Timing of Ureteral Stent Removal After Ureteroscopy on Stent-Related Symptoms: A Validated Questionnaire Comparison of 3 and 7 Days Stent Duration.

Objectives: To determine whether urinary symptoms are significantly improved with a shorter duration of stent placement without an increase in complications. Methods: A total of 100 patients were prospectively randomized to two groups, either a 3-day (n = 59, Group 1) or 7-day (n = 41, Group 2) stent placement group depending on date of operation. Patients submitted Ureteral Stent Symptom Questionnaires both while stents were in situ and 2 to 3 days after removal. Results: Group 2 reported greater urinary symptoms (p < 0.001) and pain (p < 0.001) with stents in situ compared with Group 1. Urinary symptoms (p < 0.001), pain (p = 0.003), and general health (p = 0.02) were more severe in Group 2 after stent removal as well. The analysis also revealed that urinary symptoms, pain, and general health improved after stent removal compared with stent in situ (p < 0.001). There were no significant differences in work-related functioning between two groups. There was one complication in Group 1 requiring bilateral stent replacement. There were no significant differences in emergency department visits, unplanned clinic visits, or hospitalizations between Groups 1 and 2. Conclusions: Patients with stent removal at 3-day group had better reported urinary, pain, and general health score compared with 7-day group. Patients after stent removal had improved urinary symptoms, pain symptom, and general health compared with ureteral stent in situ. There was no statistically significant difference in complications between the groups.

How do pediatric urology fellows learn outside of direct patient care? A qualitative study.

BACKGROUND: A large proportion of time during pediatric urology fellowship training is focused on surgical skill development. While fellows begin their fellowship training with some knowledge of pediatric urology from residency, they rely on self-directed learning to expand their knowledge base. OBJECTIVE: To assess how pediatric urology fellows learn about their field outside of direct patient care experiences. Additionally, we were interested in how the pandemic affected fellows self-directed learning. METHODS: First and second year pediatric urology fellows at Accreditation Council of Graduate Medical Education (ACGME)-accredited programs were asked to participate in the study. Individual virtual interviews were conducted and transcribed. Each transcript was coded shortly after transcription. Constructivist grounded theory was used in the data collection and analysis. As interviews progressed, a constant comparative analysis was used iteratively to generate themes. RESULTS: A convenience sample of thirteen fellows from programs across the U.S. agreed to participate; eight were male and five were female. The following four themes emerged from the interviews: most learning in fellowship is self-directed, fellows are not the target audience for didactics, fellows have little independent study time, and there is a lack of organization and guidance for formal didactics (Summary Table). Additionally, we found that teleconferences were used for the majority of teaching after the start of the coronavirus pandemic. CONCLUSION: Fellows in pediatric urology programs are independent learners who understand the need for self-directed learning outside of the setting of formal didactics in fellowship. However, many lack appropriate time, guidance and/or mentorship to facilitate self-directed learning. We identified a need for more structure in pediatric urology fellowship clinical didactics. Videoconferencing software may enable the creation of a national pediatric urology fellowship curriculum.

Validation of the modified Bosniak classification system to risk stratify pediatric cystic renal masses: An international, multi-site study from the pediatric urologic oncology working group of the societies for pediatric urology.

BACKGROUND: Pediatric cystic renal lesions are challenging to manage as little is known about their natural course. A modified Bosniak (mBosniak) classification system has been proposed for risk stratification in pediatric patients that takes ultrasound (US) and/or computed tomogram (CT) characteristics into account. However, literature validating this system remains limited. OBJECTIVE: To determine if the mBosniak classification system correlates with pathologic diagnoses. The hypothesis is that mBosniak classification can stratify the risk of malignancy in children with renal cysts. STUDY DESIGN: Patients treated for cystic renal masses with available imaging and pathology between 2000 and 2019 from five institutions were identified. Clinical characteristics and pathology were obtained retrospectively. Characteristics from the most recent US, CT, and/or magnetic resonance imaging (MRI) were recorded. Reviewers assigned a mBosniak classification to each scan. mBosniak scores 1/2 were considered low-risk and 3/4 high-risk. These groups were compared with pathology (classified as benign, intermediate, malignant). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were calculated to assess this categorization as a screening tool to guide surgical intervention. Agreement between imaging modalities was also explored. RESULTS: 99 patients were identified. High-risk imaging findings were correlated with malignant or intermediate pathology with a sensitivity of 88.3%, specificity of 84.6%, PPV of 89.8%, NPV of 82.5%, +LR of 5.7, and -LR of 0.14. The sensitivity for detecting malignant lesions only was 100%. There was substantial agreement between US/CT (n = 55; κ = 0.66) and moderate agreement between US/MRI (n = 20; κ = 0.52) and CT/MRI (n = 13; κ = 0.47). DISCUSSION: The mBos classification system is a useful tool in predicting the likelihood of benign vs. intermediate or malignant pathology. The relatively high sensitivity and specificity of the system for prediction of high-risk lesions makes this classification applicable to clinical decision making. In addition, all malignant lesions were accurately identified as mBosniak 4 on imaging. This study adds substantial data to the relatively small body of literature validating the mBosniak system for risk stratifying pediatric cystic renal lesions. CONCLUSIONS: Pediatric cystic renal lesions assigned mBosniak class 1/2 are mostly benign, whereas class 3/4 lesions are likely intermediate or malignant pathology. We observed that the mBosniak system correctly identified pathology appropriate for surgical management in 88% of cases and did not miss malignant pathologies. There is substantial agreement between CT and US scans concerning mBos classification.

