Capturing anatomy in computed tomography scans for genital pathology.

PURPOSE: In this cross-sectional study, we aimed to characterize how frequently the anatomy of interest (AOI) was excluded when evaluating genital pathology using the current CT pelvis protocol recommended by the American College of Radiology and evaluate how AOI exclusion affects patient management. METHODS: We retrospectively reviewed medical records, using diagnosis and CPT codes, of patients admitted with genital pathology who obtained a CT scan at our institution from July 1, 2020-April 30, 2023. Baseline patient demographics were included. Data about each index CT scan (scan obtained at our institution) were recorded and assessed for exclusion of the AOI. Statistical analysis was performed to determine the rate of AOI exclusion and to compare patient management between patients with AOI excluded versus those without AOI exclusion. RESULTS: 113 presentations for genital pathology included an index CT scan and were included for analysis. Patients were primarily men (98%) with a mean age of 53.1 years (SD 13.9). The most common diagnoses were Fournier's gangrene (35%), scrotal abscess (22%) and unspecified infection (19%). 26/113 scans (23%) did not capture the entire AOI. When the AOI was missed during the index scan, there was a higher rate of obtaining additional scans (38% vs. 21%), but a similar rate of intervention (77% vs. 63%) when compared to index scans that captured the entire AOI. 35 scans (31%) had protocol-extending instructions; index scans that captured the entire AOI were more likely to have specific protocol-extending instructions (38% vs. 8% p < 0.01). CONCLUSIONS: Creating a specific CT protocol for genital pathology could decrease the amount of inappropriate irradiation and improve AOI capture rates without relying on specific request for protocol deviation.

Early Post-Operative Events After Urethroplasty in Obese Patients: A Multi-Institutional Retrospective Series.

OBJECTIVE: To compare early urethroplasty outcomes in non-obese, obese and morbidly obese patients undergoing urethroplasty for urethral stricture disease. The impact of obesity on outcomes is poorly understood but will be increasingly important as obesity continues to rise. METHODS: Patients underwent urethroplasty at one of the 5 institutions between January 2016 and December 2020. Obese (BMI 30-39.9, n = 72) and morbidly obese (BMI >40, n = 49) patients were compared to normal weight (BMI <25, n = 29) and overweight (BMI 25-29.9, n = 51) patients. Demographics, comorbidities, and stricture characteristics were collected. Outcomes including complications, recurrence, and secondary interventions were compared using univariate and multivariate analysis. RESULTS: Two hundred and one patients (Mean BMI 34.1, Range 18.4-65.2) with mean age 52.2 years (SD=17.2) were analyzed. Median follow-up time was 3.71 months. Obese patients were younger (P = .008), had more anterior (P <.001), iatrogenic and LS-associated strictures (P = .036). Sixty-day complication rate was 26.3% with no differences between cohorts (P = .788). Around 9.5% of patients had extravasation at catheter removal, 18.9% reported stricture recurrence, and 7.4% required additional interventions. Obese patients had greater estimated blood loss (P = .001) and length of stay (P = .001). On multivariate analysis, smoking associated with contrast leak (OR 7.176, 95% CI 1.13-45.5) but not recurrence or need for intervention (P = .155, .927). CONCLUSION: Obese patients in our cohort had more anterior, iatrogenic, and LS-related strictures. However, obesity is not associated with complications, contrast leak, secondary interventions, or recurrence. Obese had higher blood loss and length of stay. Urethroplasty is safe and effective in obese patients.

Postoperative events and complications of next-day stent removal following uncomplicated percutaneous nephrolithotomy compared to longer stenting.

