An Updated Systematic Review and Meta-Analysis on the Technical, Oncologic, and Safety Outcomes of Microwave Ablation in Patients with Renal Cell Carcinoma.

Introduction: Percutaneous microwave ablation (MWA) has emerged as a new energy modality for percutaneous renal tumor ablation with potential advantages over radiofrequency and cryoablation. The goal of our study was to determine MWA outcomes for suspicious renal masses, with a subset analysis for biopsy-proven renal cell carcinoma (RCC) and larger (T1b) tumors. Methods: Studies reporting outcomes of MWA for RCC were identified. Random-effects models with inverse-variance weighting were used to pool outcomes, including technical success rate (TSR), technical efficacy rate (TER), local recurrence rate (LRR), cancer-specific survival rate (CSSR), overall survival rate (OSR), and complications. Results: Among 914 studies captured, 27 studies with 1584 patients (1683 malignant renal tumors) were included. The pooled TSR and TER were 99.6% (95% confidence interval [CI], 98.0%-100%) and 96.2% (95% CI, 93.8%-98.2%). The pooled LRR was 3.2% (95% CI, 1.9%-4.7%). At 1, 3, and 5 years, the pooled CSSRs were 100% (95% CI, 99.4%-100%), 100% (95% CI, 98.4%-100%), and 97.7% (95% CI, 94.5%-99.7%), while pooled OSRs were 99.0% (95% CI, 97.5%-99.9%), 96.0% (95% CI, 93.1%-98.3%), and 88.1% (95% CI, 80.3%-94.2%). The pooled minor and major complication rates were 10.3% (95% CI, 7.1%-13.9%) and 1.0% (95% CI, 0.3%-2.1%). In 204 patients with 208 T1b tumors, the pooled TSR and TER were 100% (95% CI, 96.6%-100%) and 85.2% (95% CI, 71.0%-95.8%). The pooled LRR was 4.2% (95% CI, 0.9%-8.9%). At 1, 3, and 5 years, the pooled CSSRs were 98.2% (95% CI, 88.7%-100%), 97.2% (95% CI, 78.5%-100%), and 98.1% (95% CI, 72.3%-100%). At 1 and 3 years, the pooled OSRs were 94.3% (95% CI, 85.7%-99.6%) and 89.3% (95% CI, 68.7%-100%). The pooled minor and major complication rates were 14.8% (95% CI, 7.4%-23.8%) and 2.6% (95% CI, 0%-7.8%). Conclusions: MWA demonstrated favorable short- to intermediate-term oncologic outcomes with low complication rates, including in the T1b subset, with moderate quality of data and heterogeneity of assessed outcomes. This supports MWA as a safe and effective treatment for RCC and a potential viable option for larger tumors.

A Population-Based Analysis of the Impact of the COVID-19 Pandemic on Solid Organ Transplantation in Ontario, Canada: Policy Response and Changes in Volume and 90-Day Outcomes.

Objectives: To evaluate the impact of the COVID-19 pandemic on solid organ transplantation. Background: COVID-19 caused unprecedented disruption to solid organ transplantation (kidney, liver, heart, lung). Concerns about safety and decreases in deceased donors due to pandemic lockdowns have been described as potential causes. Methods: We report population-based rates of transplantation during the first 3 waves of COVID-19 in Ontario, Canada (March 1, 2020-July 3, 2021) versus a pre-COVID-19 baseline period (January 1, 2017-February 29, 2020). Poisson models were used to predict transplantation rates during COVID-19, based on pre-COVID-19 rates, and generate observed to expected rate ratios (RRs). Ninety-day transplant outcomes (mortality, retransplantation, transplant nephrectomy) were captured. Results: A 34.4% decrease (RR, 0.656; 95% confidence interval [CI], 0.586-0.734) in transplant rates was observed, coinciding with wave 1 and the deployment of a provincial transplant triaging system. Transplants decreased by 14.6% in wave 2 (RR, 0.854; 95% CI, 0.770-0.947) and 23.1% in wave 3 (RR, 0.769; 95% CI, 0.690-0.857) despite the triaging system not being activated. Overall, there was a 24.3% decrease (RR, 0.757; 95% CI, 0.679-0.844) in transplant rates, equivalent to 409 fewer transplants. No sustained changes were observed in heart or liver but sustained and large decreases were seen for lung (RR, 0.664; 95% CI, 0.482-0.915) and kidney (RR, 0.721; 95% CI, 0.602-0.863) transplantation. A low prevalence (1.7%) of COVID-19 infection within 90 days of transplantation was seen. No differences were observed in other 90-day outcomes. Conclusions: Early safety concerns limited transplantation to immediate life-saving procedures; however, the reductions in kidney and lung transplants continued for the rest of the pandemic, where no restrictions were in place.