Comparison of risk of anticholinergic utilization for treatment of neurogenic bladder between in utero or postnatal myelomeningocele repair.

INTRODUCTION: In utero myelomeningocele (MMC) repair has resulted in significant decrease in need for shunt-dependent hydrocephalus, however its impact on bladder function remains less clear. Neurogenic detrusor overactivity (NDO) due to MMC can be addressed with combination of clean intermittent catheterization (CIC) and anticholinergic (AC) therapy to minimize its effect on bladder function and upper urinary tract. The aim of this study was to compare the risk of postnatal AC utilization for in patients that underwent either postnatal or in utero MMC repair related to neurogenic bladder (NGB) management. We hypothesized that postnatal MMC repair would be associated with increased risk of postnatal AC utilization compared to in utero MMC repair. MATERIAL AND METHODS: All newborns with MMC in our hospital undergo prospective surveillance radiographic and urodynamic testing as part of institutional MMC protocol. Those MMC patients born between 2013 and 2018 at our institution, who underwent in utero or postnatal MMC repair were retrospectively analyzed. We identified postnatal AC utilization from electronic medical records and recorded indications for AC therapy according to the urodynamic, radiographic and clinical findings related to NGB management. RESULTS: 97 patients fulfilled the inclusion criteria. 56 patients underwent a postnatal and 41 an in utero repair. Median follow-up for the in utero and postnatal MMC repair groups was the same at 37 months (p = 0.53). More newborns from the postnatal group were discharged from birth hospital performing CIC (91.1% vs. 58.5%, p < 0.0001), however upon last follow up no difference existed between the groups on use of CIC (83.9% postnatal group % vs. 82.9% in utero group, p = 0.78). At last follow up, postnatal AC utilization was observed in 75% of postnatal MMC group compared to 78.1% of the in utero MMC repair group, p = 0.81 (Figure). The median time to AC utilization was 6.9 months and 8.8 months in the in utero and postnatal groups, respectively (p = 0.28). DISCUSSION: We observed no reduction in risk of AC utilization with in utero repair which refuted the hypothesis of our study. Indications for AC utilization were urodynamic abnormalities such as NDO (81.3% in utero vs. 81% postnatal) or impaired bladder compliance (53.1% in utero vs. 64.3% postnatal). CONCLUSIONS: We found no difference in risk of postnatal AC utilization between in utero or postnatal MMC repair. CIC rates were higher at birth hospital discharge in the postnatal repair group, however at last follow up CIC rates did not differ between groups.

High incidence of abnormal imaging findings in circumcised boys diagnosed with urinary tract infections.