INTRODUCTION: Options for renal drainage after percutaneous nephrolithotomy (PCNL) vary and depend primarily on surgeon preference and case considerations. In our practice, patients traditionally returned one week postoperatively to remove the stents in the office via cystoscopy; however, following uncomplicated PCNL with no plans for second-look procedure, a ureteral stent on a tether is currently removed in tandem with the Foley catheter on postoperative day 1 (POD1) prior to patient discharge. This study compared the number of postoperative events between POD1 stent removal and their longer stented counterparts. METHODS: We conducted a retrospective chart review on all patients who had undergone PCNL at our institution from January 1, 2020, to June 31, 2021. Patient demographics, operative metrics, and postoperative events (telephone calls, emergency department [ED ]/clinic visits, and complications) were recorded and compared between the two groups. RESULTS: A total of 243 patients were included in final analysis: 46% (n=111) had their stent removed on POD1 and 54% (n=132) had longer indwelling stent times. Baseline demographics were similar between the two groups. Number of telephone calls (p=0.081), ED /clinic visits (p=0.093), and complications (p=0.647) were similar between groups. There were three (1.3%) unplanned second-look procedures: two (1.8%) in the POD1 stent removal group and one (0.8%, p=0.475) in the later stent removal group. CONCLUSIONS: In this limited, retrospective study, we did not detect a difference in postoperative events or short-term complications for POD1 vs. later stent removal after uncomplicated PCNL.

Advanced Urology Boot Camp: A Simulation-based Curriculum to Enhance Fourth-year Medical Student Procedural Competency.

INTRODUCTION: Simulation-based medical education continues to gain popularity as the clinical environment requires exemplary patient safety while simultaneously maximizing the learner's educational experience. There is a current lack of urology-focused medical student education curricula in the literature. Here, we present the findings of a didactic and simulation-based medical student advanced "urology boot camp" curriculum, which was designed for learners interested in pursuing careers in urology. METHODS: Twenty-nine fourth-year urology-dedicated medical students completing their subinternship at our institution during the 2018-2019 academic year participated in an advanced hands-on simulation "boot camp," which taught both simple and advanced Foley catheter placement, manual and continuous bladder irrigation, and diagnostic cystoscopy. Knowledge acquisition was assessed through quizzes administered before and after completing electronic modules, and a post-simulation survey assessing learners' confidence in their knowledge and skill set, as well as their satisfaction with the curriculum. RESULTS: Medical students demonstrated significant gains in knowledge from pre-test (mean 73.7%) to post-test (mean 94.5%, P < .001), which was consistent across each simulation procedure. Participants self-reported significant improvement in confidence with the procedures from before to after the educational intervention (P < .001). Students also found the curriculum to be beneficial to their understanding of the subject matter (P < .001), would recommend this curriculum to other medical students (P < .001), and thought it better prepared them to meet expected ACGME (Accreditation Council for Graduate Medical Education) milestones (P < .001). CONCLUSIONS: Findings from our advanced "boot camp" simulation curriculum demonstrated successful gains in knowledge and confidence following learning modules and hands-on simulation, indicating that this type of educational intervention could be beneficial in improving exposure to skills and developing confidence prior to urology internship and junior residency.

Intraoperative Embolization during Inferior Vena Cava Tumor Thrombectomy for Renal Cell Carcinoma.

Intraoperative tumor thrombus embolization is a potentially lethal complication during inferior vena cava (IVC) thrombectomy for renal cell carcinoma (RCC). Intraoperative embolization is uncommonly encountered because IVC thrombectomy surgical technique is focused on avoiding this complication. Nonetheless, early recognition of embolization is essential so that emergent management can be instituted. When available, cardiopulmonary bypass (CPB) and embolectomy should be considered the gold standard for the management of intraoperative embolization. Several novel endovascular techniques are also available for selective use. We present the case of a 71-year-old female with a right renal mass and level II (retrohepatic) IVC tumor thrombus. During cytoreductive nephrectomy and IVC thrombectomy, tumor embolization was diagnosed during a period of hypotension based on transesophageal echocardiographic finding of new thrombus within the right atrium. This prompted sternotomy, CPB, and pulmonary artery embolectomy. The patient survived this embolization event and has a complete response to systemic therapy 9 months postoperatively. This case serves as the framework for a discussion on management considerations surrounding intraoperative embolization during IVC thrombectomy.

