27-year trends in incidence rates for testis cancer across a large statewide registry.

PURPOSE: To review 27-years of testicular cancer (TC) incidence data (1990-2017) within the state of Pennsylvania to better define incidence, geographic distribution, and trends over time. METHODS: The Pennsylvania Cancer Registry was reviewed for statewide and component county age-adjusted TC incidence rates and stage distribution. We reported annual percent changes (APCs) in age-adjusted rates. Maps plotting county-level incidence rates across the state in five-year time intervals were created. RESULTS: In Pennsylvania, 9,933 TC cases were recorded between 1990-2017. Over two-thirds of patients were < 40 years of age and 95% were White. Approximately 89% presented as local and regional disease. Age-adjusted annual rates of total TC increased from 4.80 to 7.20 patients per 100,000 with an APC of 0.94 (95% Confidence Interval (CI) = (0.59, 1.29), P < 0.01) over the study interval. Annual rates of local disease increased from 3.20 to 5.00 patients per 100,000 with an APC of 1.07 (95% CI = (0.67, 1.46), P < 0.01). Annual rates of distant disease were stable and ranged from 0.50 to 0.80 patients per 100,000 with an APC of 0.69 (95% CI = (-0.02, 1.40), P = 0.06). Geospatial investigation noted increased incidence in urban centers. CONCLUSIONS: Although TC is rare, incidence is rising. Rates of TC in Pennsylvania almost doubled over the past two decades. Fortunately, this rising trend is primarily attributed to increases in local and regional disease. Counties with higher incidence rates cluster in urban centers which may reflect exposure risk, access to care, or reporting bias.

Synchronous melanosis of upper and lower urinary tract.

Urothelial melanosis is an exceptionally rare diagnosis, with less than 25 cases being reported in the literature. Melanosis of the urothelium is characterized by abnormal melanin deposition within tissues, producing a black, velvety appearance to the urothelial mucosa. We present a 67-year-old male undergoing cystoscopy during a routine percutaneous nephrolithotomy (PCNL), who was found to have diffuse bladder melanosis extending up the ureter and into the renal pelvis. To our knowledge, this is the first reported case of synchronous melanosis of upper and lower urinary tract.

Incidence and Distribution of New Renal Cell Carcinoma Cases: 27-Year Trends from a Statewide Cancer Registry.

Nationwide databases have implicated an increased incidence of renal cell carcinoma (RCC). The Pennsylvania (PA) Cancer Registry was queried to better define incidence, geographic distribution, and statewide trends of new RCC cases over a 27-year period. JoinPoint Trend Analysis Software modeled average annual percent changes (APCs) in age-adjusted rates (AAR). Maps plotting county-level incidence rates and stage distribution of disease across the state in 5-year time intervals were created using R 4.0.2 software. Overall, 59,628 cases of RCC were recorded in PA from 1990 to 2017. Eighty six percent of patients were >50 years of age, 61% were males, and 89% were Caucasian. Stage distribution using the SEER staging system included 64% local, 17% regional, and 16% distant. Over the study interval, AAR of all RCC cases increased from 9.9 to 18.0 patients per 100,000 population with an APC of 2.3% (p < 0.01). AAR of local disease increased from 5.4 to 12.7 patients per 100,000 population with an APC of 3.2% (p < 0.01). AAR of regional disease also increased from 1.9 to 2.9 patients per 100,000 population with an APC of 1.0% (p = 0.01). Younger patients (<50 years) had a greater rate of increase than older counterparts (APC 3.8% vs. 2.0%, p < 0.05). Geospatial investigation of new RCC cases noted certain geographic concentrations of greater disease incidence. The incidence of RCC in PA has increased over the past 27 years in PA. One-third of the cases are regional or metastatic at presentation and rates of increase were most notable in younger patients.

Network Analysis of Postoperative Surgical Complications in a Cohort of Children Reported to the National Surgical Quality Improvement Program: Pediatric.

