Implementation and Validation of a High-fidelity Simulation Model for Surgical Resident Training: Management of Acute Intraoperative Hemorrhage during Robot-assisted Surgery.

OBJECTIVE: To improve our previous simulation-based training module by using sustainable material to mold an anatomically accurate terrain and reproducing major vascular injuries encountered during robot-assisted nephrectomy. METHODS: The simulator was built with a pump, gauge, and valve linked via silicone tubing. Artificial blood was made from cornstarch, water, and red dye, and pumped through 3D-Med artificial vessels with the dimensions of an average renal artery. Silicone was used to emulate the pliability of organic tissue and mold an anatomically accurate terrain. Eight urologic residents participated in the pilot simulation. We employed validated assessment tools including Non-Technical Skills for Surgeons and Objective Structured Assessment of Technical Skills forms to guide debrief sessions moderated by an expert physician after individual performance evaluations. RESULTS: The apparatus demonstrated high reproducibility across all simulation scenarios, enhancing resident problem-solving skills. Residents' pre-simulation surveys revealed significant concern regarding their acute hemorrhage management. Residents' post-simulation survey demonstrated average realism scores increased from 4.375 to 4.75. Residents also felt the simulator enhanced learning, offering valuable practice and knowledge applicable to their surgical specialty. CONCLUSION: The management of acute hemorrhage during robot-assisted surgery remains a space for additional surgical education and training. Our simulation successfully provided a reliable, reproducible training for residents to practice their technical and non-technical skills in managing acute hemorrhage.

Patient Perceptions of Standardized Risk Language Used in ACR Prostate MRI PI-RADS Scores.

INTRODUCTION: Prostate MRI reports use standardized language to describe risk of clinically significant prostate cancer (csPCa) from "equivocal" (Prostate Imaging Reporting and Data System [PI-RADS] 3), "likely" (PI-RADS 4), to "highly likely" (PI-RADS 5). These terms correspond to risks of 11%, 37%, and 70% according to American Urological Association guidelines, respectively. We assessed how men perceive risk associated with standardized PI-RADS language. METHODOLOGY: We conducted a crowdsourced survey of 1,204 men matching a US prostate cancer demographic. We queried participants' risk perception associated with standardized PI-RADS language across increasing contexts: words only, PI-RADS sentence, full report, and full report with numeric estimate. Median perceived risk (interquartile range) and absolute under/overestimation compared with American Urological Association standards were reported. Multivariable linear mixed-effects analysis identified factors associated with accuracy of risk perception. RESULTS: Median perceived risks of csPCa (interquartile range) for the word-only context were "equivocal" 50% (50%-74%), "likely" 75% (68%-85%), and "highly likely" 87% (78%-92%), corresponding to +39%, +38%, and +17% overestimation, respectively. Median perceived risks for the PI-RADS-sentence context were 50% (50%-50%), 75% (68%-81%), and 90% (80%-94%) for PI-RADS 3, 4, and 5, corresponding to +39%, +38%, and +20% overestimation, respectively. Median perceived risks for the full-report context were 50% (35%-70%), 72% (50%-80%), and 84% (54%-91%) for PI-RADS 3, 4, and 5, corresponding to +39%, +35%, and +14% overestimation, respectively. For the full-report-with-numeric-estimate context describing a PI-RADS 4 lesion, median perceived risk was 70% (50%-%80), corresponding to +33% overestimation. Including numeric estimates increased correct perception of risk from 3% to 11% (P < .001), driven by men with higher numeracy (odds ratio 1.24, P = .04). CONCLUSION: Men overestimate risk of csPCa associated with standardized PI-RADS language regardless of context, especially for PI-RADS 3 and 4 lesions. Changes to PI-RADS language or data-sharing policies for imaging reports should be considered.

Simultaneous Bladder Drainage via Suprapubic and Urethral Catheters: Which Drains More Completely and Why?