Testicular Cancer Knowledge and Viewpoints of American Men.

Introduction: We sought to better understand the baseline knowledge and practices of the general population regarding testicular cancer (TC) and testicular self-examination (TSE) in an effort to understand whether current screening guidelines reflect their viewpoint. The U.S. Preventive Services Task Force (USPSTF) currently recommends against TSE for TC screening due to a lack of data to support a benefit. Early detection of TC may reduce the required burden of therapy and associated long-term toxicities. Methods: This was a cross-sectional survey study. Participants (median age 33 years, IQR 28-39) were recruited via Amazon Mechanical Turk, a validated crowdsourcing platform used to recruit minimally compensated participants. Results: A total of 250 men rated themselves as "somewhat unknowledgeable" about TC, with no respondents considering themselves "very knowledgeable." Only 26.4% of men knew that TC was curable most of the time. Despite 90.8% of men feeling that their doctor had some role in discussing TC/TSE, only 17.2% had discussed these topics with their doctor. Even after being informed of the rationale behind USPSTF recommendations, only 8% of men thought that potential false positives of TSE would be more important than the rare chance of finding early TC. Conclusions: American men do not feel knowledgeable about TC, have a favorable attitude toward TSE and want their doctor to discuss these topics. Shared decision making regarding TC screening is warranted given the low risk of harm and patient interest, and continued accrual of data on this topic is necessary given the lack of prospective work to date.

Incidental splenosis discovered during robotic assisted radical prostatectomy: A case report.

Splenosis refers to the benign heterotopic auto transplantation of splenic tissue that most commonly arises following traumatic rupture of the spleen. It is most often associated with traumatic rupture of the spleen. While often asymptomatic, splenosis can mimic malignancy and may lead to unnecessary biopsy, chemotherapy, and surgery. This case report highlights an instance of splenosis discovered incidentally during robotic assisted radical prostatectomy. Splenules were sent for frozen section due to concern for malignancy. Retrospective analysis of imaging obtained prior to the procedure was consistent with splenosis.

Current Knowledge and Opinions of Medical Trainees Regarding PSA Screening.

After 2008 and 2012 USPSTF recommendations against PSA screening, studies revealed a decline in screening rates and trend towards more advanced disease at presentation. After revision of this recommendation in 2017, PSA screening guidelines remain inconsistent and controversy still exists about its clinical utility. We seek to better understand the knowledge of medical trainees regarding this fundamental controversy and gain better insight into what they are being taught regarding this topic. Participants were medical students (n = 66) and residents (n = 60) from a single institution. REDCap software was used for informed consent, survey distribution, and data collection. Variables measured included PSA clinical knowledge, awareness of the PSA guideline changes, and attitudes, confidence, and viewpoints on use of PSA screening in clinical practice. More than 60% of medical trainees reported little or no knowledge of PSA screening guidelines. Although residents reported more knowledge than medical students, actual assessed knowledge of PSA screening did not differ between groups. Trainees reported receiving education primarily from other healthcare professionals and didactics, with some self-learning online. Though confidence was low overall, residents were more confident than medical students in discussing PSA screening with patients. The majority of respondents wanted more information about PSA testing, with medical students particularly interested in diagnosis/detection, treatment, and survival. Overall, opinions towards PSA testing as an aid were generally positive. Better education about the current PSA screening guidelines for medical trainees is imperative, particularly given that shared decision-making is of great importance when counseling patients on cancer screening.

Risk factors, demographic profiles, and management of uncomplicated recurrent urinary tract infections: a single institution study.

