Developing a Diagnostic Multivariable Prediction Model for Urinary Tract Cancer in Patients Referred with Haematuria: Results from the IDENTIFY Collaborative Study.

BACKGROUND: Patient factors associated with urinary tract cancer can be used to risk stratify patients referred with haematuria, prioritising those with a higher risk of cancer for prompt investigation. OBJECTIVE: To develop a prediction model for urinary tract cancer in patients referred with haematuria. DESIGN, SETTING, AND PARTICIPANTS: A prospective observational study was conducted in 10 282 patients from 110 hospitals across 26 countries, aged ≥16 yr and referred to secondary care with haematuria. Patients with a known or previous urological malignancy were excluded. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcomes were the presence or absence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC], and renal cancer). Mixed-effect multivariable logistic regression was performed with site and country as random effects and clinically important patient-level candidate predictors, chosen a priori, as fixed effects. Predictors were selected primarily using clinical reasoning, in addition to backward stepwise selection. Calibration and discrimination were calculated, and bootstrap validation was performed to calculate optimism. RESULTS AND LIMITATIONS: The unadjusted prevalence was 17.2% (n = 1763) for bladder cancer, 1.20% (n = 123) for UTUC, and 1.00% (n = 103) for renal cancer. The final model included predictors of increased risk (visible haematuria, age, smoking history, male sex, and family history) and reduced risk (previous haematuria investigations, urinary tract infection, dysuria/suprapubic pain, anticoagulation, catheter use, and previous pelvic radiotherapy). The area under the receiver operating characteristic curve of the final model was 0.86 (95% confidence interval 0.85-0.87). The model is limited to patients without previous urological malignancy. CONCLUSIONS: This cancer prediction model is the first to consider established and novel urinary tract cancer diagnostic markers. It can be used in secondary care for risk stratifying patients and aid the clinician's decision-making process in prioritising patients for investigation. PATIENT SUMMARY: We have developed a tool that uses a person's characteristics to determine the risk of cancer if that person develops blood in the urine (haematuria). This can be used to help prioritise patients for further investigation.

Urological Survivorship Issues Among Adolescent Boys and Young Men Who Are Cancer Survivors.

BACKGROUND: Urological survivorship issues encompass an area that may potentially be overlooked after treatment of childhood cancer in adolescent boys and young men. Side effects of cancer therapy may include subsequent development of erectile dysfunction (ED), hypogonadism, and infertility in adulthood. AIM: The purpose of this review is to focus on the etiology and prevalence of the range of sexual and gonadal dysfunction in adolescent boys and young men who are cancer survivors, while discussing current recommendations for evaluation and treatment. METHODS: We performed a literature review of articles evaluating hypogonadism, sexual dysfunction, ED, and infertility in young men cancer survivors. OUTCOMES: There is compelling evidence that significant survivorship issues are faced by boys entering adulthood after completing cancer therapy. RESULTS: Overall, young men cancer survivors are much more likely to report symptoms of sexual dysfunction than the general population of men. These patients can develop ED due to physiologic and psychological changes that take place with diagnosis of a malignancy and subsequent treatment. Primary hypogonadism can arise due to pelvic radiation or chemotherapy, and central hypogonadism may arise from pituitary insufficiency after brain radiation or surgery. Infertility develops from direct damage to the Sertoli cells and germinal epithelium from radiotherapy or chemotherapy. Cancer survivors who are men should therefore be screened for these important urological survivorship issues, although exact surveillance strategies remain unclear. CONCLUSIONS: Urological survivorship issues including ED, hypogonadism, and infertility are common among cancer survivors and result in significant morbidity. Due to the medical complexity of cancer survivorship, the population of adolescent and young adult survivors would benefit from a network of multidisciplinary survivorship experts to aid the transition into adulthood. Improved research efforts may help to clarify risk factors and to develop enhanced strategies for evaluation and treatment. Sukhu T, Ross S, Coward RM. Urological Survivorship Issues Among Adolescent Boys and Young Men Who Are Cancer Survivors. Sex Med Rev 2018;6:396-409.

Workforce Characteristics in Urology.

