess the reporting quality of randomized controlled trials and experimental animal studies examining urethroplasty in reconstructive urological surgery literature. METHODS: We performed a comprehensive literature search to identify all urethroplasty-related RCTs examining humans as well as animal models. We used the Consolidated Standards of Reporting Trials (CONSORT) and the Animals in Research: Reporting in vivo Experiments (ARRIVE) guidelines to assess reporting quality. Two reviewers performed data abstraction independently and in duplicate. We then generated descriptive statistics including CONSORT (0-25) and ARRIVE (0-20) summary scores using the median and interquartile range. RESULTS: Twenty studies were ultimately included; 14 randomized controlled trials and 6 experimental animal studies. All studies were two-armed, parallel group studies. Median sample sizes (and interquartile range) of the human and animal studies were 48.5 (31.8-53.8) and 18 (15.3-27.5), respectively. The median CONSORT and ARRIVE scores were 10.0 (8.75-12.63) and 7.97 (6.79-8.64), respectively. Human randomized controlled trials did not consistently report the method of allocation concealment (6/14; 42.9%), blinding (2/14; 14.3%), or discuss the generalizability of the results (6/14; 42.9%). Animal studies infrequently reported why a given animal model was used (1/6; 16.7%), how they were allocated to groups (0/6; 0%) or what the experimental primary and secondary outcomes were (0/6; 0%). CONCLUSIONS: Urethroplasty literature is marked by a paucity of both randomized controlled trials and experimental design animal studies. The existing studies are inconsistently reported and are therefore of uncertain methodological quality.

Alvimopan as part of the Enhanced Recovery After Surgery protocol following radical cystectomy is associated with decreased hospital stay.

OBJECTIVE: To study the effect of alvimopan and the Enhanced Recovery After Surgery protocol on length of hospital stay in patients undergoing radical cystectomy. METHODS: Our retrospective study involved 296 consecutive patients undergoing radical cystectomy for bladder cancer at our institution from 2010 through 2018. Patients were grouped according to three stages of the Enhanced Recovery After Surgery protocol implementation: (i) pre-Enhanced Recovery After Surgery (group A; n = 146); (ii) pre-alvimopan Enhanced Recovery After Surgery (group B; n = 102); and (iii) Enhanced Recovery After Surgery plus alvimopan (group C; n = 48). The primary outcome was the length of hospital stay. Secondary outcomes were time to first bowel movement, time to tolerate a regular diet, the incidence of postoperative ileus, postoperative complications and 30-day readmission rate. RESULTS: Group C showed a significantly shorter median length of hospital stay (7 days, P = 0.003), shorter gastrointestinal recovery time (4 days, P = 0.018) and a lower rate of postoperative ileus (14.6%, P = 0.005). The reduction in length of hospital stay, gastrointestinal recovery time and a lower rate of postoperative ileus was significant after controlling for other confounders on multivariable regression analysis. With the open approach, group C showed a significantly shorter length of hospital stay and gastrointestinal recovery time (P = 0.005, P = 0.001, respectively); however, in robotic cohorts, no significant differences were observed. There was no difference among groups in the 30-day readmission rate or postoperative complications. CONCLUSIONS: Patients undergoing radical cystectomy and managed by an Enhanced Recovery After Surgery protocol experience a significantly shorter length of hospital stay when receiving alvimopan as part of the protocol. Patients seem to derive the optimum benefits of alvimopan when it is used with an open approach; however, these benefits become less obvious with the robotic approach.

Acute Kidney Injury following Enhanced Recovery after Surgery in Patients Undergoing Radical Cystectomy.

