Cost-Effectiveness Analysis of the Clear Cell Likelihood Score Against Renal Mass Biopsy for Evaluating Small Renal Masses.

OBJECTIVE: To examine the cost-effectiveness of the clear cell likelihood score compared to renal mass biopsy (RMB) alone. METHODS: The clear cell likelihood score, a new grading system based on multiparametric magnetic resonance imaging, has been proposed as a possible alternative to percutaneous RMB for identifying clear cell renal carcinoma in small renal masses and expediting treatment of high-risk patients. A decision analysis model was developed to compare a RMB strategy where all patients undergo biopsy and a clear cell likelihood score strategy where only patients that received an indeterminant score of 3 undergo biopsy. Effectiveness was assigned 1 for correct diagnoses and 0 for incorrect or indeterminant diagnoses. Costs were obtained from institutional fees and Medicare reimbursement rates. Probabilities were derived from literature estimates from radiologists trained in the clear cell likelihood score. RESULTS: In the base case model, the clear cell likelihood score was both more effective (0.77 vs 0.70) and less expensive than RMB ($1629 vs $1966). Sensitivity analysis found that the nondiagnostic rate of RMB and the sensitivity of the clear cell likelihood score had the greatest impact on the model. In threshold analyses, the clear cell likelihood score was the preferred strategy when its sensitivity was greater than 62.7% and when an MRI cost less than $5332. CONCLUSION: The clear cell likelihood score is a more cost-effective option than RMB alone for evaluating small renal masses for clear cell renal carcinoma.

Split-bolus CT urography after microwave ablation of renal cell carcinoma improves image quality and reduces radiation exposure.

OBJECTIVE: To compare image quality and radiation dose between single-bolus 2-phase and split-bolus 1-phase CT Urography (CTU) performed immediately after microwave ablation (MWA) of clinically localized T1 (cT1) RCC. METHODS: Forty-two consecutive patients (30 M, mean age 67.5 ± 9.0) with cT1 RCC were treated with MWA from 7/2013 to 12/2013 at two academic quaternary-care institutions. Renal parenchymal enhancement, collecting system opacification and distention and size-specific dose estimate (SSDE) were quantified and image quality subjectively assessed on single-bolus 2-phase versus split-bolus 1-phase CTU. Kruskal-Wallis and Pearson's Chi-squared tests were performed to assess differences in continuous and categorical variables, respectively. Two-sample T test with equal variances was used to determine differences in quantitative and qualitative image data. RESULTS: Median tumor diameter was larger [2.9 cm (IQR 1.7-5.3) vs 3.6 cm (IQR 1.7-5.7), p = 0.01] in the split-bolus cohort. Mean abdominal girth (p = 0.20) was similar. Number of antennas used and unenhanced CTs obtained before and during MWA were similar (p = 0.11-0.32). Renal pelvis opacification (2.5 vs 3.5, p < 0.001) and distention (4 mm vs 8 mm, p < 0.001) were improved and renal enhancement (Right: 127 HU vs 177 HU, p = 0.001; Left: 124 HU vs 185 HU, p < 0.001) was higher for the split-bolus CTU. Image quality was superior for split-bolus CTU (3.2 vs 4.0, p = 0.004). Mean SSDE for the split-bolus CTU was significantly lower [163.9 mGy (SD ± 73.9) vs 36.3 mGy (SD ± 7.7), p < 0.001]. CONCLUSION: Split-bolus CTU immediately after MWA of cT1 RCC offers higher image quality, improved opacification/distention of the collecting system and renal parenchymal enhancement at a lower radiation dose.

Analysis of executional and procedural errors in dry-lab robotic surgery experiments.