OBJECTIVE: To understand the temporal relationships of postoperative complications in children and determine if they are related to each other in a predictable manner. SUMMARY OF BACKGROUND DATA: Children with multiple postoperative complications have increased suffering and higher risk for mortality. Rigorous analysis of the temporal relations between complications, how complications might cluster, and the implications of such clusters for children have not been published. Herein, we analyze the relationships between postoperative complications in children. METHODS: Data source: Surgical operations included in the National Surgical Quality Improvement Program Pediatric Participant Use Data File from 2013 to 2017. The main outcomes measure was presence of 1 or more postoperative complications within 30 days of surgery. Operations followed by multiple complications were analyzed using network analysis to study prevalence, timing, and co-occurrences of clusters of complications. RESULTS: This study cohort consisted of 432,090 operations; 388,738 (89.97%) had no postoperative complications identified, 36,105 (8.35%) operations resulted in 1 postoperative complication and 7247 (1.68%) operations resulted in 2 or more complications. Patients with multiple complications were more likely to be younger, male, African American, with a higher American Society of Anesthesiologists score, and to undergo nonelective operations (P < 0.001). More patients died with 2 complication versus 1 complication vs no complication (5.3% vs 1.5% vs 0.14%, P < 0.001). Network analysis identified 4 Louvain clusters of complications with dense intracluster relationships. CONCLUSIONS: Children with multiple postoperative complications are at higher risk of death, than patients with no complication, or a single complication. Multiple complications are grouped into defined clusters and are not independent.

The state of telehealth: 2 years into the COVID-19 pandemic - back to business as usual?

INTRODUCTION: Telemedicine (TM) was underutilized prior to the COVID-19 pandemic presumably due to non-standardized reimbursement routes and a perceived lack of need. Early experience with the pandemic necessitated this form of medical care, although durability of consistent delivery remains in question. We quantify the utilization patterns of TM over the past 2 years over multiple waves of the pandemic across various service lines in a large rural health system. MATERIALS: Data of TM utilization were prospectively collected between March 2020-January 2022. Rates of adoption among the various surgical and non-surgical services disciplines were compared. Subgroup analyses between different surgical subspecialties and within the urologic subspecialties was performed. RESULTS: 3.5 million visits were recorded; 3.14 million (90%) on-site and 349,989 (10%) TM; 254,919 (73%) video-assisted and 95,070 (27%) were telephonic. Throughout the pandemic, non-surgical services utilized TM to a greater extent than surgical services (mean% 12 vs 6). Significant variation in the utilization among surgical services was reported, with Urology representing a high utilizer (15%); Among Urologic subspecialties utilization, Endourology (28%) was highest and Pediatric Urology (5%) was lowest. Following an initial spike in TM utilization during the pandemic, rates have declined and plateaued at 5-7% of all visits over the past 6-months. CONCLUSION: TM utilization in this large health system has remained under 10% following the initial surge in 2020. Non-surgical services preferentially use TM more than surgical domains. Certain subspecialties utilize TM more than others, possible due to patient population, practice patterns and medical conditions. Barriers to adoption are essential to determine the relatively low volume of use across this health system.

The Optimal Parathyroid Hormone Cut-Off Threshold for Early and Safe Management of Hypocalcemia After Total Thyroidectomy.

OBJECTIVE: To define optimal intact parathyroid hormone (iPTH) cut-off threshold predictive of hypocalcemia after total thyroidectomy for safe and effective postoperative management. METHODS: This prospective single center study was done in 2 phases. In phase I, predictors of symptomatic hypocalcemia were analyzed and the receiver operating characteristic curve was used to define the optimal iPTH cut-off threshold predictive of hypocalcemia. Phase II studied giving prompt prophylactic supplemental calcium and vitamin D to all patients who had iPTH levels below the calculated threshold, while phase I patients were given prompt selective supplementation if they had postoperative hypocalcemia or symptoms. RESULTS: Univariate analysis of patients in phase I showed that postoperative iPTH was the only significant variable that can predict symptomatic hypocalcemia. Using receiver operating characteristic curve and Youden index, the confirmed optimal cut-off threshold predictive of hypocalcemia was iPTH 19.95 pg/mL, with area under the curve of 0.903, 100% sensitivity, negative predictive value, and highest Youden index, while iPTH 15 pg/mL and iPTH 10 pg/mL were less optimal. Symptomatic hypocalcemia occurred in 30% of the phase I cohort who received selective supplementation versus 3% of those in the phase II cohort who received prophylactic supplementation. Return to emergency department and need for intravenous calcium were also significantly better in phase II. CONCLUSION: iPTH cut-off for post-thyroidectomy hypocalcemia was 19.95 pg/mL. Low-risk patients were discharged with no supplementation while all high-risk patients received prompt calcium and vitamin D supplementation, which led to effective hypocalcemia management and safe 24-hour discharge.