Surgical Outcomes between Routes of Hysterectomy in Patients with a Previous Cesarean Section.

STUDY OBJECTIVE: To determine the difference in surgical complications for patients with a previous cesarean section (CS) undergoing abdominal, vaginal, or laparoscopic hysterectomy. DESIGN: A population-based retrospective cohort study. SETTING: Province of Ontario, Canada. PATIENTS: 10 300 patients with at least 1 CS between July 1, 1991, and February 17, 2018. INTERVENTIONS: Benign, nongravid hysterectomy between Apr 1, 2002, and March 31, 2018. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite of all surgical complications within 30 days of surgery. Secondary outcomes were rate of genitourinary complications, readmission to hospital, and emergency department visit occurring within 30 days of surgery. Of 10 300 patients who had at least one previous CS, who underwent subsequent hysterectomy for a benign indication, 7370 underwent an abdominal hysterectomy (71.55%), 813 (7.9%) had a vaginal hysterectomy, and 2117 (20.55%) underwent a laparoscopic hysterectomy. The adjusted odds of any surgical complication from hysterectomy was significantly lower when performed by the vaginal approach than the laparoscopic approach (odds ratio, 0.32; 95% confidence interval, 0.20-0.51; p <.0001). There was no difference in the odds of surgical complication between abdominal and laparoscopic approaches (odds ratio, 1.09; 95% confidence interval, 0.87-1.37; p = .45). CONCLUSION: Our retrospective population-based study demonstrates that, after previous CS, patients selected to undergo vaginal hysterectomy experienced lower risk than either abdominal or laparoscopic approaches. This suggests that CS alone should not be a contraindication to vaginal hysterectomy.

5α-reductase inhibitors and the risk of bladder cancer in a large, population-based cohort.

PURPOSE: The ability of 5α-reductase inhibitors (5ARI) to reduce the risk of new onset bladder cancer (BC) has been studied with variable results. Our objective was to conduct a retrospective cohort population-based study to evaluate the association between 5ARI use, BC diagnosis, and BC mortality. PATIENTS AND METHODS: We used routinely collected health care data from Ontario, Canada. Men ≥66 years of age with a prescription for a 5ARI were matched to non-5ARI users. Matching was done using a propensity score of selected covariates to make 96 different covariates comparable. We measured 5 additional baseline variables which may have impacted the risk of future BC diagnosis: prior cystoscopy, urine cytology, urinalysis, gross hematuria episodes, and transurethral resection of a bladder lesion. Only the first period of continuous usage of 5ARIs was considered. The prespecified at-risk period for outcomes started 1 year after initiating therapy and ended at the last date of 5ARI exposure + 1 year. RESULTS: We identified 93,197 men who initiated 5ARI therapy (52% dutasteride, and 48% finasteride) between 2003 and 2013 and matched them 1:1 to men who did not start a 5ARI. The median at-risk period for the 5ARI group was 1.68 years (interquartile range 1.00, 4.27). With adjustment for the variables related to prior BC investigations there was no significant difference in BC diagnosis (hazard ratio [HR] 1.05, 95% confidence interval [CI] 0.82-1.32) during the period of 0 to <2 years of 5ARI use; however, after ≥2 years of 5ARI use, the risk of BC diagnosis was significantly lower among the 5ARI group (HR 0.82, 95% CI 0.79-0.94). In a similarly adjusted model, BC mortality was lower among 5ARI users, but no longer statistically significant (HR 0.82, 95% CI 0.65, 1.02). When stratified by type of 5ARI, finasteride significantly reduced the risk of BC diagnosis after ≥2 years of continuous use (HR 0.86, 95% CI 0.76, 0.96); however, dutasteride did not (HR 0.92, 95% CI 0.83, 1.03). CONCLUSIONS: In a large cohort of men, the use of a 5ARI was associated with a significantly decreased the risk of BC diagnosis after more than 2 years of continuous therapy.