BACKGROUND: Analysing kinematic and video data can help identify potentially erroneous motions that lead to sub-optimal surgeon performance and safety-critical events in robot-assisted surgery. METHODS: We develop a rubric for identifying task and gesture-specific executional and procedural errors and evaluate dry-lab demonstrations of suturing and needle passing tasks from the JIGSAWS dataset. We characterise erroneous parts of demonstrations by labelling video data, and use distribution similarity analysis and trajectory averaging on kinematic data to identify parameters that distinguish erroneous gestures. RESULTS: Executional error frequency varies by task and gesture, and correlates with skill level. Some predominant error modes in each gesture are distinguishable by analysing error-specific kinematic parameters. Procedural errors could lead to lower performance scores and increased demonstration times but also depend on surgical style. CONCLUSIONS: This study provides insights into context-dependent errors that can be used to design automated error detection mechanisms and improve training and skill assessment.

Urologic Complications Requiring Intervention Following High-dose Pelvic Radiation for Cervical Cancer.

OBJECTIVE: To identify the incidence of radiation-induced urologic complication requiring procedural intervention following high-dose radiotherapy for cervical carcinoma, and to identify predictors of complication occurrence. MATERIALS AND METHODS: We performed a retrospective chart review of cervical cancer patients undergoing radiotherapy with primary focus on procedural complications (Clavien-Dindo ≥ III). Clinical data were collected including radiation dose, procedure performed, timing of complication, and need for additional procedures. Univariate and multivariate logistic regression modeling was performed to assess predictive value of demographic and clinical variables. RESULTS: A total of 126 patients with FIGO stage 1A2-4B cervical cancer were included in study analysis, with 18 patients experiencing procedural complication (14.3%). A total of 22 complications were identified, representing an average of 1.2 complications per patient with complication. The most common complications were ureteral stricture and radiation cystitis. The most common nononcologic procedures performed in the treatment of these complications were ureteral stenting, percutaneous nephrostomy tube placement, and cystoscopy. Notably, a total of 259 procedures were performed in the treatment of urologic complications, representing 14.4 procedures per patient and 24.6 procedures per patient with ureteral stricture. Logistic regression demonstrated active smoking at the time of diagnosis to be a predictor of procedural complication. CONCLUSION: Radiotherapy in the treatment of cervical cancer is associated with a high rate of urologic procedural complication. These complications often require numerous procedures and long-term management given their complexity. These findings suggest a need for awareness and plans for multidisciplinary management of urologic complications in this patient population.

Optimizing Telemedicine Technologic Infrastructure with Animal Models: A Case in Telecystoscopy.

Background: Rapid evolution of telemedicine technology requires procedures in telemedicine to adapt frequently. An example in urology, telecystoscopy, allows certified advanced practice providers to perform cystoscopy, endoscopic examination of the bladder, in rural areas with real-time interpretation and guidance by an off-site urologist. We have previously shown the technological infrastructure for optimized video quality. Introduction: Newer models of cystoscope and coder/decoder (codec) are available with anticipation that components used in our original model will become unavailable. Our objective is to assess the diagnostic ability of two cystoscopes (Storz, Wolf) with old (SX20) and new (DX70) codecs. Materials and Methods: A single urologist performed flexible cystoscopy on an ex vivo porcine bladder. Combinations of cystoscope (Storz vs. Wolf), codec (SX20 vs. DX70), and internet transmission speed were used to create eight distinct recordings. Deidentified videos were reviewed by expert urologist reviewers via electronic survey with questions on video quality and diagnostic ability. A logistic regression model was used to assess the ability to make a diagnosis. Results: Eight transmitted cystoscopy videos were reviewed by 16 urologists. Despite new technology, the Storz cystoscope combined with the SX20 codec (the original combination) provides the best diagnostic capacity. Discussion: Technical infrastructure must be routinely validated to assess the component impact on overall quality because newer is not always better. Should the SX20 become obsolete, ex vivo animal models are safe, inexpensive anatomic models for testing. Conclusions: As technology continues to evolve, procedures in telemedicine must critically scrutinize the impact of new technologic components to uphold quality.

Tele-Urology During COVID-19: Rapid Implementation of Remote Video Visits.

