Urology Residency Training in Medically Underserved Areas Through the Integration of a Federally Qualified Health Center Rotation.

OBJECTIVE: To identify workforce related barriers to urologic care in Medically Underserved Areas (MUA) and Health Professional Shortage Areas (HPSA). Federally Qualified Health Centers (FQHC) are community-based organizations that aim to close gaps, but little is known about exposure to underserved areas during residency training. METHODS: The objective of this study was to characterize the experiences of urology residents who participated in a rotation within a FQHC. The study consisted of: (1) 12-item post-rotation self-assessment (2) review of career paths of former graduates who completed the rotation, and (3) retrospective review of patients treated at FQHC from 2016 to 2018. RESULTS: There were a total of 1735 patient visits, 97 were for cystoscopy, 76.36% of patients had Medicaid or no insurance. There were 1092 unique patients seen and 281 (25.73%) were referred for surgery. A majority of residents (100%) stated they had a better appreciation of treating patients in underserved areas. A majority of residents (71.6%) of residents said they were more likely to practice in an underserved area after residency. Among former graduates who rotated through the clinic, 100% (n = 4) were practicing in a MUA or HPSA. CONCLUSION: The integration of an FQHC during urology residency training was associated with highly favorable satisfaction by trainees. Given persistent workforce related shortages in urology, these findings support exposure to medically underserved areas during training.

Comparison of long-term outcomes in a 10-year experience of robotic cystectomy vs. open cystectomy.

To compare the outcomes of robotic-assisted (RARC) vs. open radical cystectomy (ORC) at a single academic institution. We retrospectively identified patients undergoing radical cystectomy for urothelial carcinoma of the bladder at our institution from 2007 to 2017. Data collected included age, sex, Body Mass Index (BMI), Charlson Age-Adjusted Comorbidity Index (CCI), final pathologic stage, surgical margins, lymph-node yield, estimated blood loss (EBL), 90-day complication rate, and length of stay (LOS). We evaluated overall survival (OS) and recurrence-free survival (RFS). Multivariable Cox proportional hazard models were used to adjust for covariates. We identified 232 patients (73 RARC, 159 ORC) who underwent radical cystectomy. Patients who underwent RARC were older (71.8 vs. 67.5, p < 0.05) and had higher CCI scores (6.2 vs. 5.3, p < 0.05). In comparing perioperative outcomes, RARC patients had lower EBL (500 vs. 850, p < 0.01), lower blood transfusion rate (p < 0.01), and lower lymph-node yield (12 vs. 20, p < 0.01), and higher ICU admission rate (29% vs. 16% p < 0.01). There was no difference in BMI (p = 0.93), sex (p = 0.28), final pathological stage (p = 0.35), positive surgical margins (p = 0.47), complications (p = 0.58), or LOS (p = 0.34). Kaplan-Meier analysis showed no difference in OS (p = 0.26) or RFS (p = 0.86). There was no difference in restricted mean survival time for OS (53 vs. 56 months, p = 0.81) or for RFS (65 vs. 64 months, p = 0.90). Cox multivariate regression models showed that surgical approach does not have a significant impact on OS (p = 0.46) or RFS (p = 0.35). Our study indicates that in our 10-year experience, patients undergoing there was no difference between RARC and ORC patients with respect to OS and RFS despite being older and having more comorbidities. Our work supports the importance of patient selection to optimize outcomes.

Association of Human Development Index with global bladder, kidney, prostate and testis cancer incidence and mortality.