Infection complications after transrectal ultrasound-guided prostate biopsy: A radiology department's experience and strategy for improvement.

INTRODUCTION: Transrectal ultrasound (TRUS)-guided prostate biopsy is a common procedure performed to diagnose prostate cancer. The risk of infection complications is well-described in the literature, and strategies to avoid such complications continue to evolve over time. We performed a retrospective review of our infection complications and propose a strategy for improvement. METHODS: We reviewed clinical outcomes from patients undergoing TRUS-guided prostate biopsy at our institution from November 2018 to November 2020. We reported the antimicrobial prophylaxis received, whether the biopsy was systematic or targeted, and we examined the rate of clinically significant infection complications and hospitalization. RESULTS: Among 312 men who underwent TRUS-guided prostate biopsy during the study period, seven (2.2%) had an infection. Four patient groups with distinct antimicrobial regimen were identified; the largest of these patient groups received a three-day course of cefixime and a single dose of fosfomycin (59%). The proportion of patients with infection complications across these groups did not demonstrate a statistically significant difference (p=0.803). There was no significant difference in proportion of infection between systematic and targeted biopsy groups (3.0% vs. 0%, p=0.204). The proportion of patients hospitalized was 1.3%, with a mean length of stay of four days. CONCLUSIONS: We report a rate of clinically significant infection following TRUS-guided prostate biopsy of 2.2%. Due to our referral pathway, we have an inconsistent approach to antimicrobial prophylaxis, although there was no statistically significant difference in infection rate between the groups. We propose a standardized approach that may lead to improved patient outcomes.

A high-fidelity, virtual-reality, transurethral resection of bladder tumor simulator: Validation as a tool for training.

INTRODUCTION: Simulation-based training is used to help trainees learn surgical procedures in a safe environment. The objective of our study was to test the face, content, and construct validity of the transurethral resection of bladder tumor (TURBT) module built on the Simbionix TURP Mentor simulator. METHODS: Participants performed five standardized cases on the simulator. Domains of the simulator were evaluated on a five-point Likert scale to establish face and content validity. Construct validity was assessed through the simulator's built-in scoring metrics, as well as video recordings of the simulator screen and an anonymized view of participants' hands and feet, which were evaluated using an objective structured assessment of technical skills (OSATS) tool. RESULTS: Ten experienced operators and 15 novices participated. Face validity was somewhat acceptable (mean realism 3.8/5±1.03 standard deviation [SD]; mean appearance 4.1/5±0.57), as was content validity, represented by simulation of key steps (mean 3.9±0.57). The simulator failed to achieve construct validity. There was no difference in mean simulator scores or OSATS scoring between experienced operators and novices. Novices significantly improved their mean simulator scores (305.9 vs. 332.4, p=0.006) and OSATS scoring (15.8 vs. 18.1, p=0.001), while 87% felt their confidence to perform TURBT improved. Overall, 92% of participants agreed that the simulator should be incorporated into residency training. CONCLUSIONS: Our study suggests a role for the TURBT module of the Simbionix TURP Mentor simulator as an introduction to TURBT for urology trainees. Strong support was found from both experienced operators and novices for its formal inclusion in resident education.

Systematic Review of the Prevalence of Kidney Stones in Cystic Fibrosis.

Purpose: To investigate the prevalence of urolithiasis in cystic fibrosis (CF) and to summarize the available clinical features within this unique population. Methods: Studies reporting the prevalence of urolithiasis in CF patients were identified by a systematic search of the literature from inception to July 31, 2020 on three databases: Ovid Medline, Ovid Embase, and Web of Science. Data were extracted on a predetermined standardized form by two independent authors. Results: A total of 596 publications were retrieved and screened, 15 of which met the eligibility criteria. The publications were published between 1993 and 2019 and were all observational in design. There was a total of 2982 patients with CF included in this review. The overall prevalence of stone formation in the CF population was 4.6% (137/2982). The mean age of diagnosis was 25.1 ± 9.6 and ranged from 0.25 to 47. Ultrasound was the most common imaging modality for kidney stone diagnosis. There was no apparent sex difference, with a female to male ratio of 1:1. Surgical intervention was required in 37.8% (34/90) of cases. Stone recurrence was reported in 42.9% (33/77) of stone formers. Conclusions: This review provides the most recent update for the prevalence of urolithiasis in CF patients and summarizes the available clinical data. Our findings suggest that patients with CF could be at risk for developing stones at a younger age and require interventional management strategies at higher rates compared with the general population. Given the heterogeneity of the literature for urolithiasis in CF, larger population-based studies reporting the epidemiology, clinical features, and management strategies are required to further our understanding of urolithiasis in CF.