INTRODUCTION: COVID-19 has brought unprecedented challenges to the delivery of urological care. Following rapid implementation of remote video visits at our tertiary academic medical center serving a large rural population we describe and assess our experience with planned video visits and ongoing scheduling efforts. METHODS: Patients scheduled for video visits between April 14 and April 27, 2020 were included. Prospective and retrospective data were collected on patient and clinical characteristics as well as telemedicine outcomes. Multivariable logistic regression was performed to evaluate factors influencing video visit success. Concurrently scheduling data were collected from a separate cohort regarding patient access to technology and willingness to participate in video visits. RESULTS: A total of 209 patients were included with an overall video visit success rate of 67%. Of video visits that failed (69) reasons included no-show (35%), inability to connect to the telemedicine platform (23%) and lack of Internet access (10%). Nearly half of failed video visits (46.4%) were completed as phone visits. After adjustment for patient demographics commercial insurance was significantly associated with video visit success. In assessment of scheduling outcomes 179 patients were contacted to offer video visits. Of these patients 6.7% reported not having Internet access. Of those with Internet access 87% agreed to proceed with a video visit in lieu of visiting in person. CONCLUSIONS: Our experience indicates that rapid implementation of video telemedicine is feasible and highly accepted by patients. Efforts focused on standardized pre-visit patient education may further optimize successful telemedicine visits.

Multi-Institutional Collaborative Resident Education in the Era of COVID-19.

INTRODUCTION: The 2019-2020 coronavirus pandemic has had a significant impact on all aspects of health care. Decrease in clinical and operative volume and limitations for conferences has drastically decreased educational opportunities for resident trainees. We describe the formation and initial success of the Collaborative Online Video Didactics lecture series, a multi-institutional online video didactics collaboration. METHODS: Zoom data extraction and postlecture evaluation surveys were used to collect data on the impact of the pandemic on local educational activities as well as feedback about the lecture series. Lectures are being given by faculty from 35 institutions. The twice daily, hour-long webinar averages more than 470 live viewers per session with an average of 33.5 questions per session and has over 7,000 YouTube views of the recordings after the first 2 weeks. RESULTS: Viewers reported significant decreases in outpatient (75.2%), inpatient (64.9%) and operating room (77.7%) volumes at local programs, and only half (52.7%) of the survey responders indicated an increase in didactics locally. The lectures have been well-received, with over 90% of respondents giving the lecturers and series above average or excellent ratings. A significant majority of responders indicated that the lecture series has allowed for ongoing education opportunities during the pandemic (95.0%), helped to access faculty experts from other institutions (92.3%) and provided a sense of community connectedness during this period of social isolation (81.7%). CONCLUSIONS: We strongly encourage other institutions and trainees to participate in the didactic series and hope that this series can continue to evolve and be of benefit beyond the pandemic.

Thermal ablation of the small renal mass: a critical analysis of current literature.

INTRODUCTION: Thermal ablation is increasingly utilized as a management strategy for small renal masses (<4 cm). Partial nephrectomy is recognized as the gold standard; thermal ablation has been reserved for older patients with comorbidities due to concern for local tumor recurrence. As long-term data regarding the safety and efficacy of ablative techniques accumulate with encouraging results, clinicians are widening the utility in select patient populations. This review summarizes the currently available technologies in terms of procedural differences, oncologic outcomes, renal function, and complication rates. EVIDENCE ACQUISITION: A structured literature review was conducted using PubMed and Web of Science, using the keywords: "renal cell carcinoma," "ablation techniques," "cryosurgery," "radiofrequency ablation," "microwave ablation," "outcomes assessment," "post-operative complication," and "hospital costs." Articles were reviewed to summarize oncologic outcomes, complications, and impact on renal function of cryoablation, radiofrequency ablation, and microwave ablation. EVIDENCE SYNTHESIS: Thermal ablation is a safe and effective management option for small renal masses in select patients, particularly in those with multiple tumors and/or those unable or unwilling to undergo more invasive surgery. Slightly higher rates of local recurrence rates (~1-10%) with thermal ablation are offset by lower complication rates and reduced morbidity, and equivalent or better renal function outcomes compared to surgery. CONCLUSIONS: The established modalities of cryo-, radiofrequency, and microwave ablation offer equivalent outcomes with similar complication rates; technique choice is primarily based on tumor characteristics and operator preference. Better quality evidence comparing thermal ablation with surgical nephron-sparing intervention is needed to make informed conclusions on efficacy.