BACKGROUND: The American Academy of Pediatrics guidelines recommend delaying voiding cystourethrogram (VCUG) until the second febrile urinary tract infection (UTI). Similarly, the NICE Guidelines do not recommend VCUG after the first febrile UTI in infants and children under three years of age. Currently, there is no good clinical indicator to determine which patients would benefit from an earlier cystogram. Here, we sought to identify clinical and bacteriologic findings that are associated with an increased risk of urinary tract anatomic anomalies in pediatric males presenting to the Emergency Department with a UTI. METHODS: A retrospective review was performed of all urine cultures from the Emergency Department at our institution between 2006 and 2015. Males under 18 years of age with ≥50,000 CFU/mL of Proteus, Klebsiella, Escherichia coli, Staphylococcus, Streptococcus and Enterococcus were included. Clean catch, catheterized and suprapubic aspiration specimens were included. Bagged specimens and specimens from patients on intermittent catheterization were excluded. Ultrasound and cystogram images were reviewed when available. Univariate and multivariable Poisson regression with robust variance was used to calculate and compare prevalence ratios. Statistical analysis was performed with Stata software, version 15.1 MP (Stata Corporation, College Station, Texas, USA). RESULTS: We reviewed 1585 urine cultures, of which 812 met eligibility criteria including 619 (76.2%) E. coli, 84 (10.3%) Proteus, 55 (6.8%) Klebsiella, 29 (3.6%) Staphylococcus, 13 (1.6%) Enterococcus and 12 (1.5%) Streptococcus. Median age was six months (2.4-36 months IQR). After adjusting for age, ethnicity and bacterial species, the prevalence of dilating vesicoureteral reflux (VUR, defined as grades III-V) was 5.3 times higher in circumcised males compared to uncircumcised males (95% CI: 2.4-11.4, p = 0.001). Circumcised males had a 3.1 times increased prevalence of high-grade hydronephrosis (defined as SFU grades 3 and 4) compared to uncircumcised males (prevalence ratio: 3.1, 95% CI: 1.0-10.0, p = 0.05). Among bacterial pathogens, no patients with Proteus UTI had high-grade hydronephrosis or dilating VUR. In contrast, Staphylococcal infections were associated significantly with dilating VUR (prevalence ratio 10.1, 95% CI: 2.3, 44.8; p = 0.002) and high-grade hydronephrosis (prevalence ratio 8.1, 95% CI: 1.7, 39.7; p = 0.010). CONCLUSIONS: Circumcision status is an independent predictor of structural urinary anomalies of the bladder and upper tracts in pediatric males with UTI, therefore circumcised males should be considered for early imaging, including VCUG, after their first UTI. Furthermore, Staphylococcal infections were associated with an even higher prevalence of high-grade hydronephrosis and dilating VUR and therefore warrant early investigation with VCUG. In contrast, none of the Proteus infections, which were seen almost exclusively in uncircumcised males, were associated with dilating VUR or hydronephrosis, making initial observation more appropriate in these patients.

Trends in the use of neoadjuvant chemotherapy for bladder cancer with nonurothelial variant histology: An analysis of the National Cancer Database.

INTRODUCTION: The aim of this study is to evaluate the trends in the use of neoadjuvant chemotherapy (NAC) over time (2006-2014) for patients diagnosed with muscle-invasive bladder cancer (MIBC) with nonurothelial variant histology (NUVH) in the National Cancer Database. MATERIALS AND METHODS: We queried the NCDB for patients with muscle-invasive (i.e. cT2-4N0-3M0/X) urothelial carcinoma (UC) of the bladder. We examined demographic, clinical, and pathologic features associated with NAC, also substratifying into pure UC and NUVH. Tests of association were performed using Chi-square/Fisher's exact test for categorical variables and t-tests, ANOVA, or Kruskal-Wallis test for continuous variables. Outcomes were examined with Cox proportional hazards and 90-day mortality with the Kaplan-Meier method. RESULTS: Totally 22,320 patients met our inclusion criteria, of whom 22.6% received NAC. The proportion of NAC increased significantly over time in the neuroendocrine and urothelial cell categories with 57.1% and 34.1% of patients in 2014 receiving NAC vs. 44% and 10.6% in 2006. No other variant histology showed a significant increase across the time sampled. Patients receiving NAC were more likely to have downstaging to pT0 (13.4% vs. 2.7%), negative surgical margin (89.1% vs. 86%), and pN0 (63.2% vs. 60.5%) and were less likely to have 30-day (1.4% vs. 3%) or 90-day (5% vs. 8.3%) mortality. Rates of downstaging to pT0 after NAC were similar among histologies. CONCLUSION: Neoadjuvant chemotherapy utilization continues to slowly increase in patients with MIBC. Patients with variant histology lag behind in terms of receiving NAC but appear to derive as much benefit as patients with pure urothelial cell bladder cancer.

Variation in Kidney Stone Composition Within the United States.