Background: Reconstructive urologists often place both a urethral and suprapubic catheter intraoperatively to prevent extravasation of undrained urine across anastomosis sutures. As no consensus exists on which catheter drains the bladder more completely, many surgeons leave one catheter to gravity drainage and cap the other postoperatively. We sought to identify differences in catheter urine outflow during dual bladder drainage with suprapubic and urethral catheters in postoperative urology patients. Methods: Urine output (UOP) from transgender men who underwent Stage II Phalloplasty with urethral lengthening was retrospectively reviewed. Both 16 French urethral and suprapubic catheters were placed to gravity drainage postoperatively. Urine output from each catheter was recorded separately, twice daily. Mixed model regression modeling tested for differences in urine output by time of day (day/night) and activity status (Bedrest: Postop Day 0-2, Ambulatory: Postop Day 3+). Results: The aggregate number of 12-hour shift urine output observations was 250 (125 for urethral and 125 for suprapubic catheters) across 14 inpatients. Suprapubic catheters had a mean 410 ml higher output than urethral catheters per 12-hour shift (p=0.002; 95% CI: 185, 636 ml). During daytime, Suprapubic catheters demonstrated higher UOP than urethral catheters per 12-hour shift (Estimated Difference: 464 ml; p=0.002; 95% CI: 211, 718 ml). During nighttime, a similar phenomenon was observed (Estimated Difference: 356 ml; p=0.009; 95% CI: 104, 606 ml). When comparing mean UOP from each catheter during the Bedrest Phase, suprapubic catheters averaged an estimated 295 ml higher UOP compared to urethral catheters per 12-hour shift with a trend toward statistical significance (p=0.052; 95% CI -3, 594 ml). During the Ambulatory Phase, mean suprapubic catheter UOP was an estimated 472 ml higher than urethral catheters per 12-hour shift (p=0.009; 95% CI 142, 802 ml). Conclusions: Simultaneous bladder drainage with urethral and suprapubic catheters shows greater drainage from the suprapubic catheter (35% vs 65%). When using two catheters, both can be placed to gravity to maximize bladder drainage as the suprapubic catheter can drain residual urine not adequately drained by the urethral catheter.

Genetic Factors Associated with Prostate Cancer Conversion from Active Surveillance to Treatment.

Men diagnosed with low-risk prostate cancer (PC) are increasingly electing active surveillance (AS) as their initial management strategy. While this may reduce the side effects of treatment for prostate cancer, many men on AS eventually convert to active treatment. PC is one of the most heritable cancers, and genetic factors that predispose to aggressive tumors may help distinguish men who are more likely to discontinue AS. To investigate this, we undertook a multi-institutional genome-wide association study (GWAS) of 5,222 PC patients and 1,139 other patients from replication cohorts, all of whom initially elected AS and were followed over time for the potential outcome of conversion from AS to active treatment. In the GWAS we detected 18 variants associated with conversion, 15 of which were not previously associated with PC risk. With a transcriptome-wide association study (TWAS), we found two genes associated with conversion (MAST3, p = 6.9×10-7 and GAB2, p = 2.0×10-6). Moreover, increasing values of a previously validated 269-variant genetic risk score (GRS) for PC was positively associated with conversion (e.g., comparing the highest to the two middle deciles gave a hazard ratio [HR] = 1.13; 95% Confidence Interval [CI]= 0.94-1.36); whereas, decreasing values of a 36-variant GRS for prostate-specific antigen (PSA) levels were positively associated with conversion (e.g., comparing the lowest to the two middle deciles gave a HR = 1.25; 95% CI, 1.04-1.50). These results suggest that germline genetics may help inform and individualize the decision of AS-or the intensity of monitoring on AS-versus treatment for the initial management of patients with low-risk PC.

Are postoperative antibiotics necessary after artificial urinary sphincter insertion?