Does renal mass biopsy influence multidisciplinary treatment recommendations?

Purpose: To examine how a multidisciplinary team approach incorporating renal mass biopsy (RMB) into decision making changes the management strategy.Methods: A multidisciplinary team comprised of a radiology proceduralist, a pathologist and urologists convened monthly for renal mass conference with a structured presentation of patient demographics, co-mborbidities, tumor pathology, laboratory and radiographic features. Biopsy protocol was standardized to an 18-gauge core needle biopsy using a sheathed apparatus under renal ultrasound guidance. Biopsy diagnostic rate, and concordance with nephrectomy specimens were summarized. Descriptive statistics were used to evaluate influence of RMB on management decisions.Results: A total of 83 patients with a ≤4 cm mass were discussed, and 66% of patients underwent RMB. Of those, 87% were diagnostic with 9% of core biopsies showing benign pathology. Active surveillance (AS) was recommended for 34% of patients with biopsy data as compared to 64% of those without biopsy. Ablation was recommended for 38% of the biopsy cohort compared to 7% without biopsy. Partial nephrectomy rates were similar for both cohorts, approximately 17% and 22%, respectively. Our complication rate was 1.5%, with only 1 Clavien-Dindo Grade 2 complication. Histology was concordant in 93% of patients that ultimately underwent partial nephrectomy after biopsy.Conclusions: Over half of our SRM patients underwent a RMB that provided a diagnosis in 85% of cases. RMB aided in shared decision making by providing insight into the biology of renal masses, which helps to guide multidisciplinary management and consideration of nephron sparing options.

Effect of active versus passive void trials on time to patient discharge, urinary tract infection, and urinary retention: a randomized clinical trial.

PURPOSE: We sought to determine the effect of active versus passive voiding trials on time to hospital discharge and rates of urinary tract infection (UTI) and urinary retention (UR). METHODS: We performed a prospective, randomized trial comparing active (AVT) versus passive (PVT) void trials of inpatients requiring urethral catheter removal. Of 329 eligible patients, 274 were randomized to AVT (bladder filled with saline before catheter removal) or PVT (spontaneous bladder filling after catheter removal). Primary outcome was time to hospital discharge. Secondary outcomes were UTI (NSQIP criteria) and UR (requiring repeat catheterization) within 2 weeks of void trial. RESULTS: The median time to void was 18 (5-115) versus 236 (136-360) min in the AVT and PVT groups, respectively (p < 0.0001). However, no difference was seen in comparison of the median time to hospital discharge between AVT [28.4 (13.6-69.3) h] and PVT [30.0 (10.4-75.6) h] cohorts, respectively (p = 0.93). Six (4.8%) and 13 (12.9%) patients developed UTI in the AVT and PVT groups, respectively (p = 0.03). Eleven (8.8%) and 12 (11.9%) patients developed UR in the AVT and PVT groups, respectively (p = 0.36). CONCLUSION: Our study comparing AVT versus PVT demonstrated no difference in time to discharge despite a 3.6 h reduction in time to void associated with AVT. AVT was associated with a 63% reduction in UTI, with no difference seen in UR rates across cohorts. Given the reduction in UTI and technical advantages, our data suggest that AVT should be considered as a recommended technique for void trial protocol. TRIAL REGISTRATION: NCT02886143 (clinicaltrials.gov).

Creation of a Novel Digital Rectal Examination Evaluation Instrument to Teach and Assess Prostate Examination Proficiency.