Clips Can be Safely Used for Vascular Control of the Renal Vessels During Laparoscopic Donor Nephrectomy.

OBJECTIVE: To review our experience using clips to control the renal vessels during laparoscopic donor nephrectomy (LDN) and determine the safety of this practice. METHODS: We performed a retrospective review of patients who underwent LDN at our centre January 1, 2007-September 17, 2019. The primary outcome was the rate of complication associated with vascular control of the renal vessels, which included (1) conversion to open to manage bleeding, (2) additional procedures for bleeding, and (3) major bleeding requiring blood transfusion. Secondary outcomes included the rate of renal artery/vein clip dislodgement or crossing, change in hemoglobin, warm ischemia time and the incidence of intra-operative complications and postoperative in-hospital complications. RESULTS: We included 503 patients who underwent LDN, of which 497 were left sided. The main renal artery was controlled with 3 titanium clips in 489 (97%) cases. The main renal vein was controlled with 2 polymer-locking clips in 478 (95%) cases. For our primary outcome, there were no conversions to open to manage bleeding, no secondary procedures due to bleeding and no major bleeding requiring blood transfusion. Additionally, there were no donor deaths. Regarding our secondary outcomes, there were 5 intraoperative events related to the titanium clips being placed on the renal artery and 1 intraoperative event related to the polymer-locking clips on the renal vein, none of which resulted in any morbidity. CONCLUSION: Using 3 titanium clips on the renal artery and 2 polymer-locking clips on the renal vein during left LDN is safe and provides excellent vascular control.

Assessing the Necessity of Routine Crossmatching for Blood Transfusion in Renal Transplantation.

INTRODUCTION: Routine crossmatch of packed red blood cells (pRBCs) is completed preoperatively at many centers despite conflicting evidence on the incidence of blood transfusions with renal transplantation. In the current economic climate, resource adjudication should be judicious and medically appropriate. The objective of this study was to determine the incidence, timing, and predictors of early postoperative pRBC transfusion in patients undergoing renal transplantation. METHODS: A retrospective review of all patients undergoing renal transplantation at our institution from January 2013 to May 2016 was performed. Demographic, biochemical, and clinical parameters were recorded. The primary outcome was early postoperative transfusion, defined as an intraoperative transfusion or within 2 days of surgery. Multivariable logistic regression was performed to identify associations with early postoperative transfusion. RESULTS: We identified 428 patients during the study period (average age 55 years, 60% male, 30% obese, 67% deceased donor, and 43% preoperative antithrombotic use). Forty (9.3%) patients required early postoperative transfusion (mean: 2.8 pRBCs/transfusion) and most did not require blood urgently. Only 20 (4.7%) patients required a transfusion intraoperatively or on the same day of surgery. Lower preoperative hemoglobin (per g/L unit: odds ratio [OR]: 0.943), female gender (OR: 2.752), and preoperative antithrombotic use (OR 2.369) were associated with a need for early postoperative transfusion. CONCLUSION: Transfusion in the early postoperative period following renal transplantation was less than 10%, suggesting that routine crossmatch may not be necessary for all patients. Preoperative hemoglobin, female gender, and preoperative antithrombotic use were associated with increased risk and may be useful to risk-stratify patients who require crossmatch.

A Propensity Score-weighted Comparison of Outcomes Between Living and Standard Criteria Deceased Donor Kidney Transplant Recipients.