INTRODUCTION AND OBJECTIVES: Kidney stone incidence has been known to vary with temperature and climate. However, little is known about any variation in the composition of kidney stones across different regions of the United States. We attempted to evaluate whether stone composition changes depending on region. METHODS: We were given access to de-identified data from LABCORPs database of kidney stone composition from August 1, 2016, to October 24, 2016, for states in seven representative areas of the country: Virginia, Minnesota, Florida, Arizona, Colorado, California, and Texas. We analyzed each component of kidney stones with optical microscopy supplemented with Fourier-transform infrared spectroscopy (FT-IR) spectrometry using both the percentage of the stone that was composed of that component as well as a binary variable coded none vs any. Univariate associations between component and state were examined using chi-square or Fisher's exact test for the binary indicator, and analysis of variance for the continuous percentage. The same set of analyses was used for decade of age vs each component. The association between age and state was examined using analysis of variance. RESULTS: Data were available for 4335 kidney stones, from patients in the 7 states mentioned. The most common components across all stones were calcium oxalate monohydrate and calcium phosphate (both present in 93% of stones), calcium oxalate dihydrate (in 57% of stones), and uric acid (in 12% of stones). Stone composition did not vary widely across regions, except for uric acid stones, which were more prevalent in Florida compared to other states, with an odds ratio of 1.43 (95% confidence interval 1.12, 1.83). CONCLUSION: Kidney stone composition does not vary widely by region within the United States. Although temperature and humidity play a role in stone incidence, there does not appear to be a large variation between different climates, with the exception of uric acid stone formation in Florida.

Current clinical trials in non-muscle invasive bladder cancer.

BACKGROUND: The treatment options for non-muscle invasive bladder cancer (NMIBC) remain limited. Bacillus Calmette-Guerin (BCG) was the last major breakthrough in bladder cancer therapy almost 4 decades ago. There have been improvements in the understanding of immune therapies and cancer biology, leading to the development of novel agents. This has led to many clinical trials that are currently underway to find the next generation of therapies for NMIBC. METHOD: We reviewed clinicaltrials.org and pubmed.gov to find the recently completed and ongoing clinical trials in NIMBC. Included in this review are clinical trials that are currently active and trials that were completed in and after 2014. RESULT: Many trials with BCG-naive and BCG-unresponsive/recurrent/refractory/failure patients with NMIBC are either currently underway or have been recently completed. A wide variety of novel therapeutic agents are being investigated that range from cytotoxic agents to immunomodulatory agents to targeted molecular therapies. Other approaches include cancer vaccines, gene therapies, and chemoradiation potentiation agents. Novel drug-delivery methods are also being tested. CONCLUSION: This comprehensive update of current trials provides researchers an overview of the current clinical trial landscape for patients with NMIBC.

Genitourinary paraganglioma: Demographic, pathologic, and clinical characteristics in the surveillance, epidemiology, and end results database (2000-2012).

BACKGROUND: Extra-adrenal paragangliomas (PGLs) are infrequent, benign, and neuroendocrine tumors arising from chromaffin cells of the autonomic nervous system. Most PGLs are sporadic, but up to 32% are associated with inherited syndromes such as neurofibromatosis type 1, von Hippel-Lindau disease, and familial PGL. Although most PGLs develop above the umbilicus, they have been reported in the genitourinary (GU) tract. Owing to the paucity of literature on the rates of GU PGL, the objective of our study is to describe the demographic, pathologic, and clinical characteristics of GU PGL, and compare them to non-GU sites of PGL using the surveillance, epidemiology, and end results (SEER) database. METHODS: The SEER 18 database was used to identify all cases of PGL from 2000 to 2012. Demographic, pathologic, and clinical characteristics were described using chi-square and t-test for categorical and continuous variables, respectively. The Kaplan-Meier method was used to compare overall survival (OS) between GU and non-GU PGL. Statistical significance was defined as P<0.05. All analyses were performed using excel and SAS/Stat version 9.4. RESULTS: A total of 299 cases of PGL were retrieved from SEER, and 20 (6.7%) of the total PGL arose from the GU tract. The mean age at diagnosis was higher in non-GU than GU PGL (50.4±17.2 vs. 40.8±15.6, P = 0.026). Furthermore, 75% of GU PGLs developed in the bladder, followed by the kidneys/renal pelvis, and spermatic cord (20%). Non-GU PGL developed most frequently within the endocrine system (43%). PGL, overall, was more common in men than in women, and it was more common in whites than all other races. Although 55.5% of GU PGLs were organ confined, only 22.2% of non-GU PGLs were localized at diagnosis. All cases of PGL were treated with surgery. There were 2 cause-specific deaths in the GU PGL groups between 2000 and 2012. The 5-year OS was 93.3% for GU PGL vs. 65.5% in non-GU PGL (P = 0.062). CONCLUSIONS: GU PGL remains rare with low incidence (6.7% of all PGL cases) in the US population between 2000 and 2012. Bladder PGL represents just 5% of all PGL. Moreover, GU PGL had better OS compared to PGL developing outside of the GU tract although the P-value only approached statistical significance. The bladder represents the most common site of involvement, and surgery is the mainstay of treatment for GU PGL. Clearer prognostic factors, including tumor grade and stage, are needed to better elucidate PGL management in the future; thus, pooled studies from various institutions with detailed clinical information are needed to delineate these prognostic factors.