OBJECTIVE: To create a validated tool to measure digital rectal examination proficiency and aid with teaching of the examination. DESIGN: The Digital Rectal Examination Clinical Tool was created using a modified Delphi method with 5 urologists and 5 radiation oncologists. The instrument was then validated in a population of preclinical medical students examining male urological teaching associates, and clinical trainees (third- and fourth-year medical students and urology resident physicians) examining prospectively enrolled subjects. Trainees completed paired examinations with an attending urologist, and responses were scored with reference to the attending responses. SETTING: The instrument was validated at the University of Virginia in the urology clinic, endoscopic operating room, and main operating room settings. PARTICIPANTS: We tested the instrument on consenting subjects consisting of male urologic teaching associates (n = 12), clinic patients (n = 4), and operating room patients (n = 64). The participants were undergraduate (n = 302) and graduate (n = 9) medical trainees. RESULTS: In preclerkship trainees, improved scores in subjects without abnormal compared to those with abnormal findings demonstrated validity. In clinical trainees, scores on the Digital Rectal Examination Clinical Tool increased by 2% for each additional year of training, demonstrating construct validity. CONCLUSIONS: We used an expert panel to create a novel instrument for measuring digital rectal examination proficiency and validated it with preclinical and clinical trainee cohorts at our institution.

Does Robotic Surgical Simulator Performance Correlate With Surgical Skill?

OBJECTIVE: To assess the relationship between robotic surgical simulation performance and the real-life surgical skill of attending surgeons. We hypothesized that simulation performance would not correlate with real-life robotic surgical skill in attending surgeons. DESIGN: In 2013, Birkmeyer et al. demonstrated an association between laparoscopic surgical performance as determined by expert review of video clips and surgical outcomes. Using that model of expert review, we studied the relationship between robotic simulator performance and real-life surgical skill. Ten attending robotic surgeons performed 4 tasks on the da Vinci Skills Simulator (Camera Targeting 1, Ring Walk 3, Suture Sponge 3, and Energy Dissection 3). Two video clips of a robotic-assisted operation were then recorded for each surgeon. Three expert robotic surgeons reviewed the recordings and rated surgical technique using the Global Evaluative Assessment of Robotic Skills. SETTING: University of Virginia; Charlottesville, VA; tertiary hospital PARTICIPANTS: All attending surgeons who perform robotic-assisted surgery at our institution were enrolled and completed the study. RESULTS: The surgeons had a median of 7.25 years of robotic surgical experience with a median of 91 cases (ranging: 20-346 cases) in the last 4 years. Median scores for each simulator task were 87.5%, 39.0%, 77.5%, and 81.5%. Using Pearson's correlation, scores for each of the individual tasks correlated poorly with expert review of intraoperative performance. There was also no correlation (r = -0.0304) between overall simulation score (mean: 70.7 ± 9.6%) and expert video ratings (mean: 3.66 ± 0.32 points). CONCLUSIONS: There was no correlation between attending surgeons' simulator performance and expert ratings of intraoperative videos based on the Global Evaluative Assessment of Robotic Skills scale. Although novice surgeons may put considerable effort into training on robotic simulators, performance on a simulator may not correlate with attending robotic surgical performance. Development of simulation exercises that guide novice surgeons toward expert performance is needed.

Remote Development of Tumor-to-Tumor Metastasis of Breast Adenocarcinoma in a Renal Oncocytoma.

Tumor-to-tumor metastasis (TTM) is a rare phenomenon where a focus of distinct metastatic disease is discovered with a second primary tumor. Although renal cell carcinoma is the most frequent recipient of metastatic tumor cells, oncocytomas have also previously been described. We present the case of a patient with incidentally detected mammary adenocarcinoma within an oncocytoma 16 years following primary treatment. The mass was treated with partial nephrectomy, with the surgical pathology specimen showing clear delineation of the pleomorphic lobular carcinoma and oncocytoma cells.

Erdheim-Chester Disease Presenting as a Solid Renal Mass.

Erdheim-Chester disease is a rare, systemic histiocytic disorder, usually presenting due to bone manifestations. The most commonly seen urologic manifestation is retroperitoneal fibrosis, leading to ureteral obstruction. We describe a patient with a solid right renal mass, initially concerning for renal cell carcinoma, in addition to diffuse retroperitoneal fibrosis and a chronically obstructed left kidney. The renal mass and retroperitoneal fibrosis are thought to be caused by Erdheim-Chester disease based on imaging findings and biopsy results.