OBJECTIVE: Recurrent urinary tract infections (rUTI) are a common urologic chief complaint. Although rUTIs are a significant burden on the healthcare system, until recently there were no published guidelines to delineate optimal management of this condition. The objective of this study was to describe the demographic profile of rUTI patients and summarize practice patterns at a single tertiary health center, as well as to assess whether our real-life practice patterns parallel the recently published guidelines. METHODS: We conducted a retrospective record review of female patients presenting for diagnosis of uncomplicated rUTI/cystitis between October 2010 and September 2018. Analyses were conducted to investigate (a) whether pre- versus postmenopausal women differed in their risk factors for rUTI, (b) whether providers adjust their practice patterns when treating pre- versus postmenopausal women with rUTIs, and (c) whether certain treatment regimens led to lower rates of rUTI than others. RESULTS: Of the 125 cases included in the final analysis, pre- versus postmenopausal women did differ in their risk factors for rUTI, specifically age, Charlson Comorbidity Index score, and comorbidities. Although common treatments were found across menopausal status, providers did adjust their practice patterns when treating pre- versus postmenopausal women, including the use of postcoital suppression, conservative measures, cranberry juice/extract, and probiotics for premenopausal women and daily suppression and vaginal estrogens for postmenopausal women. rUTI after treatment (<40%) was highest after the use of conservative measures for all women and rates of rUTI after treatment generally did not differ as a function of menopausal status, but rather by treatment option. CONCLUSIONS: This single institution report sheds light on practice patterns at a major academic center, specifically as it compares to the new American Urological Association guidelines and the use of estrogen cream for postmenopausal women.

Fournier's Gangrene in Females: Presentation and Management at a Tertiary Center.

OBJECTIVE: To report and compare presentation and management of Fournier's Gangrene (FG) in female vs male patients at a single tertiary care center. METHODS: Patient demographics, clinical characteristics, treatments and outcomes were summarized and compared between males and females who were treated for FG from 2011 to 2018 at a single institution. RESULTS: Of the 143 patients treated for FG at our institution, 33 (23%) were female. Female patients were predominantly white (82%), with a median (IQR) age of 55 (46, 59). Median female boby mass index (BMI) was 42.1 (32, 50.4). Female patients' wound cultures were polymicrobial mix of gram positive and gram negative organisms. Median number of debridements for females was 2 (1,3). The most common anatomic region of gangrene involvement in females was labia (76%) followed by perineum (55%) and gluteus/buttocks (42%). Mortality rate during initial admission was 6% for females. Female patients had a higher median BMI than males (42.1 vs 33.7 respectively; P = .003). FG severity index, length of hospital stay, number of debridements, and wound cultures were comparable to males. The surgical team managing initial debridements differed with females managed primarily by general surgery and males primarily by urology. Mortality rate was comparable to men (6% vs 7%, P >.05). CONCLUSION: Female patients with FG have greater BMI but similar clinical presentation, microbiologic characteristics and mortality rate compared to men. Urologists have little involvement during initial management for females at our institution.

NCL Inhibition Exerts Antineoplastic Effects against Prostate Cancer Cells by Modulating Oncogenic MicroRNAs.

Prostate cancer (PCa) is the most frequently diagnosed cancer in men and second most common cause of cancer-related deaths in the United States. Androgen deprivation therapy (ADT) is only temporarily effective for advanced-stage PCa, as the disease inevitably progresses to castration-resistant prostate cancer (CRPC). The protein nucleolin (NCL) is overexpressed in several types of human tumors where it is also mislocalized to the cell surface. We previously reported the identification of a single-chain fragment variable (scFv) immuno-agent that is able to bind NCL on the surface of breast cancer cells and inhibit proliferation both in vitro and in vivo. In the present study, we evaluated whether NCL could be a valid therapeutic target for PCa, utilizing DU145, PC3 (CRPC), and LNCaP (androgen-sensitive) cell lines. First, we interrogated the publicly available databases and noted that higher NCL mRNA levels are associated with higher Gleason Scores as well as with recurrent and metastatic tumors. Then, using our anti-NCL scFv, we demonstrated that NCL is expressed on the surface of all three tested cell lines and that NCL inhibition results in reduced proliferation and migration. We also measured the inhibitory effect of NCL targeting on the biogenesis of oncogenic microRNAs such as miR-21, -221 and -222, which was cell context dependent. Taken together, our data provide evidence that NCL targeting inhibits the key hallmarks of malignancy in PCa cells and may provide a novel therapeutic option for patients with advanced-stage PCa.