BACKGROUND: Consider a theoretical situation in which 2 patients with similar baseline characteristics receive a kidney transplant on the same day: 1 from a standard criteria deceased donor, the other from a living donor. Which kidney transplant will last longer? METHODS: We conducted a population-based cohort study using linked administrative healthcare databases from Ontario, Canada, from January 1, 2005, to March 31, 2014, to evaluate several posttransplant outcomes in individuals who received a kidney transplant from a standard criteria deceased donor (n = 1523) or from a living donor (n = 1373). We used PS weighting using overlap weights, a novel weighting method that emphasizes the population of recipients with the most overlap in baseline characteristics. RESULTS: Compared with recipients of a living donor, the rate of all-cause graft failure was not statistically higher for recipients of a standard criteria deceased donor (hazard ratio, 1.1; 95% confidence interval [CI], 0.8-1.6). Recipients of a standard criteria deceased donor, compared with recipients of a living donor had a higher rate of delayed graft function (23.6% versus 18.7%; odds ratio, 1.3; 95% CI, 1.0-1.6) and a longer length of stay for the kidney transplant surgery (mean difference, 1.7 d; 95% CI, 0.5-3.0). CONCLUSIONS: After accounting for many important donor and recipient factors, we failed to observe a large difference in the risk of all-cause graft failure for recipients of a standard criteria deceased versus living donor. Some estimates were imprecise, which meant we could not rule out the presence of smaller clinically important effects.

Objective Assessment and Standard Setting for Basic Flexible Ureterorenoscopy Skills Among Urology Trainees Using Simulation-Based Methods.

Objective: To objectively assess the performance of graduating urology residents performing flexible ureterorenoscopy (fURS) using a simulation-based model and to set an entrustability standard or benchmark for use across the educational spectrum. Methods: Chief urology residents and attending endourologists performed a standardized fURS task (ureterorenoscopy and repositioning of stones) using a Boston Scientific© Lithovue ureteroscope on a Cook Medical© URS model. All performances were video-recorded and blindly scored by both endourology experts and crowd-workers (C-SATS) using the Ureteroscopic Global Rating Scale, plus an overall entrustability score. Validity evidence supporting the scores was collected and categorized. The Borderline Group (BG) method was used to set absolute performance standards for the expert and crowdsourced ratings. Results: A total of 44 participants (40 chief residents, 4 faculties) completed testing. Eighty-three percent of participants had performed >50 fURS cases at the time of the study. Only 47.7% (mean score 12.6/20) and 61.4% (mean score 12.4/20) of participants were deemed "entrustable" by experts and crowd-workers, respectively. The BG method produced entrustability benchmarks of 11.8/20 for experts and 11.4/20 for crowd-worker ratings, resulting in pass rates of 56.9% and 61.4%. Conclusion: Using absolute standard setting methods, benchmark scores were set to identify trainees who could safely carry out fURS in the simulated setting. Only 60% of residents in our cohort were rated as entrustable. These findings support the use of benchmarks to earlier identify trainees requiring remediation.

Population-based assessment of re-treatment and healthcare utilisation after photoselective vaporisation of the prostate or electrosurgical transurethral resection of the prostate.

OBJECTIVE: To compare the healthcare utilisation and repeat surgical treatment rate amongst older men undergoing an electrosurgical-transurethral resection of the prostate (TURP) vs photoselective vaporisation of the prostate (PVP), as the real-world implementation and outcomes of laser-based treatment have not been well studied. PATIENTS AND METHODS: We used administrative data from the province of Ontario, Canada, to identify all men aged >66 years who underwent their first electrosurgical-TURP/PVP between 2003 and 2016. Our primary exposure was type of procedure (PVP or electrosurgical-TURP). Our primary outcome was need for repeat surgical treatment. The primary analysis was an adjusted marginal Cox model approach, which accounted for clustering of patients within surgeons; adjusted hazard ratios (aHRs) or odds ratios (aORs) and 95% confidence intervals (CIs) are reported. RESULTS: We identified 52 748 men: 6838 (13%) underwent PVP, and 45 910 (87%) underwent electrosurgical-TURP. The median age was similar, and PVP became more common with time. Compared to the PVP group, more patients in the electrosurgical-TURP group had prior gross haematuria or urinary retention, and fewer had used anticoagulants, α-blockers, or 5α-reductase inhibitors. The need for repeat surgical treatment was significantly higher amongst men who had PVP (aHR 1.57, 95% CI 1.38-1.78; absolute risk difference +2.3%). PVP was also associated with a slightly higher risk of return to the emergency room within 30 days (aOR 1.11, 95% CI 1.01-1.22) and a significantly lower risk of blood transfusion (aOR 0.24, CI 0.16-0.37); the majority of PVP cases were done with a <24 h stay (73%) vs electrosurgical-TURP (7%). CONCLUSIONS: While some of the expected benefits of PVP (such as reduced transfusion risk and shorter length of stay) were observed, the significantly higher rate of repeat surgical treatment compared to electrosurgical-TURP may represent an important difference in implementation of this technology outside of clinical trials.