INTRODUCTION We sought to explore whether patients discharged without antibiotics after artificial urinary sphincter (AUS) insertion were more likely to require device explantation for infection or erosion compared to patients discharged with antibiotics at our institution and compared to patients in other large, contemporary series. MATERIALS AND METHODS: AUS insertions performed at our institution between 2013 and 2017 were retrospectively reviewed to determine demographics, comorbidities, and perioperative and medium-term outcomes. Patients were grouped based on 1) known risk factors for infectious complications or erosion and 2) postoperative antibiotic prescription status. Patients were placed in Group 1 if they did not demonstrate risk factors and did not receive postoperative antibiotics, Group 2 if they did possess risk factors but did not receive postoperative antibiotics, and Group 3 if they had risk factors and received postoperative antibiotics. RESULTS: Of the 155 men who met inclusion criteria, 44, 47, and 64 were categorized in Groups 1, 2, and 3, respectively. Median (IQR) follow up was similar across Groups 1, 2, and 3 (12.7 [4.6-25.1] versus 10.7 [4.5-31.3] versus 8.3 [4.4-26.4] months, p = 0.808). Rates of explantation due to device infection (0 versus 2 versus 6%, p = 0.172) or cuff erosion (2 versus 2 versus 8%, p = 0.253) did not vary significantly between Groups 1-3. CONCLUSIONS: Patients undergoing AUS insertion may be unlikely to benefit from the routine administration of postoperative antibiotics. In light of the known consequences of antibiotic overuse, a randomized controlled trial is warranted.

Minimal Inpatient Narcotic Requirement and Immediate Complication Profile Supports Same Day Discharge Following Artificial Urinary Sphincter Insertion.

INTRODUCTION: With more than 3,500 artificial urinary sphincters placed annually in the United States a significant cost burden is associated with overnight observation following surgery. We sought to determine whether inpatient management after artificial urinary sphincter insertion, our current local standard of care, is necessary with regards to inpatient narcotic requirements and immediate postoperative complications. METHODS: This was an institutional review board approved, retrospective review of artificial urinary sphincter insertions identified by CPT code 53445 between June 2013 and September 2017. Medical records were reviewed for patient demographics, postoperative narcotic use and immediate postoperative complications. RESULTS: We identified 163 men who underwent artificial urinary sphincter insertion for analysis. The cohort had a mean age of 69.8 ± 8.5 years, body mass index of 28.9 ± 5.1 kg/m2 and preoperative pad per day use of 5.8 ± 3.5. Of all patients identified 25 (15%) were using chronic narcotic pain medication preoperatively and 51 (31%) had a diagnosis of diabetes (mean A1c 7.0 ± 1.5%). All but 1 (99%) patients were discharged on the first postoperative day and 1 left on the second postoperative day. Two (1.2%) patients experienced immediate postoperative complication, and 8 (6%) patients failed a voiding trial on postoperative day 1. The 154 (94%) patients who required orally administrated narcotic pain medication after leaving the postanesthesia care unit used a median of 31.0 ± 22.9 morphine milligram equivalents. CONCLUSIONS: Immediate postoperative and peridischarge complication rates are around 1% after artificial urinary sphincter insertion, and narcotic requirements following postanesthesia care unit stay are minimal. Outpatient artificial urinary sphincter insertion is likely to be safe, effective and beneficial with regards to patient experience and total costs.

Penile Prosthesis Insertion in the Era of Antibiotic Stewardship-Are Postoperative Antibiotics Necessary?

PURPOSE: We sought to determine whether patients discharged from the hospital without antibiotics after inflatable penile prosthesis insertion were at increased risk for infectious complications compared to patients at our institution discharged with oral antibiotics and patients in other contemporary series. MATERIALS AND METHODS: We reviewed the medical records of patients who underwent inflatable penile prosthesis insertion from 2013 through 2017. Group 1 patients had no risk factors for infectious complications and did not receive postoperative antibiotics. Group 2 patients had risk factors for infectious complications but did not receive postoperative antibiotics. Group 3 patients had risk factors for infectious complications and received postoperative antibiotics. RESULTS: Of the 222 men who met study inclusion criteria 88 (40%) were in group 1, 48 (21%) were in group 2 and 86 (39%) were in group 3. The mean ± SD number of risk factors for infection was lower in group 2 than in group 3 (1.08 ± 0.28 vs 1.24 ± 0.46, p = 0.013). Median followup did not vary among groups 1, 2 and 3 (4.6 months, IQR 1.8-7.2; 3.5, IQR 1.4-6.9; and 4.5, IQR 1.4-7.4; p = 0.146, respectively). Rates of explantation due to device infection (0% vs 4% vs 5%, p = 0.130) and nonoperative infectious complications (1% vs 2% vs 2%, p = 0.829) did not vary among groups 1 to 3, respectively. CONCLUSIONS: Patients who undergo inflatable penile prosthesis insertion appeared unlikely to benefit from routine administration of postoperative antibiotics. In the current era of antibiotic stewardship these findings have the potential for substantial individual and population health benefits.