PURPOSE: We assessed the effect of enhanced recovery after surgery protocol related fluid restriction on kidney function and the incidence of postoperative acute kidney injury and 3-month kidney function. MATERIALS AND METHODS: In a retrospectively collected, single institution cohort we studied 296 consecutive patients (146 pre-enhanced recovery after surgery vs 150 enhanced recovery after surgery) who underwent radical cystectomy from 2010 to 2018. The primary outcome was the incidence of postoperative acute kidney injury. Secondary outcomes were length of hospital stay, time to bowel movements, time to tolerate regular diet, postoperative complications and 30-day readmission rate. Study limitations include its retrospective design and relatively modest sample size. RESULTS: We observed an increased rate of postoperative acute kidney injury in patients on the enhanced recovery after surgery protocol (42.7% vs 30.1%, OR 1.725, p=0.025). On multivariate analysis enhanced recovery after surgery protocol remained a significant predictor of acute kidney injury even when controlling for other covariates including baseline kidney function (OR 1.8, 95% CI 1.04-3.30, p=0.036). Patients with postoperative acute kidney injury demonstrated significantly higher odds of stage 3 chronic kidney disease at 3 months even after controlling for baseline renal function (OR 2.5, 95% CI 1.3-4.9, p=0.016). CONCLUSIONS: Use of an enhanced recovery after surgery protocol following radical cystectomy was associated with a higher risk of postoperative acute kidney injury in patients who had baseline chronic kidney disease which could be related to the restricted perioperative fluid management mandated by enhanced recovery after surgery. Use of the enhanced recovery after surgery protocol did not impact the length of hospital stay or readmission rates.

Skeletal Muscle and Fat Mass Indexes Predict Discharge Disposition after Radical Cystectomy.

PURPOSE: Skeletal muscle and fat mass indexes have emerged as easily obtained, objective and useful tools to assess susceptibility to unfavorable postoperative outcomes. We examined the association between skeletal muscle and fat mass indexes, and the discharge disposition after radical cystectomy. MATERIALS AND METHODS: In a retrospectively collected, single institution cohort we studied patients who underwent radical cystectomy with pelvic lymphadenectomy of primary, nonmetastatic muscle invasive bladder cancer between 2009 and 2015. Included patients had undergone adequate axial computerized tomography at the L3 level within 90 days prior to surgery. Skeletal muscle and fat mass indexes were measured on preoperative computerized tomography and relationships to the outcomes of interest were analyzed. Multivariable logistic regression analysis was performed to assess the effect of the skeletal muscle and fat mass indexes on the discharge disposition while controlling for age, comorbidities, complications and previous neoadjuvant chemotherapy. RESULTS: A total of 136 patients met study inclusion criteria. The median skeletal muscle index among women and men in our study cohort was 36.4 and 47.6 cm2/m2, respectively. On multivariable logistic regression analysis a decreased skeletal muscle index (OR 0.94, 95% CI 0.90-0.98) and an increased fat mass index (OR 1.24, 95% CI 1.04-1.48) were associated with greater odds of discharge to a facility. Higher fat mass-to-skeletal muscle [corrected] index ratios were also associated with greater odds of discharge to a facility (OR 1.69, 95% CI 1.22-2.44). Study limitations include the retrospective design and unknown confounders. CONCLUSIONS: Low skeletal muscle and high fat compositions are independent predictors of discharge to a facility after radical cystectomy of nonmetastatic muscle invasive bladder cancer.

Use of the IDEAL framework in the urological literature: where are we in 2018?

OBJECTIVES: To assess uptake and application of the IDEAL principles in original surgical procedure- or device-related clinical research studies, as well as its reported relevance as characterized by secondary publications, editorials and reviews. MATERIALS AND METHODS: IDEAL (Idea, Development, Exploration, Assessment, Long-term study) is a framework that provides stage-specific guidance for surgical innovation and represented a major advance towards raising evidential standards. We performed a comprehensive literature search of all urology-related publications citing one or more of seven key publications on IDEAL in The Lancet and BMJ using multiple databases up to 31 December 2017. RESULTS: We identified a total of 150 urology-related manuscripts citing IDEAL, of which 83 (55.3%) were original research and 67 (44.7%) were secondary publications. Among the original research articles, 40 (48.2%) did not explicitly apply IDEAL principles or were not surgical innovation studies. The IDEAL phases of the 43 (51.8%) remaining original research studies were IDEAL, in nine (20.9%), 27 (62.8%), four (9.3%), 0 (0%), and three publications (7.0%), respectively. Across IDEAL stages, 30 (75.0%) studies were prospective, 29 (85.3%) reported ethical oversight, and 39 (90.7%) captured treatment-related harms. None of the studies collected information on physician experience. CONCLUSIONS: The IDEAL framework has found widespread adoption in the urology literature as witnessed by a large number of original manuscripts and secondary publications citing IDEAL; however, its application is largely limited to the early stages of surgical innovation, frequently with inappropriate and incomplete implementation. Further efforts are needed to guide investigators in the optimal use of the IDEAL framework as it relates to surgical innovation in urology.