The Utilization of Benign Prostatic Hyperplasia and Bladder-Related Medications After a Transurethral Prostatectomy.

OBJECTIVE: To determine how often prostate- and bladder-specific medications for lower urinary tract symptoms are used following a transurethral prostatectomy (TURP). METHODS: This study utilized several linked, routinely collected datasets from the province of Ontario, Canada to identify men older than 66 years who underwent their first TURP between April 2003 and March 2016. The primary outcome was the probability of using at least 30 days of either prostate-specific alpha blockers (AB), 5-alpha reductase inhibitors (5ARI), or anticholinergics/beta-3 agonists (AC/B3) after their TURP. RESULTS: We identified 58,038 men (median age 75), with a median follow-up of 4.9 years. In the 6 months prior to their TURP, AB, 5ARIs or AC/B3 were used by 62%, 32%, and 6%, respectively. Following a 90-day washout period after TURP, these medications were used by 27%, 20%, and 15% of men, respectively. The cumulative probability of using these medications within the first 10 years after TURP was 38%, 28%, and 20%, respectively. Family physicians prescribed the majority of AB, while urologists prescribed the majority of the AC/B3. Among men on AC/B3 prior to TURP, 46% used them after TURP; in multivariate cox regression analysis age ≥75, diabetes, preoperative use of AC/B3, and no preoperative urinary retention predicted postoperative utilization of AC/B3 medications. CONCLUSION: There is considerable use of AB and 5ARIs despite a lack of evidence for using these medications after a TURP. Given the well-characterized placebo response in BPH patients, this practice should be properly evaluated for clinical efficacy.

Evaluation of Optimal Timing of Expert Feedback in a Simulated Flexible Ureteroscopy Course.

Introduction: Simulation-based training (SBT) has become an increasingly popular modality to train novice surgical residents in the face of rapidly increasing innovative surgical techniques across all surgical disciplines. Recent studies have already demonstrated SBT to be effective in helping overcome the learning curve associated with new surgical techniques, especially in junior residents and endoscopic procedures. In addition, it is known that trainees benefit significantly from expert feedback; however, there is a paucity of data looking into the optimal timing of this feedback during SBT. To address this knowledge deficit, an SBT curriculum was developed for junior urology residents to assess optimal timing of feedback during SBT for flexible ureteroscopy (fURS). Materials and Methods: The SBT course consisted of a pretraining assessment, three independent practice sessions, and a post-training assessment, with residents receiving expert feedback right after their pretraining assessment (early feedback [EF]) or after their final independent training session (late feedback [LF]). Results: Fifteen trainees with similar baseline fURS experience and precourse fURS task performance score participated in the study. There was a significant difference between the pre- and post-task completion times overall (15.2 minutes vs 9.1 minutes, p < 0.001), with no difference between the early or LF groups (p = 0.884). The mean performance scores improved for both groups (18.2 vs 24.2, p < 0.001) with the EF group having a more statistically significant improvement in performance scores than the LF group (p = 0.05), and most (73%) of residents preferred EF. Conclusions: This study demonstrates that an SBT curriculum for fURS is effective for technical skills development among junior trainees, and that EF resulted in marginally better overall scores and was preferred by residents.

Is extracorporeal shockwave lithotripsy a risk factor for the development of diabetes mellitus? A population-based study.

OBJECTIVE: To determine if patients treated with extracorporeal shockwave lithotripsy (ESWL) are at a greater risk of developing diabetes mellitus (DM) than those treated with ureteroscopy (URS). PATIENTS AND METHODS: A retrospective population-based cohort study was performed of all ESWL and URS stone treatments done in Ontario between January 1994 and March 2014, utilising linked encoded healthcare databases. The primary outcome was the development of DM >90 days after treatment. The Kaplan-Meier method was used for unadjusted survival analysis and multivariable analysis with Cox proportional hazards regression was used to assess the risk of DM between the ESWL and URS groups whilst controlling for age, gender, region of residence, income quintile, year of treatment, and comorbidity index. A sensitivity analysis with a subset of ESWL patients treated for left renal or proximal ureteric stones was completed. RESULTS: We identified 106 963 patients who underwent ESWL or URS over the study period with a median follow-up of 6.6 years (ESWL 8.5 years, URS 5.6 years). Unadjusted survival analysis showed an increased risk of developing DM in the ESWL group compared to the URS group (P < 0.001); however, multivariable analysis showed no increased risk of DM in the ESWL cohort (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.91-1.02; P = 0.25). Similarly, sensitivity analysis showed no increased risk of DM in the left renal/proximal ureteric stone ESWL cohort compared to the URS cohort (HR 1.04, 95% CI 0.96-1.13; P = 0.35). CONCLUSIONS: Our population-based cohort study demonstrated no increased risk of DM in patients undergoing ESWL compared to URS.