INTRODUCTION: In this study we holistically describe and characterize the current state of urology practice by evaluating compensation, workload and practice factors as they relate to our demographic makeup as a specialty. METHODS: We collaborated with the American Urological Association to query its domestic membership of practicing urologists regarding socioeconomic, workforce and quality of life issues. The survey consisted of 26 questions and took approximately 13 minutes to complete. A total of 733 responders had complete data for the factors statistically analyzed in the study. RESULTS: Mean yearly compensation for urologists surveyed was $404,755 and median compensation was $380,000 (IQR $300,000-480,000). Female respondents had a significantly lower median yearly compensation vs males ($318,422 vs $400,000) on univariate and multivariate analysis. Respondents reported a median of 60 work hours per week (IQR 50-60) and the median number of call days per month was 7 (IQR 5-10). Of the respondents 62% indicated that they use advanced practice providers in their practice. In addition, 30% reported employed status, 49% reported self-employed status and 21% reported academic status. Overall 20% of respondents plan to retire within 5 years and 40% within 10 years. CONCLUSIONS: Higher income was associated with greater job satisfaction and hourly wage appeared to decrease at increased work hours per week. Several workplace and demographic factors drive compensation, number of hours worked per week, number of call days per month and job satisfaction.

Do Overweight and Obese Pediatric Stone Formers Have Differences in Metabolic Abnormalities Compared With Normal-weight Stone Formers?

OBJECTIVE: To determine if 24-hour urinary parameters in children with nephrolithiasis across 4 institutions were influenced by body mass index (BMI). MATERIALS AND METHODS: The 24-hour urinary parameters obtained from children with nephrolithiasis between 2000 and 2013 were stratified by BMI percentile ≥85th and <85th (overweight and obese patients vs healthy weight, respectively). A total of 206 children were included in the study. Exclusion criteria included patients with a history of spina bifida, neurogenic bladder, and cerebral palsy, and patients on medical treatment before the first 24-hour urine collection. RESULTS: Overweight and obese patients consisted of 35.4% of the cohort (n = 73). Metabolic abnormalities were present in 130 children (63.1%). The most common abnormality present in the <85th percentile was hypercalciuria (32.3%), and in the ≥85th percentile, hyperoxaluria (37.0%). Univariable and multivariable analyses revealed that overweight and obese children were more likely to have low urinary volume and elevated uric acid compared to normal-weight children. CONCLUSION: Although there is a link between stone formation and BMI in adults, no definitive conclusions have been proven in the pediatric literature. Our study indicates that stone-forming children who are overweight or obese have low urinary volume and elevated uric acid compared to normal-weight stone-forming children.

Sacral neuromodulation in overactive bladder: a review and current perspectives.

Overactive bladder (OAB) symptoms of urgency, frequency, and urge incontinence currently affect a substantial portion of the population, especially as age increases. Sacral neuromodulation has become a popular option for refractory OAB symptoms over the past 2 decades. Studies have demonstrated that it is an effective treatment for OAB and urge incontinence as indicated by decreased number of voids, increased bladder capacity, and fewer leakage events. In addition, the effects have proved to be durable to multiple years following implantation. These benefits come at the expense of a high rate of adverse events, although with comparable long-term cost-effectiveness to botulinum toxin A. We aimed to review the literature that demonstrates that sacral neuromodulation continues to be an efficacious treatment for refractory OAB wet and dry patients, with continuously expanding indications.

National multi-institutional cooperative on urolithiasis in children: Age is a significant predictor of urine abnormalities.