Impact of Virtual Care on Outpatient Urinary Tract Infection Management.

OBJECTIVE: To examine the effect of virtual care on urine testing, antibiotic prescription patterns, and outcomes of care in urinary tract infection (UTI) management. METHODS: We conducted retrospective analysis of adults treated for UTI in an ambulatory setting across a large health system from March 2020-2021. Outcomes included urine testing, antibiotic prescription, and retreatment or hospitalization, stratified by in-person vs virtual visit. Multivariable logistic regression was performed to examine factors contributing to outcomes. RESULTS: Significantly fewer patients seen virtually had urine testing as compared to those seen in-person (19% vs 69%, P <.001). On multivariable logistic regression analysis, virtual visit was the most significant predictor of urine testing, associated with an 86% reduction in the odds of urine testing (odds ratio (OR) 0.14, P <.001). Having a complicated UTI did not affect the likelihood of urine testing (OR 1.0, P = .95). Patients seen virtually were more likely to have a subsequent repeat ambulatory UTI visit (OR 1.16) or repeat antibiotic prescription (1.06) more than 2 weeks after the index encounter, though no more likely to be hospitalized for UTI (OR 1.00). CONCLUSION: Virtual care for UTI is associated with a significant reduction in urine testing and an increase in repeat UTI encounters and additional antibiotics among patients with complicated and uncomplicated UTIs.

Illeal conduit associated parastomal hernias: A novel laparoscopic top hat repair.

Parastomal hernias (PH) are a well-known complication following ileal conduit urinary diversion. We present a case report of a woman in her mid-nineties with a symptomatic parastomal hernia at the site of her ileal conduit which was repaired laparoscopically by an inverted top-hat technique. The "top hat" is constructed by assembling a transected ring of synthetic mesh with a secondary mesh cylinder and laparoscopically securing this mesh construct in an underlay fashion. At eighteen months follow-up, the patient remains pain free and without evidence of hernia recurrence.

Management of bladder tumors in pregnancy: A case of tumor prolapse and avulsion during labor.

Pregnancy presents unique obstacles to diagnosis and management of urologic disease. We present a case of a primigravid female with clot retention requiring evacuation in the operating room due to the avulsion of a bladder mass which prolapsed during labor. Tumor pathology demonstrated a low-grade spindle cell lesion positive for progesterone receptor (PR) and high mobility group A2 (HMGA2), suggestive of deep angiomyxoma versus a benign fibroepithelial polyp or inflammatory myofibroblastic tumor.

Five New Cases of Primary Renal Carcinoid Tumor: Case Reports and Literature Review.

Carcinoid tumors, a slow-growing NET, most commonly arise in the gastrointestinal tract (73.7%), followed by the bronchopulmonary system (25.1%), and least commonly in the genitourinary system (<1%). Primary carcinoid tumors of the kidney-with approximately 100 cases reported in the literature since the first described case in 1966-are thought to be so rare because neuroendocrine cells are not typically found in the renal parenchyma. Here we present a series of five cases at our institution with primary carcinoid tumors of the kidney followed by a literature review. In the literature we describe the diagnostic stains used to determine renal carcinoid tumors. We also describe why partial nephrectomies are the gold standard treatment in these cases, while radical nephrectomy can be used in certain circumstances. Limited research on treatment of metastasis of these tumors exists, but we summarize the results of existing treatments. Major prognostic factors and survival of patients with these tumors is described as well as the increased prevalence of this tumors in patients with horseshoe kidneys. This study presents five new cases of primary renal carcinoid tumors and a comprehensive review of the previously published cases. We are able to make limited prognostic predictions from currently published literature, but we will continue to learn from our patients' long-term courses to draw conclusions about biological behavior, treatment outcomes, and recurrence of rare disease.