Percutaneous microwave ablation of T1a and T1b renal cell carcinoma: short-term efficacy and complications with emphasis on tumor complexity and single session treatment.

PURPOSE: To update the oncologic outcomes and safety for microwave (MW) ablation of T1a (≤4.0 cm) and T1b (4.1-7.0 cm) renal cell carcinoma (RCC) with emphasis on tumor complexity and single session treatment. MATERIALS AND METHODS: Retrospective review of 29 consecutive patients (30 tumors) with localized (NOMO) RCC (23 T1a; 7 T1b) treated with percutaneous MW ablation between 3/2013 and 6/2014. Primary outcomes investigated were technical success, local tumor progression (LTP), and complications. Technical success was assessed with contrast-enhanced computed tomography (CECT) immediately after MW ablation. Presence of LTP was assessed with CECT or contrast-enhanced magnetic resonance at 6-month target intervals for the first two years and annually thereafter. Complications were categorized using the Clavien-Dindo classification system. RESULTS: Median tumor diameter was 2.8 cm [IQR 2.1-3.3] for T1a and 4.7 cm [IQR 4.1-5.7] for T1b tumors. Median RENAL nephrometry score was 7 [IQR 4-8] for T1a tumors and 9 [IQR 6.25-9.75] for T1b tumors. Technical success was achieved for 22 T1a (96%) and 7 T1b (100%) tumors. There were no LTP during a median imaging follow-up of 12.0 months [IQR 6-18] for the 23 patients (24 tumors) with greater than 6 months of follow-up. There were three Clavien-Dindo grade I-II complication (10%) and no Clavien-Dindo grade III-V complications (0%). All but two patients (93%) are alive without metastatic disease; two patients died after 12-month follow-up of causes unrelated to the MW ablation. CONCLUSION: Percutaneous MW ablation appears to be a safe and effective treatment option for low, moderate, and highly complex T1a and T1b RCC in early follow-up.

Evaluation of Laparoscopic Curricula in American Urology Residency Training: A 5-Year Update.

INTRODUCTION/PURPOSE: Medical simulation offers the advantage of improving resident skill and comfort without impacting patient care. Five years ago, we identified trends in the use of robotic and laparoscopic simulation in 2008 and 2009 at American urology residency training programs. We seek to identify the changes in the use of simulators and the presence of formal curricula in the wake of technological advances and changes in graduate medical education. METHODS: Attendees of the American Urological Association (AUA) Basic Sciences Course, mostly in their second or third year of residency, were surveyed on the availability and use of laparoscopic/robotic simulators at their program, the presence of a formal curriculum, and a Likert scale questionnaire regarding face and content validity. RESULTS: Over a 5-year period, the availability of virtual reality robotic simulators substantially increased from 14% to nearly 60% availability in 2013. Despite this increase, the frequency of simulator use remained unchanged (p = 0.40) and the reported presence of formal curricula decreased from 41% to 34.8%. There was no significant difference in simulator use between residents in programs with or without laparoscopic/robotic curricula (p = 0.95). There was also a decrease in the percentage of residents who felt official laparoscopic curricula (93%-81%) and simulators (82%-74%) should be involved in resident education. CONCLUSIONS: In the past 5 years, despite evidence supporting benefits from simulator use and increasing availability, self-reported resident use has remained unchanged and the reporting of presence of laparoscopic/robotic curricula has decreased. With more dedicated investment in formal curricula, residency training programs may receive greater returns on their simulator investments, improve resident skills and comfort, and ultimately improve the quality of patient care.

Occult Radiographically Evident Port-Site Hernia After Robot-Assisted Urologic Surgery: Incidence and Risk Factors.