OBJECTIVES: To describe contemporary worldwide age-standardized incidence and mortality rates for bladder, kidney, prostate and testis cancer and their association with development. MATERIALS AND METHODS: We obtained gender-specific, age-standardized incidence and mortality rates for 184 countries and 16 major world regions from the GLOBOCAN 2012 database. We compared the mortality-to-incidence ratios (MIRs) at national and regional levels in males and females, and assessed the association with socio-economic development using the 2014 United Nations Human Development Index (HDI). RESULTS: Age-standardized incidence rates were 2.9 (bladder) to 7.4 (testis) times higher for genitourinary malignancies in more developed countries compared with less developed countries. Age-standardized mortality rates were 1.5-2.2 times higher in more vs less developed countries for prostate, bladder and kidney cancer, with no variation in mortality rates observed in testis cancer. There was a strong inverse relationship between HDI and MIR in testis (regression coefficient 1.65, R2 = 0.78), prostate (regression coefficient -1.56, R2 = 0.85), kidney (regression coefficient -1.34, R2 = 0.74), and bladder cancer (regression coefficient -1.01, R2 = 0.80). CONCLUSION: While incidence and mortality rates for genitourinary cancers vary widely throughout the world, the MIR is highest in less developed countries for all four major genitourinary malignancies. Further research is needed to understand whether differences in comorbidities, exposures, time to diagnosis, access to healthcare, diagnostic techniques or treatment options explain the observed inequalities in genitourinary cancer outcomes.

Adverse pathologic characteristics in the small renal mass: implications for active surveillance.

INTRODUCTION: Evidence has demonstrated that tumor size is related to adverse oncologic outcomes in small renal tumors (≤ 4 cm). We evaluated the association of adverse pathologic features (APF) with tumor size and survival in patients with a small renal mass (SRM). MATERIALS AND METHODS: We retrospectively reviewed the pathologic characteristics of 380 surgically resected SRMs from a single institution. APFs included lymphovascular invasion, coagulative necrosis, sarcomatoid/rhabdoid features, papillary type II histology, and perinephric fat/renal sinus invasion. The number and type of APFs were compared with tumor size. Survival analysis was performed using the Kaplan-Meier method. RESULTS: There were 244 (64.2%) males and 136 (35.8%) females. The median age was 61 years, and median tumor size was 2.7 cm. The median follow up time was 65 months. A significant association was found between tumor size and presence of APFs (p = 0.018). At least 1 APF could be found in 22%, 32%, 36%, and 49% of tumors ≤ 1 cm, 1 cm-2 cm, 2 cm-3 cm, and 3 cm-4 cm, respectively. There were no differences in overall survival or recurrence free survival when compared by tumor size at diagnosis (p = 0.22 and 0.15 respectively). Compared to patients with ≤ 1 APFs, disease specific survival was worse for patients with ≥ 2 APFs (p < 0.002). CONCLUSION: Our data support that aggressive tumor biology in a SRM is associated with greater size. In patients with a SRM, the decision to pursue active surveillance and the trigger for intervention should take tumor size and APFs into consideration as this may have future oncologic implications.

Negative Multiparametric Magnetic Resonance Imaging of the Prostate Predicts Absence of Clinically Significant Prostate Cancer on 12-Core Template Prostate Biopsy.

OBJECTIVE: To determine the negative predictive value of multiparametric magnetic resonance imaging (mpMRI), we evaluated the frequency of prostate cancer detection by 12-core template mapping biopsy in men whose mpMRI showed no suspicious regions. METHODS: Six hundred seventy patients underwent mpMRI followed by transrectal ultrasound (TRUS)-guided systematic prostate biopsy from December 2012 to June 2016. Of this cohort, 100 patients had a negative mpMRI. mpMRI imaging sequences included T2-weighted and diffusion-weighted imaging, and dynamic contrast enhancement sequences. RESULTS: The mean age, prostate-specific antigen, and prostate volume of the 100 men included were 64.3 years, 7.2 ng/mL, and 71 mL, respectively. Overall cancer detection was 27% (27 of 100). Prostate cancer was detected in 26.3% (10 of 38) of patients who were biopsy-naïve, 12.1% (4 of 33) of patients who had a prior negative biopsy, and in 44.8% (13 of 29) of patients previously on active surveillance; Gleason grade ≥7 was detected in 3% of patients overall (3 of 100). The negative predictive value of a negative mpMRI was 73% for all prostate cancer and 97% for Gleason ≥7 prostate cancer. CONCLUSION: There is an approximately 3% chance of detecting clinically significant prostate cancer with systematic TRUS-guided biopsy in patients with no suspicious findings on mpMRI. This information should help guide recommendations to patients about undergoing systematic TRUS-guided biopsy when mpMRI is negative.