Nonstented Tubularized Incised Plate Distal Hypospadias Repair: A Single Center 5 Years' Experience.

OBJECTIVES: To report our immediate and delayed outcomes of nonstented tubularized incised plate (TIP) distal hypospadias repair. METHODS: We retrospectively reviewed all charts of children who underwent distal hypospadias repair in a single children's hospital from 2013 to 2018. Patients' demographics, hypospadias characteristics, operative technique, and immediate and delayed outcomes were recorded. RESULTS: Of 280 consecutive distal hypospadias repairs that were identified, 74 were excluded due to the use of a repair other than TIP. Eleven stented TIP repairs were excluded as well. Of 195 nonstented repairs, immediate postoperative voiding complications were recorded in 11 (5.6%) and included multiple/split stream in 6 (3%), dysuria and voiding difficulty in 2 (1%), urinary retention in 2 (1%), and gross hematuria that spontaneously resolved in 1 (0.5%). Late follow up was recorded in 142 of 195 (72.8%) repairs. Delayed urethroplasty/glansplasty complications were recorded in 12 (8.5%) and included urethrocutaneous fistula in 10 (7.0%), meatal stenosis in 6 (4.2%) and glans/urethroplasty dehiscence in 2 (1.4%). CONCLUSION: Avoiding postoperative urethral stents in distal hypospadias TIP repair reduces the morbidity associated with the stent and is a feasible option that carries acceptable immediate and delayed complication rates. Avoiding the stent eliminates stent-related bladder spasms, the need for other medications, and the short-term office visit for stent removal, therefore reducing parental anxiety, patient discomfort, and reducing cost.

Inappropriate imaging for management of cryptorchidism: Has the choosing Wisely® recommendation reduced occurrence?

INTRODUCTION: Cryptorchidism is one of the most common referral diagnoses to pediatric urologists. It is well recognized in the urologic community that diagnostic imaging is unnecessary in the work-up of these patients, and the Choosing Wisely® recommendation (CWR) on this subject re-emphasized this in 2013. Many boys, however, still are sent for testing prior to referral. OBJECTIVE: The purpose of our study was dual in nature. We pursued, first, to identify any factors that make patients more likely to be sent for imaging prior to referral, and second, to determine if rates of diagnostic imaging for cryptorchidism decreased after the release of the CWR. STUDY DESIGN: We included all boys who had surgery for cryptorchidism by Urology at our institution between January 2007 and August 2018. Demographics and clinical data were collected including height, weight, race, insurance type, pre-referral imaging status, testis location at time of surgery, and distance from our medical center. Chi-squared analysis was utilized to compare imaging use before and after CWR. Influence of other clinical and socioeconomic factors on imaging utilization was also evaluated using chi-squared and two-sample t tests. Those found to be significant at the 0.2 level were analyzed in multivariate logistic regression. Significance was set at 0.05. RESULTS: 1010 boys were available for analysis. Of the 256 patients (25.3%) with pre-referral studies, 7 had axial exams (CT or MRI), and the remainder underwent ultrasounds. Children living closer to the medical center were more likely to undergo imaging (p < 0.01) as were boys with testes not found in the inguinal canal at the time of surgery (p = 0.007). Race, insurance status, age at first visit, and increased body mass index were not found to be influential. Similarly, the release of CWR had no impact on the imaging usage (p = 0.61). CONCLUSION: Utilization of pre-referral diagnostic imaging remains inappropriately high despite evidence demonstrating the ineffectiveness of the studies. Boys living closer to the medical center and those with non-inguinal testes are more likely to undergo these studies, but no other factors were found to have an effect. Further, the Choosing Wisely® recommendation has not improved rates of inappropriate imaging use in boys with cryptorchidism in our referral area. Our findings indicate the need for increased efforts to disseminate this evidence-based guideline more widely to primary care providers in order to promote more cost-effective and timely care of boys with undescended testes.

Alpha-dystroglycan staining pattern and mortality in patients undergoing radical prostatectomy with lymph node positive prostate cancer.