INTRODUCTION: Pediatric nephrolithiasis is a growing problem and prior studies have shown the greatest increase in nephrolithiasis in the adolescent population. Metabolic abnormalities have historically been cited as the primary cause of pediatric nephrolithiasis; however, dietary and other factors such as obesity have also been studied with mixed results. OBJECTIVE: We reviewed the charts of pediatric patients with a history of nephrolithiasis to determine the number and types of metabolic abnormalities present on 24-h urine analysis. STUDY DESIGN: We retrospectively reviewed the charts of all pediatric patients with a history of nephrolithiasis from 1999-2013 across four different institutions. The subjects were excluded if they had a history of spina bifida, neurogenic bladder, cerebral palsy, isolated bladder stones, or if they were on medical therapy for nephrolithiasis before the first 24-h urine collection. RESULTS: There were 206 subjects included in the analysis with an average age of 13 (±3.9) years. The patients were stratified into two age groups based on an apparent bimodal distribution of metabolic abnormalities, ≤10 years and >10 years of age. Metabolic abnormalities were present in 130 children (63.1%) and there was a difference between the groups, with children ≤10 years more likely to have a metabolic abnormality compared with those >10 years of age (75% vs. 60.6%, p = 0.0443) on univariate analysis. In children ≤10 years hypercalciuria was the most common disorder present (48.4%), and in children >10 years hypocitraturia was the most common disorder present (26.1%). Children ≤10 years of age were more likely to have normal volume (p = 0.006), elevated urinary oxalate (p = 0.0351), elevated urinary calcium (p < 0.001), elevated supersaturation of calcium phosphate (p < 0.001), and elevated supersaturation of calcium oxalate (p = 0.002). On multivariate analysis, children ≤10 years of age were more likely to have normal volume, hyperoxaluria, elevated supersaturation of calcium phosphate and a trend towards hypercalciuria (Table). DISCUSSION: Our study reveals that younger children are more likely to have a metabolic abnormality present on 24-h urine analysis. This has important implications when deciding on treatment options, with younger children potentially requiring more aggressive management with medical therapy. Older children were more likely to have low urinary volume and their most common metabolic abnormality was hypocitraturia. Although dietary factors have not been established as the definitive reason behind the rising incidence of nephrolithiasis in the adolescent population, older children may benefit more from diet modification with a strong focus on increasing volume intake. CONCLUSION: We found differences in younger compared with older age groups in terms of the number and types of metabolic disorders present. Children ≤10 years of age were more likely to have a metabolic disorder including elevations in calcium, oxalate and supersaturation of calcium phosphate, while children >10 years of age were more likely to have low urinary volume. These differences have important implications for future investigative studies on the rising incidence as well as the best course of treatment for children with nephrolithiasis.

Laparoscopic percutaneous inguinal hernia repair in children: review of technique and comparison with open surgery.

INTRODUCTION: Minimally-invasive approaches for inguinal hernia repair have evolved from conventional laparoscopy requiring placement of three ports and intracorporeal suturing to simple, one and two port extraperitoneal closure techniques. We utilize a single port laparoscopic percutaneous repair (LPHR) technique for selected children requiring operative intervention for inguinal hernia. We suspect that compared to open surgery, LPHR offers shorter operative duration with comparable safety and efficacy. Our objectives are to (1) illustrate this technique and (2) compare operative times and surgical outcomes in patients undergoing LPHR versus traditional open repair. METHODS: We reviewed operative times, complications, and recurrence rates in 38 patients (49 hernias) who underwent LPHR at our institution between January 2010 and September 2013. These data were compared with an age-, gender-, weight-, and laterality-matched cohort undergoing open repair during the same 3 year period. All cases were performed by a pediatric urologist or pediatric surgeon. RESULTS: Thirty-eight patients with a median age of 21.5 months underwent LPHR, and 38 patients with a median age of 23 months underwent open repair. In both groups, 27/38 patients (71%) had unilateral repairs, and 11/38 patients (29%) had bilateral repairs. For unilateral procedures, average operative duration was 25 min for LPHR and 59 min for OHR (p < 0.001). For bilateral procedures, average operative duration was 31 min for LPHR and 79 min for OHR (p < 0.001). There were no intraabdominal injuries in either group. In the LPHR group, there were no vascular or cord structure injuries and no conversions to open technique. Median follow-up was 51 days for the LPHR group and 47 days for the OHR group (p = 0.346). No hernia recurrence was observed in either group. CONCLUSIONS: In select patients, LPHR is an efficient, safe, and effective minimally invasive alternative to OHR, with reduced operative times but without increased rates of complications or recurrences. The technique has a short learning curve and is a practical alternative to OHR for pediatric urologists who infrequently utilize pure laparoscopic technique.

Patient positioning and prevention of injuries in patients undergoing laparoscopic and robot-assisted urologic procedures.

Positioning injuries in the perioperative period are one of the inherent risks of surgery, but particularly in robot-assisted urologic surgery, and can result in often unrecognized morbidity. Injuries such as upper or lower extremity peripheral neuropathies occur via neural mechanisms and injuries such as compartment syndrome, rhabdomyolysis, ischemic optic neuropathy, and acute arterial occlusion occur via vascular mechanisms. The risk of injury may be exacerbated by operative and patient-related risk factors. Patient-related risk factors include ASA class and BMI, while surgery-related risk factors include physical orientation of the patient and operative length. These injuries can be prevented or reduced by joint effort of the surgeon, anesthesiologist, and operating room staff.