Three testicles in one hemiscrotum: an unusual presentation of polyorchidism.

Polyorchidism, or more than one testicle in a hemiscrotum, is a relatively rare phenomenon. It is often associated with several other conditions, including inguinal hernia, testicular maldescent, testicular torsion, hydrocele or hypospadias. In this report, we describe a patient who presented with three testicles in one hemiscrotum, which is a highly unusual presentation for an already uncommon condition. We also review the relevant literature as it relates to the need for surveillance due to the increased risk for malignancy.

Perivascular epithelioid cell tumour of the bladder.

A 39-year-old woman presented with a long history of pelvic pain and urinary urgency. Prior workup by her primary care doctor had been negative. The patient's gynaecologist ultimately referred her to a urologist following an ultrasound that revealed a possible bladder mass. MRI of the abdomen and pelvis demonstrated a 4 cm soft tissue lesion arising from the bladder. Cystoscopy showed an atypical mass on the anterior bladder wall, and pathological examination of the TURBT (transurethral resection of the bladder tumour) specimen revealed a perivascular epithelioid cell tumour (PEComa) with involvement of the detrusor muscle. The patient underwent a robotically assisted laparoscopic partial cystectomy. Final pathology confirmed a PEComa with negative margins. The patient had an uncomplicated postoperative course and is doing well following surgery. A surveillance cystoscopy at 6 months showed no evidence of recurrence. This case underscores the variability of clinical presentation of PEComas while proposing an appropriate method of surgical management.

Patient perception of transvaginal mesh and the media.

OBJECTIVE: To assess the penetration of media-based information on transvaginal mesh (TVM) in our patient population and to determine whether exposure affects patient opinion. Since the 2011 Federal Drug Administration communication on TVM, many advertisements from legal practices have been directed toward patients. MATERIALS AND METHODS: An 18-item survey was administered to female patients at 2 sites from August 2012 to April 2013. Patients presenting with new diagnoses of pelvic organ prolapse or stress urinary incontinence or patients who reported prior mesh surgery were excluded. RESULTS: Ninety-nine questionnaires were completed. Sixty-six of the patients (67%) were aware of TVM; and of these, 38 (58%) cited advertisements as the initial source of information. Only 12% were aware of the Food and Drug Administration's communication. Regarding opinion of TVM, 9% chose "it is a safe product," 9% "safety depends on factors related to patient," 4.5% "not a safe product," 1.5% "safety depends on the doctor," 68% "I don't know," and 4.5% marked 2 selections. Only 12% indicated knowing the difference in the use of TVM for pelvic organ prolapse vs stress urinary incontinence. When asked what influenced their opinion of TVM the most; responses were as follows: advertisement (33.3%), medical professional (22.7%), friends or family who underwent TVM procedure (12.1%), media article (6.1%), and "not sure" (25.8%). CONCLUSION: Advertisements of TVM lawsuits had a high penetration into our patient population but did not produce an overtly negative response in our sample. Clinicians should be aware of the impact of these advertisements on patient opinion and counsel patients accordingly with unbiased and scientifically accurate information.

Paratesticular fibrous pseudotumour.

A 38-year-old man presented with a 2-year history of an enlarging scrotal nodule. Scrotal ultrasound revealed two soft tissue masses separate from the testicle in the right scrotum measuring 1.7 and 0.8 cm. The patient underwent excision of the scrotal nodules, revealing firm, white tissue with a smooth, nodular surface. On histology, the lesions appeared fibrous with scattered capillaries and areas of inflammatory infiltrate consistent with paratesticular fibrous pseudotumour. On a follow-up ultrasound at 6 months, he had no evidence of recurrence.

Recurrent nephrolithiasis associated with atazanavir use.