The Harms of Hematuria Evaluation: Modeling the Risk-Benefit of Using Split Bolus Computerized Tomography Urography to Reduce Radiation Exposure in a Theoretical Cohort.

PURPOSE: Computerized tomography urography is used to evaluate patients with gross or microscopic hematuria. Computerized tomography urography is a high radiation dose scan and, thus, it confers a higher risk of secondary malignancy. A computerized tomography urography split bolus protocol reduces radiation exposure but it may reduce sensitivity. In this study we used a theoretical cohort of patients with hematuria in which to model the risk of missing malignancies against the benefit of averting secondary malignancies. MATERIALS AND METHODS: We calculated the prevalence of renal cell carcinoma and upper tract urothelial carcinoma in patients with hematuria by pooled analysis of cohort studies, which in conjunction with split bolus sensitivity allows for the estimation of missed malignancies. The number of prevented secondary malignancies was calculated from lifetime attributable risk estimates. Sensitivity analyses were run to determine the minimum sensitivity required for a net population benefit. RESULTS: Estimates of split bolus computerized tomography urography sensitivity ranged from 80% to 100% (mean 95.2%). At the low estimate of 80% sensitivity split bolus computerized tomography urography was beneficial in men and women with microscopic hematuria at ages less than 50 and less than 60 years, respectively. An increase in sensitivity to 90% improved the benefit 1 decade in each gender, representing 68.8% of patients with microscopic hematuria. The overall population of patients with microscopic hematuria benefited from split bolus computerized tomography urography at 91.1% sensitivity. However, in patients with gross hematuria the threshold for an overall population benefit was high at 98.4% sensitivity. CONCLUSIONS: Exposure to ionizing radiation risks causing secondary malignancy. These data indicate that split bolus computerized tomography urography may be performed safely in 70% of the population of patients with microscopic hematuria. However, it is not currently advisable in patients with gross hematuria or in other patients at high risk.

Micro-scale environmental variation amplifies physiological variation among individual mussels.

The contributions of temporal and spatial environmental variation to physiological variation remain poorly resolved. Rocky intertidal zone populations are subjected to thermal variation over the tidal cycle, superimposed with micro-scale variation in individuals' body temperatures. Using the sea mussel (Mytilus californianus), we assessed the consequences of this micro-scale environmental variation for physiological variation among individuals, first by examining the latter in field-acclimatized animals, second by abolishing micro-scale environmental variation via common garden acclimation, and third by restoring this variation using a reciprocal outplant approach. Common garden acclimation reduced the magnitude of variation in tissue-level antioxidant capacities by approximately 30% among mussels from a wave-protected (warm) site, but it had no effect on antioxidant variation among mussels from a wave-exposed (cool) site. The field-acclimatized level of antioxidant variation was restored only when protected-site mussels were outplanted to a high, thermally stressful site. Variation in organismal oxygen consumption rates reflected antioxidant patterns, decreasing dramatically among protected-site mussels after common gardening. These results suggest a highly plastic relationship between individuals' genotypes and their physiological phenotypes that depends on recent environmental experience. Corresponding context-dependent changes in the physiological mean-variance relationships within populations complicate prediction of responses to shifts in environmental variability that are anticipated with global change.