Outcomes of Urinary Diversion for Late Adverse Effects of Gynecologic Radiotherapy.

OBJECTIVE: To describe the risks of urinary diversion performed to address adverse effects of gynecologic radiation, with the hypothesis that high grade complications would be more common in sarcopenic women and in those undergoing continent diversion (vs noncontinent) or concomitant cystectomy (vs bladder-sparing diversion). METHODS: A retrospective review was performed of patient records of women who underwent urinary diversion for urinary adverse effects of gynecologic radiotherapy during the period of 2008-2018 from 3 tertiary centers. Skeletal muscle index was calculated to assess for sarcopenia based on preoperative computed tomography scans. Outcomes include high-grade postoperative complications within 90 days of surgery, 30-day readmission rate, and long-term (>90 days) outcomes. RESULTS: Among 34 women who met the inclusion criteria, the majority were white/Caucasian (73.5%). Twenty-six of 34 (76.5%) underwent noncontinent diversion. Seventy nine percent (27/34) (79.4%) of women experienced complications within 90 days; 9 of 34 (26.5%) experienced high-grade (Clavien grade ≥3) complications. Thirty-two percent (11/34) were readmitted within 30 days. Rates of high-grade complications were not significantly impacted by diversion type (P = .49), concurrent cystectomy (P = .70), or sarcopenia (P = 1.0). CONCLUSIONS: Urinary diversion for late adverse effects of gynecologic radiotherapy is associated with high peri-operative risk, even in skilled hands. In this series, neither sarcopenia, nor continent diversion, nor cystectomy were associated with increased complications. Patients and surgeons should consider risks and benefits when deciding to proceed with urinary diversion, however further study is needed to elucidate significant preoperative markers which may predispose patients to significant complications.

Prostate Cancer Survival Estimates by the General Public Using Unrestricted Internet Searches and Online Nomograms.

BACKGROUND: Patient understanding of cancer-associated risk influences treatment preferences and is vital for making informed treatment decisions. Although patients traditionally relied on physician visits for cancer information, most adults now use the Internet as a primary source of health information. OBJECTIVE: To evaluate whether US adults can accurately estimate survival for hypothetical prostate cancer patients using unrestricted Internet searching and an online nomogram. DESIGN, SETTING, AND PARTICIPANTS: Adults were recruited at the Minnesota State Fair. Participants were shown a pathology report for a prostatectomy cancer specimen and asked to estimate the patient's 15-yr survival using an unrestricted Internet search. Participants were then asked to re-estimate using a freely available, validated prostate cancer nomogram. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Participants' answers were compared to a "reference" estimate and a "ballpark" estimate of ±10 percentage points of the "reference" value. RESULTS AND LIMITATIONS: A total of 129 participants met the inclusion criteria and generated complete responses. Only 12% (95% confidence interval [CI] 7.8-19.2%) were within the "ballpark" estimate when using unrestricted Internet searching for overall survival estimates. 23% (95% CI 16.8-31.3%) correctly used the nomogram and 51% (95% CI 42.6-59.6%) estimated within the "ballpark" when using the nomogram. CONCLUSIONS: Use of an unrestricted Internet search often yields inaccurate estimations of life expectancy, while estimations significantly improve with nomogram use. Physicians should educate and guide patients towards credible online health resources, facilitate their effective use, and engage in discussion with patients regarding the utility of this information. PATIENT SUMMARY: The general public finds it difficult to estimate prostate cancer survival using unrestricted Internet searches. Most patients would benefit from Internet guidance from their clinicians to better understand prostate cancer pathology reports.