A 64-year-old man with HIV on antiretroviral therapy (including atazanavir, a protease inhibitor) presented with left flank pain, nausea and vomiting. A kidney stone was suspected, and a CT scan demonstrated left hydronephrosis but failed to demonstrate nephrolithiasis or extrinsic compression. The patient had a ureteral stent placed which relieved his symptoms. A few months later, he underwent left ureteroscopy and a large ureteral calculus was found. The stone was removed and analysis showed 43% atazanavir and 57% calcium oxalate. Several months later, the patient developed flank pain on the opposite side. A renal ultrasound suggested right-sided nephrolithiasis and he subsequently underwent ureteroscopy with laser lithotripsy of two stones. Stone analysis showed that they were composed of 100% atazanavir. This case highlights the fact that patients treated with protease inhibitors remain at risk for developing nephrolithiasis. Ultrasonography can be a useful diagnostic tool in the setting of these radiolucent calculi.

An animal explant model for the study of human cutaneous squamous cell carcinoma.

We established a human tissue explant model to facilitate study of cutaneous squamous cell carcinoma. We accomplished this by implanting debulked SCC, from surgical discard, into nude rats. Human SCC remained viable and continued to proliferate for at least 4 weeks and showed evidence of neovascularization. At 4 weeks, SCC implants showed a trend toward increased PCNA positive cells compared to fresh SCC cells/mm(2) tissue) supporting continued proliferation throughout engraftment. Von Willebrand's Factor (VWF) positive cells were found within implants and likely represented rat vessel neovascularization. Human Langerhans' (Langerin+) cells, but no T cells (CD3+, CD8+, FoxP3+), macrophages (CD163), or NK cells (NKp46), were present in SCC implants at 4 weeks. These findings support the possibility that LCs fail to migrate from cutaneous SCC and thus contribute to lack of effective antitumor response. Our findings also provide a novel model system for further study of primary cutaneous SCC.

Renal metastasis of an ovarian granulosa cell tumour inducing growth of a cystic nephroma.

A 44-year-old woman presented with a large pelvic mass. Pathology revealed a granulosa cell tumour of the left ovary. The patient was followed after surgery with inhibin B levels and interval imaging. Six years later, she began to experience severe back pain. A vertebral biopsy was positive for metastatic granulosa cell tumour. She underwent radiation to the spine. Inhibin B levels began to rise and, several months later, a CT scan showed a large heterogeneous mass essentially replacing the left kidney. She underwent an open left radical nephrectomy. Pathology revealed a 12 cm cystic nephroma with a 5 cm nodule of metastatic granulosa cell tumour. Immunohistochemistry demonstrated that the mass was inhibin and oestrogen receptor positive. This is a novel presentation of these coexisting pathologies. This unique case sheds light on the possibility of induction of cystic nephroma by the altered hormonal environment created by a granulosa cell tumour metastasis.

Ultrasonography in prostate cancer: current roles and potential applications in radiorecurrent disease.

The use of ultrasound technology for prostate cancer imaging has evolved over many years. In order to fully appreciate today's application of prostate ultrasound in the primary diagnostic setting as well as for radiorecurrent prostate cancer, it is helpful to understand the progression of this technology from its inception. This review begins with a brief history of the development of ultrasonography for the prostate. This is followed by a summary of the data evaluating ultrasound in the primary diagnosis of prostate cancer. Its application in the post-treatment setting is then addressed. Finally, several emerging technologies are discussed, including contrast-enhanced ultrasound, elastography and HistoScanning. These new modalities may hold promise for identifying incompletely ablated prostate tissue following radiation therapy or other ablative techniques.

Nonneoplastic renal cortical scarring at tumor nephrectomy predicts decline in kidney function.