Robotic Autotransplantation and Management of Post-transplant Anastomotic Strictures: the Future Is Here.

PURPOSE OF REVIEW: We set out to review the current published experience with robotic autotransplantation. Although the experience to date is limited, this surgery appears to be safe and technically feasible. We also examined the use of the robotic surgical platform for the management of post-transplant uretero-vesical anastomotic strictures. RECENT FINDINGS: To date, only four reported cases of robotic autotransplantation have been described with two being performed completely intra-corporeally. An intra-corporeal approach is feasible for benign conditions, while malignant masses should be inspected and dissected extra-corporeally. Ureteric strictures after renal transplantation are common. To date, the experience with robotic surgical management is limited but has also been shown to be safe and feasible. While robotic autotransplantation is still in its infancy, it is feasible and appears to be safe. Renal allograft function and surgical outcomes are favorable and provide patients the option to have a historically more morbid surgery performed with a minimally invasive approach.

The Impact of the Choosing Wisely Campaign in Urology.

OBJECTIVE: To determine if 3 of the Canadian Urological Association's Choosing Wisely recommendations (released in 2013-2014) related to urologic care altered physician and patient behavior. METHODS: Administrative data from Ontario, Canada between 2008 and 2017 was used. We identified 3 cohorts: First, we determined how many men >66 years of age had a serum testosterone level before starting testosterone therapy. Second, we determined how many boys undergoing an orchiopexy underwent abdominal imaging before their surgery. Third, we determined how many men with low risk prostate cancer underwent a Bone Scan after diagnosis. Piece-wise linear regression was used to evaluate for a significant change after Choosing Wisely. RESULTS: We identified 13,113 men who had their initial prescription for testosterone filled. Serum testosterone measurement increased over time, from approximately 43% to 68%. There were 9319 boys who underwent an orchiopexy. The use of pre-orchiopexy ultrasound was generally stable (approximately 55%). We identified 27,174 men with low risk prostate cancer. The use of bone scans after diagnosis decreased over time from approximately 24% to 20%. In all 3 of these groups, there was no significant change after Choosing Wisely (P = .74, P = .70, P = .72 respectively). CONCLUSION: In Ontario, there was no evidence of a significant change in 3 practice patterns that were featured in Choosing Wisely Urology recommendations. Further thought may be needed on how to translate these and future recommendations into behavior change.

Risk of rhabdomyolysis from 5-α reductase inhibitors.

PURPOSE: A recent regulatory warning and case reports have described the development of muscle complications with the use of 5-α reductase inhibitors (5ARIs). We wished to determine if there was a link between rhabdomyolysis and 5ARI usage. METHODS: We used a matched cohort design and linked administrative data from the province of Ontario, Canada, to investigate the risk of rhabdomyolysis in men using either finasteride or dutasteride. A total of 99 covariates were measured. We identified 93 197 men ≥66 years of age who initiated a new prescription for a 5ARI, and they were matched using a propensity score to an equal number of men not prescribed a 5ARI. RESULTS: New initiation of 5ARIs was not associated with a significantly increased risk of rhabdomyolysis (hazard ratio [HR] 1.21, 95% confidence interval [CI], 1.00-1.48, P = .06). When we examined the risk of rhabdomyolysis in the year prior to the initiation of a 5ARI, we found that men who would go on to use a 5ARI in the future had an elevated risk of rhabdomyolysis even prior to starting the medication (HR 1.31, 95% CI, 1.05-1.64, P = .01). Our secondary outcome of myositis and myopathy was significantly higher among 5ARI users (HR 1.63, 95% CI, 1.48-1.80, P < .01), and this risk was not present prior to 5ARI usage. CONCLUSION: 5-α reductase inhibitors do not appear to be associated with the development of rhabdomyolysis; however, they may be associated with an increased risk of myopathy and myositis.