INTRODUCTION: Dystroglycan (DG) is a cell surface receptor for extracellular matrix proteins involved in tissue mechanical stability and matrix organization. Initial work has demonstrated that alpha-DG expression is decreased in many types of adenocarcinoma, including prostate, and potentially associated with the development of metastatic disease. However, the consistency between prostate and lymph node alpha-DG staining has not been previously reported. In addition, identification of an immunohistochemical marker associated with prostate cancer grade, stage, need for adjuvant or salvage therapy and mortality would have potential clinical value. MATERIALS AND METHODS: Node positive, margin negative radical prostatectomy specimens at a single institution from 1982 to 2012 were reviewed and identified 35 prostate specimens, including 26 patients with available tissue from both the primary prostatectomy and lymph node specimens. The expression levels of the alpha-DG subunit were analyzed using immunohistochemistry and graded from 0 to 4. Survival was compared in different staining pattern groups. RESULTS: Strength of alpha-DG staining was found to be consistent between prostate and lymph node specimens (p < 0.004). The median overall survival was shorter in those without alpha-DG staining in the prostate compared to those with positive staining, but this difference was not statistically significant (13.2 years versus 19.4 years, p = 0.21). In addition, negative staining was associated with higher mean PSA, pathologic T stage, Gleason grade and the need for adjuvant or salvage therapy compared to positive group but none reached statistical significance (16.06 ng/mL versus 11.67 ng/mL, p = 0.79; 89% versus 68%, p = 0.38; 33.3% versus 23.1%, p = 0.66; 88.9% versus 76.9%, p = 0.44). CONCLUSIONS: DG expression by immunohistochemistry staining was consistent between prostate and metastatic lymph node specimens. In a small cohort of prostate cancer patients with margin negative but node positive disease, DG staining was not associated with Gleason grade or with overall mortality.

Circumcision, Buried Penis and Obesity in a Contemporary Cohort of Patients with Penile Cancer.

INTRODUCTION: We reviewed patient demographics and body morphology in a contemporary cohort of patients presenting to a tertiary care center for treatment of penile cancer. METHODS: The University of Iowa Oncology Registry was retrospectively reviewed for cases of penile cancer managed between 2006 and 2016. The database was queried for cancer specific details, followed by a chart review for body morphology data and comorbidity status. RESULTS: We treated 54 patients for penile cancer in the study period with a mean ± SD age of 64.3 ± 12.9 years and body mass index of 36.2 ± 10 kg/m2. Of these men 31.5% (17) had a clinically buried penis and 50% (27) reported prepubertal circumcision. Patients with a buried penis had a higher body mass index (46.53 ± 10.6 vs 31.48 ± 5.63 kg/m2, p <0.0001) and underwent fewer inguinal lymph node dissections (20% vs 58%, p = 0.05) than patients without a buried penis, but had similar rates of higher stage (2-4) presentation. Stage correlated with penile cancer death. Those with cancer specific mortality had a significantly higher body mass index (41.2 ± 12.4 kg/m2) vs those without penile cancer death (34.6 ± 9.1 kg/m2). CONCLUSIONS: Penile cancer remains relatively rare but contemporary cohorts suggest that circumcision may no longer be protective, especially in the setting of a clinically buried penis that may mimic an intact prepuce. How a buried penis and higher body mass index affect presentation, clinical management, surgical outcomes and disease course deserves further study.

Trends in Operating Room Assistance for Major Urologic Surgical Procedures: An Increasing Role for Advanced Practice Providers.

OBJECTIVE: To characterize changes in surgical assistance patterns over time for commonly performed urologic operations. MATERIALS AND METHODS: This study used the Medicare Physician/Supplier Procedure Summary Master File to identify cases performed by urologists from 2003 to 2014. Current Procedural Terminology modifiers were used to identify operations assisted by second surgeons and advanced practice providers (APPs). Rates were reported annually for 6 common urologic operations, and average annual rates of change were determined using least squares regression and tested using t tests (α = .05). RESULTS: Of the urologic operations analyzed, 5.0% of cases (n = 33,895) were assisted by APPs compared with 27.0% (n = 182,842) assisted by a second surgeon. The proportion of cases assisted by an APP rose significantly for all procedures; conversely, the proportion of cases assisted by a second surgeon declined significantly for all procedures, except for open partial nephrectomy. The largest changes were seen in robotic prostatectomies for which second surgeon assistance fell from 26% in 2004 to 15% in 2014, whereas APP assistance rose from <1% to 7%. CONCLUSION: Urologists are increasingly using APPs as assistants in surgery, particularly in robotic and laparoscopic operations. This trend will likely continue as the shortage of urologists worsens in the coming years.