CONTEXT: Evaluating nontumor portions of tumor nephrectomies is useful to diagnose nonneoplastic renal disease. OBJECTIVE: To determine the medical renal disease frequency and to assess the prognostic significance of the various renal pathologic variables with long-term follow-up in tumor nephrectomy patients. DESIGN: We reviewed nonneoplastic kidney sections of 456 consecutive cases from 1998 to 2008. Seventy-five cases were excluded (19 tumor compression, 25 no nonneoplastic tissue, 22 embolized kidneys, 9 end stage). Special staining, immunofluorescence, and/or electron microscopy was performed where appropriate. Vascular sclerosis was scored from mild to severe; interstitial fibrosis/tubular atrophy and global glomerulosclerosis (GS) were expressed as percentages. Follow-up, minimum 12 months, was evaluated in 156 cases. All renal pathologic variables were compared with regard to change in creatinine level from preoperative assessment to follow-up. RESULTS: Of 381 cases, 57 had additional medical renal disease (15%), most frequently diabetic nephropathy (28) and hypertensive nephropathy (11). Postoperative creatinine levels increased significantly in patients with severe arteriosclerosis or arteriolosclerosis, >5% GS, and >10% interstitial fibrosis/tubular atrophy. Seventy-four percent of cases with additional nonneoplastic diagnoses showed severe arteriolosclerosis. Higher corresponding GS was seen in the more affected vascular cases: mean, 5.56% GS for mild versus 23% GS for severe. Three patients progressed to renal failure 1 to 4 years after nephrectomy, 2 with hypertensive nephrosclerosis and 1 with diabetic nephropathy. CONCLUSIONS: Medical renal disease was identified in 15% of tumor nephrectomy specimens. The degrees of vascular sclerosis, GS, and interstitial fibrosis/tubular atrophy are predictive of elevated creatinine levels in postnephrectomy patients. Prognostic implications of the nontumor pathology are important in nephrectomized patients.

Salvage radical prostatectomy as management of locally recurrent prostate cancer: outcomes and complications.

PURPOSE: Management of prostate cancer following radiation therapy remains challenging, especially for younger men or those with life expectancy greater than 10 years. We outline the efficacy, safety and adequacy of radical prostatectomy for the treatment of radiorecurrent localized prostate cancer. METHODS: A systematic review was performed in September 2012 searching MEDLINE articles from 1980 to 2012 on salvage radical prostatectomy. We excluded unpublished data and non-English-language articles. RESULTS: The ideal candidate for salvage radical prostatectomy (SRP) has a life expectancy greater than 10 years, a PSA < 10 ng/ml and whose initial clinical staging was T1 or T2. A prostate biopsy and imaging studies to rule out metastatic disease should be performed prior to SRP. Salvage RP has a high complication rate, but this appears to be decreasing over time. Urinary continence rates range from 36 to 81%, whereas erectile function following SRP was generally poor with less than 30% of men regaining adequate erectile function. Men with good erectile function prior to SRP fared better than those with pre-operative erectile dysfunction. Biochemical recurrence-free probability at 5 years ranged from 37 to 55% and the estimated cancer-specific survival at 10 years ranged from 70 to 83%. Minimally invasive SRP is feasible and early outcomes suggest that this approach is not inferior to open surgery. CONCLUSION: SRP offers a potentially curative option with proven long-term disease-free survival in appropriately selected patients. Given the morbidity of this procedure, judicious patient selection and referral to providers experienced with salvage surgery may optimize patient outcomes.

Laparoendoscopic single-site radical nephrectomy for large renal masses.

PURPOSE: To report our operative experience and short-term outcomes for the laparoendoscopic single-site (LESS) management of large renal tumors and tumors of advanced stage. PATIENTS AND METHODS: Ten consecutive patients underwent LESS-radical nephrectomy (RN) for large (≥ 7 cm) and/or locally advanced tumors (>T(2)). Intraoperative, postoperative, and short-term follow-up data were analyzed. RESULTS: Median surgical time was 146 minutes (range 73-164 min), and median estimated blood loss was 100 mL (range 25-400 mL). No procedure needed conversion to open RN or hand-assisted laparoscopic RN. The median hospital stay was 47 hours (range 42 hours-12 days). One (10%) patient had a minor complication (postoperative fever treated with antibiotics) and one (10%) patient had a major complication (small bowel obstruction necessitating reoperation). Of the 10 tumors, 2 were pathologic stage T(1b), 4 were pathologic stage T(2), and 4 were stage T(3a). At a median follow-up of 12.3 months (range 1-16 mos), six (60%) patients were alive without evidence of recurrence, and 4 (40%) patients were alive with disease. Of those four patients, all four had known metastatic disease before surgery. CONCLUSION: LESS-RN for large or advanced stage renal masses is a technically challenging operation. In experienced hands, however, it is a safe and feasible therapeutic option for the management of these tumors.