PURPOSE: Laparoscopic trocar-site hernias (TSH) are rare, with a reported incidence of 1% or less. The incidence of occult radiographically evident hernias has not been described after robot-assisted urologic surgery. We evaluated the incidence and risk factors of this problem. MATERIALS AND METHODS: A single-institution retrospective review of robot-assisted urologic surgery was performed from April 2009 to December 2012. Patients with preoperative and postoperative CT were included for analysis. Imaging was reviewed by two radiologists and one urologist. RESULTS: One hundred four cases were identified, including 60 partial nephrectomy, 38 prostatectomy, and 6 cystectomy. Mean age was 58 years and mean body mass index (BMI) was 29 kg/m(2). The cohort was 77% male. Ten total hernias were identified by CT in 8 patients, 2 of which were clinically evident hernias. Excluding these two hernias, occult port-site hernias were identified radiographically in seven patients. Per-patient incidence of occult TSH was 6.7% (7/104), and per-port incidence was 1.4% (8/564). All hernias were midline and 30% contained bowel. Eight of the 10 occurred at 12 mm sites (p = 0.0065) and 3 of the 10 occurred at extended incisions. Age, gender, BMI, smoking status, diabetes mellitus, immunosuppressive drug therapy, ASA score, procedure, blood loss, prior abdominal surgery, and history of hernia were not significant risk factors. Specimen size >40 g (p = 0.024) and wound infection (p = 0.0052) were significant risk factors. CONCLUSION: While the incidence of clinically evident port-site hernia remains low in robot-assisted urologic surgery, the incidence of CT-detected occult hernia was 6.7% in this series. These occurred most often in sites extended for specimen extraction and at larger port sites. This suggests more attention should be paid to fascial closure at these sites.

Optimizing and validating the technical infrastructure of a novel tele-cystoscopy system.

INTRODUCTION: Bladder cancer is the most costly malignancy to manage per capita due to the technical nature and intensity of follow-up. There are few urologists in rural areas, often necessitating that patients travel hours to receive follow-up care multiple times per year. We plan to train registered nurses and allied health professionals to perform cystoscopies which are monitored and interpreted in real-time by board-certified urologists. The key is to ensure optimal picture resolution to guarantee this technology is not inferior to traditional cystoscopy. Our objective was to develop the technical infrastructure needed for a tele-cystoscopy system through assessment of the transmitted video quality using expert reviewers and crowd-sourcing. METHODS: All combinations of the tele-cystoscopy system were systematically tested using a single Thiel cadaver. The videos were reviewed by expert urologists and general reviewers using a crowd-sourcing website. The video quality responses were assessed to determine concordance between each set of reviewers, and to determine the optimal equipment that should be selected for the tele-cystoscopy system. RESULTS: Of eight equipment combinations, only two were of high enough quality to be appropriate for medical use. We found there to be strong concordance of responses between the expert and crowd-sourced responses. The trade-offs between cost and tele-cystoscopy system component quality were compared with efficiency frontiers to elucidate the optimal system. DISCUSSION: We created and tested the feasibility of a tele-cystoscopy system that was deemed suitable for medical diagnosis by a group of experts. We further validated tele-cystoscopy video quality using both experts and recently validated crowd-sourcing.

Persistent Müllerian duct structures presenting as hematuria in an adult: Case report of robotic surgical removal and review of the literature.

Persistent Müllerian duct syndrome is a rare genetic disorder characterized by a male with retained Müllerian structures. Remnant excision must be considered due to the possibility of malignant degeneration. We review a case of delayed diagnosis in a 25-year-old man presenting with hematuria. Preoperative counseling must emphasize the risk of malignancy versus the risks to fertility. The da Vinci robot offers a novel, safe approach for excision of the relevant Müllerian structures. Dissection should be limited to structures superior to the cavernosal neurovascular bundles to preserve the continence and erectile function. A semen analysis is recommended preoperatively to determine effects on fertility.

Colovesical fistula caused by an ingested chicken bone.

Colovesical fistula involving the sigmoid colon is the most common fistulous communication between the gastrointestinal tract and the urinary bladder. These tracts are most commonly associated with diverticulitis but might arise secondary to a neoplasm, inflammatory bowel disease, iatrogenic injuries, radiation therapy, trauma, or foreign bodies. We describe a patient who developed a fistula between the sigmoid colon and bladder secondary to an ingested chicken bone that lodged in a colonic diverticulum. A portion of the foreign body was removed by direct visualization on colonoscopy; the remaining fragment passed spontaneously per urethra after hospital discharge.