Single-Use Grasper Integrated Flexible Cystoscope for Stent Removal: A Micro-Costing Analysis-Based Comparison.

Background: A single-use flexible cystoscope with integrated grasper (Isiris; Coloplast, Denmark) has recently become commercially available. The objective of our study is to compare the costs of stent removal in an outpatient clinical environment between the single-use Isiris system (Coloplast) to our existing approach using a reusable cystoscope and stent grasper. Materials and Methods: The number of stent removal procedures at our tertiary center was recorded as a proportion of all cystoscopic procedures performed between February 2016 and February 2017. Elements in the micro-cost assessment included original purchasing price of an Olympus digital reusable cystoscope, repair fee (based on a 1-year contract), sterilization equipment and accessory costs, reprocessing costs of the cystoscope, and labor costs. The costs were estimated on a per-use basis and compared to the purchasing price of Isiris. Results: A total of 1775 cystoscopic procedures were performed, and the reusable cystoscope was used for stent removal in 871 (49%) cases. The per-use cost for stent removal procedures using the reusable cystoscope was estimated to be $161.85. The single per-use purchasing price for the Isiris device is $200. Based on the current volume, the break-even point was calculated to be 704 stent pulls. After 704 stent pulls, the cost benefit favors the reusable cystoscope. Conclusion: Based on this micro-cost analysis, per-use costs appear to favor the reusable cystoscope for stent removal. It appears that centers with high volumes of stent pulls may find the reusable cystoscope and stent grasper more cost beneficial than the single-use system.

The Impact of Ureteral Access Sheath Use on the Development of Abnormal Postoperative Upper Tract Imaging after Ureteroscopy.

PURPOSE: Ureteral access sheaths are commonly used during ureteroscopy to facilitate stone removal, improve visibility and maintain low intrarenal pressures. However, the use of a ureteral access sheath can cause ureteral wall ischemia and ureteral tears, potentially increasing the risk of postoperative ureteral stricture and obstruction. We studied the impact of ureteral access sheath use on postoperative imaging studies. Secondary objectives included studying the impact of other intraoperative parameters on postoperative imaging studies. MATERIALS AND METHODS: A retrospective chart review was conducted of cases that underwent ureteroscopy for nephroureterolithiasis across 2 high volume institutions between January 2012 and September 2016. Patient demographics, cumulative stone size, operative time, use of ureteral access sheath, laser lithotripsy, basket extraction, preoperative ureteral stent and postoperative ureteral stent placement were extracted from the electronic medical record. Findings of followup renal ultrasound, kidney-ureter-bladder x-ray and/or computerized tomography at approximately 8 weeks after surgery were recorded. RESULTS: A total of 1,332 ureteroscopies were performed with 1,060 cases (79.6%) returning for routine upper tract imaging after ureteroscopy. Postoperative hydronephrosis was noted following 127 cases (12.0%). Factors predicting presence of hydronephrosis after ureteroscopy include lower body mass index (p=0.0016), greater cumulative stone size (p=0.0003), increased operative time (p <0.0001), preoperative ureteral stent (OR 1.49, p=0.0299) and postoperative ureteral stent placement (OR 6.43, p=0.0031). Postoperative hydronephrosis was not associated with use of ureteral access sheath, age, laser lithotripsy or basket extraction. CONCLUSIONS: Use of ureteral access sheath did not have a significant impact on development of postoperative hydronephrosis, suggesting ureteral access sheath is safe for use during ureteroscopy. Ureteral strictures remain rare following ureteroscopy, seen in only 1.0% of our cohort. With an observed prevalence of hydronephrosis of 12.0% on followup imaging at 8 weeks, routine upper tract imaging after ureteroscopy remains a valuable prognostic tool.