Distal hypospadias repair using only glans wing mobilization and approximation.

INTRODUCTION: Since its first description in 1994, tubularized incised plate (TIP) technique has become the most commonly performed hypospadias procedure and involves incision of the urethral plate with subsequent tubularization. Glans wings are then developed to cover the neourethra, thereby creating a cosmetically appealing repair. In some distal hypospadias cases, mobilization and approximation of glans wings is sufficient to create a normal appearing urethral meatus. MATERIALS AND METHODS: A retrospective chart review of all pediatric urology patients who underwent hypospadias repair by a single surgeon at the University of Kentucky between July 1, 2010 and April 1, 2013 was performed. Of the 46 patients who underwent one-stage distal hypospadias repair during that time, we performed the technique described above on 13 patients with amenable anatomy. Patients were evaluated for functional and cosmetic outcomes as well as complications at subsequent office visits and via telephone. RESULTS: Patients who underwent distal hypospadias repair with our technique had excellent functional and cosmetic outcomes analogous to those who underwent standard TIP repair. The only major complication in the study group was wound dehiscence in one patient that was required a second surgery. All other patients had excellent cosmetic and functional results without fistula formation, strictures or diverticuli, and with excellent parent satisfaction. CONCLUSIONS: Perceived benefits of this technique include simplicity and rapidity of technique, applicability to glanular, coronal and subcoronal hypospadias, and avoidance of sutures between urethra and glans with potential decrease in meatal stenosis.

A 22-year-old female with invasive epithelioid angiomyolipoma and tumor thrombus into the inferior vena cava: case report and literature review.

A 22-year-old female presented with back pain and was discovered to have a right-sided abdominal mass. Computed tomography (CT) scan revealed a 9 cm enhancing right upper pole renal mass with suspicion for tumor thrombus into the right renal vein and possibly the inferior vena cava (IVC). Magnetic resonance imaging (MRI) confirmed tumor thrombus into the inferior vena cava approximately 3 cm below the hepatic venous confluence. Open right radical nephrectomy with inferior vena cava thrombectomy was performed with removal of right kidney and tumor thrombus en bloc. Pathology revealed malignant epithelioid angiomyolipoma (EAML or PEComa). Epithelioid angiomyolipoma is a rare tumor of mesenchymal tissue that has the potential for local invasion and disease progression. Diagnosis of EAML was confirmed by pathology and immunohistochemistry. She was referred to medical oncology for discussion of surveillance versus potential adjuvant therapy and ultimately opted for close surveillance.

Epithelial mesenchymal transition (EMT) in prostate growth and tumor progression.

Epithelial-mesenchymal transition (EMT) and its reversal, mesenchymal-epithelial transition (MET), are essential morphological processes during development and in the regulation of stem cell pluripotency, yet these processes are also activated in pathological contexts, such as in fibrosis and cancer progression. Multi-component signaling pathways cooperate in initiation of EMT and MET programs, via transcriptional, post-transcriptional, translational, and post-translational regulation. EMT is required for tissue regeneration and normal embryonic development as it enables epithelial cells to acquire the mesenchymal phenotype, conferring them migratory and dynamic properties towards forming three-dimensional structures during gastrulation and organ formation. Uncontrolled activation of such phenomenon and the pathways signaling EMT events in adult life, leads to cancer growth and orchestrated by signaling interactions from the microenvironment, epithelial tumor cells with enhanced polarity, become invasive and rapidly metastasize to distant sites. Loss of epithelial markers (E-cadherin) and gain of mesenchymal markers (N-cadherin), at the leading edge of solid tumors is associated with progression to metastasis. This review will explore the contribution of EMT to embryonic development of GU organs and the functional consequences of EMT-MET cycles in prostate tumorigenesis. Recent insights identifying key players driving EMT and its reversal to MET during prostate cancer progression to metastatic castration-resistant disease will be discussed, with specific focus on androgen receptor (AR) and transforming growth factor-ß (TGF-ß) signaling in the context of their predictive and targeting value in prostate cancer progression.