Nomograms to predict patency after microsurgical vasectomy reversal.

PURPOSE: After undergoing vasectomy up to 6% of men will elect to undergo vasectomy reversal. For these men paternity can be achieved with vasectomy reversal or surgical sperm retrieval coupled with assisted reproduction. Nevertheless, it remains difficult for surgeons to accurately counsel men on the chance of patency after vasectomy reversal. MATERIALS AND METHODS: A retrospective review was conducted of 548 patients who underwent microsurgical vasectomy reversal. Surgery was considered successful if sperm concentration was 100,000 or more sperm per ml, total count was 100,000 or more sperm per ejaculate, motile sperm were present and there was no evidence of subsequent failure. A multivariate logistic regression model was constructed to calculate the probability of having a successful vasectomy reversal and nomograms for patency were generated from this model. RESULTS: A total of 548 patients met the inclusion criteria for this study. Mean followup was 1.8 ± 0.10 years. Mean patient age was 43.4 ± 0.3 years and mean duration of obstruction was 10.4 ± 0.2 years. Two nomograms to predict patency were generated, one for preoperative counseling and a second for postoperative counseling. The factors with the largest effect on patency were average testicular volume and obstruction duration. The factor with the least effect was the presence of sperm granuloma. The concordance index for the preoperative and the postoperative nomograms was 0.64 and 0.66, respectively. CONCLUSIONS: To our knowledge this represents the first use of nomograms to predict the likelihood of patency after microsurgical vasectomy reversal. These nomograms may prove useful to guide further treatment decisions.

Older age is associated with similar improvements in semen parameters and testosterone after subinguinal microsurgical varicocelectomy.

PURPOSE: It is generally accepted that men with clinically palpable varicocele are at high risk for a progressive decrease in fertility and testosterone levels with time. Varicocelectomy is thought to improve testicular function or at least halt the accelerated decrease in testicular function associated with varicocele. Substantial controversy exists as to whether varicocelectomy is effective in older men, possibly due to irreversible testicular damage or limited potential for recovery from varicocele induced damage. MATERIALS AND METHODS: We retrospectively reviewed the records of men who underwent microsurgical subinguinal varicocelectomy, as done by a single surgeon. Demographics, patient questionnaires, operative notes, charts, testosterone and semen analysis were reviewed. Patients were divided into 3 groups based on age at surgery, including less than 30, 30 to 39 and 40 years or greater. RESULTS: A total of 272 men met study inclusion criteria. In all 3 age groups we noted similar testosterone and baseline semen analysis parameters. There were significant increases in sperm concentration and total sperm count in all age groups. When analysis was restricted to men with baseline testosterone 400 ng/dl or less, there was a mean 110, 133 and 136 ng/dl increase in 21 men who were 40 years old or older, in 30 who were 30 to 39 years old and in 21 who were younger than 30 years, respectively. CONCLUSIONS: Microsurgical varicocelectomy resulted in significant increases in sperm concentration, total sperm count and testosterone in all age groups studied, including men in the fifth and sixth decades of life. Microsurgical varicocelectomy should be offered to older men for infertility and/or hypogonadism.

The emerging role of robotics in adrenal surgery.

Robotic surgery is being performed more frequently for a variety of urologic procedures. Since the first robotic adrenalectomy less than a decade ago, this modality has gained increased acceptance in the urologic community and has been employed with increased frequency in minimally invasive centers. This review evaluates the current literature on robotic adrenalectomy, its indications, as well as its advantages and limitations compared with other forms of surgical management of adrenal pathology.