Racial disparities in stage at bladder cancer diagnosis in the US Veterans Affairs healthcare system.

OBJECTIVE: To describe patient characteristics and pathological stage at bladder cancer (BCa) diagnosis in a diverse population within a national, equal-access healthcare system. METHODS: This retrospective cohort study identified 15 966 men diagnosed with BCa in the Veterans Affairs (VA) healthcare system from 2000 to 2020. The primary outcome was pathological stage at diagnosis, determined by index transurethral resection of bladder tumour. Logistic regression was used to assess the relationship between race and stage. Competing risk models tested the association between race and BCa-specific mortality with cumulative incidence estimates. RESULTS: Of 15 966 BCa patients, 12 868 (81%), 1726 (11%), 493 (3%) and 879 (6%) were White, Black, Hispanic and Other race, respectively. Black patients had significantly higher muscle-invasive bladder cancer (MIBC) rates than White patients (35% vs 32%; P = 0.009). In multivariable analysis, the odds of presenting with MIBC did not differ significantly between Black and White patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.98-1.22) or between Hispanic patients (OR 0.82, 95% CI 0.67-1.01) and White patients. Compared to White patients, Black patients had a similar risk of BCa-specific mortality (hazard ratio [HR] 0.89, 95% CI 0.75-1.06), whereas Hispanic patients had a lower risk (HR 0.56, 95% CI 0.38-0.82). CONCLUSIONS: Black patients presented with the highest rates of de novo MIBC. However, in a large, equal-access healthcare system, this did not result in a difference in BCa-specific mortality. In contrast, Hispanic patients had lower risks of MIBC and BCa-specific mortality.

National Postoperative Opioid Prescribing Rates Following Pediatric Urology Procedures Before and After the 2018 American Academy of Pediatrics Challenge to Reduce Opioid Prescribing: A Claims Database Analysis.

OBJECTIVE: To evaluate trends in opioid prescribing rates following pediatric urologic surgery. METHODS: We queried the TriNetX Research database for patients under age 18 who underwent one of seven common pediatric urology procedures. We identified the proportion of patients that received an oral opioid prescription within 5days of surgery. The primary analysis evaluated the trend in postoperative opioid prescriptions using 3-month intervals from January 2010 to December 2022. We performed an interrupted time series analysis assessing trends in opioid prescribing patterns both before and after the American Academy of Pediatrics challenge. RESULTS: Of the 81,644 pediatric urology procedures, 29,595 (36.2%) received a postoperative opioid prescription, including 29.8% of circumcisions, 25.8% of hydrocelectomies, 39.6% of hypospadias repairs, 42.7% of pyeloplasties, 42.8% of ureteral reimplants. For all procedures we observed rising rates of opioid prescribing, increasing by 0.9% per 3-month interval prior to the challenge statement release from 2010 to 2018. We observed an overall significant decrease in opioid prescribing by 2.2% per 3-month interval following the challenge statement release. Additionally, since 2018, there was a significant decrease in opioid prescribing in all of the race, ethnicity, and age cohorts. CONCLUSION: Opioid prescribing following pediatric urology procedures has sharply decreased following the 2018 American Academy of Pediatrics challenge statement which underscores the value of cross-specialty quality improvement initiatives. Nonetheless, opioid prescribing remains high with potential racial or age disparities that warrant further investigation.

Robotic management of a large mullerian duct cyst: a case report and review of surgical options.

Introduction: Mullerian duct cysts (MDCs) are a rare diagnosis in adulthood, primarily found in men aged 20 to 40 due to reproductive or urinary symptoms. Asymptomatic patients are generally observed. Treatment of symptomatic patients varies widely based on the presentation. Small cysts can be treated with transurethral and percutaneous methods due to a lower risk of damage to surrounding structures. However, larger and more complicated cysts are often treated using open or laparoscopic approaches. Case Description: Our case presents a 38-year-old male with worsening obstructive lower urinary tract symptoms and recurrent episodes of acute urinary retention. Preliminary diagnosis of a MDC was made using CT and MRI. After failing initial minimally invasive therapy, the patient was treated with definitive robotic-assisted laparoscopic surgical excision of the cyst. At the one-month follow-up, the patient reported no complications and resolution of symptoms. As shown by this case, robotic surgical methods may be used as a more precise approach, reducing the risk of damage to vessels, nerves, and structures within the abdomen and pelvis. Conclusions: Asymptomatic patients can be observed. Treatment of symptomatic patients varies widely based on the presentation. Small cysts can be treated with transurethral and percutaneous methods due to a lower risk of damage to surrounding structures. Larger, more complicated cysts are often treated using open, laparoscopic, or robotic surgical methods. More precise approaches, including robotic methods, can reduce the risk of damage to vessels, nerves, and structures within the abdomen and pelvis.

Ewing's sarcoma of the male external genitalia: a case report and review of the literature.

BACKGROUND: Ewing's sarcoma (ES) within the genitourinary tract are relatively unheard of and those within the external male genitalia are even rarer. To our knowledge, this is the first known case of primary ES within the paratesticular region in an adult. CASE PRESENTATION: We present a case of a 24-year-old man with a right sided testicular mass on examination that was initially characterized as an adenomatoid tumor on ultrasound. After the patient was lost to follow up over the course of 9 months, the testicular mass grew significantly and was excised with pathology revealing primary paratesticular Ewing's sarcoma. This rare case emphasizes the importance of elucidating between the broad differentials of paratesticular masses, including the rare presentation of primary ES and adds a review of the literature of ES in the external male genitalia. CONCLUSIONS: Rare differentials such as this case should be considered in patients with paratesticular masses. Further diagnostic and management algorithms for extraosseous Ewing Sarcoma, particularly in the adult population, are warranted.

Robotic pyelolithotomy in a solitary pelvic kidney complicated with fulminant Clostridium difficile: a case report.

BACKGROUND: Robotic-assisted surgeries have gradually become the standard of care for many procedures, especially in the field of urology. Despite the widespread use of robotic assistance in surgeries, data on its postoperative complications are extremely limited. We detail a rare presentation of fulminant Clostridium difficile colitis requiring surgical intervention in a patient with a solitary ectopic pelvic kidney who underwent a robotic-assisted pyelolithotomy. Highlights of the most recent management recommendations for C. difficile infection are also presented. CASE PRESENTATION: A 26-year-old Caucasian woman who underwent a robot-assisted pyelolithotomy of a pelvic kidney developed tachycardia, leukocytosis, and severe diarrhea 2 days following surgery. Because of her long history of antibiotic use, her severe symptoms were concerning for C. difficile colitis. This was confirmed by a C. difficile toxin test and a computed tomography scan. She was given recommended antibiotics, but her condition progressively deteriorated. The patient developed fulminant colitis and toxic megacolon, for which she underwent an exploratory laparotomy with subtotal abdominal colectomy and ileostomy creation on the twelfth day of her hospitalization. She fully recovered and was discharged 3 weeks after her subtotal colectomy. CONCLUSION: Although robotic surgeries have been shown to have several advantages, risk of postsurgical complications remains. We present a rare case of fulminant C. difficile colitis that complicated a robotic-assisted pyelolithotomy. Active prevention, early detection, and optimization of management are essential to preventing unfavorable outcomes.

Geographic distribution of racial differences in mortality in muscle-invasive bladder cancer patients: an opportunity for improvement.

OBJECTIVES: To determine the geographic distribution of muscle-invasive bladder cancer mortality according to race in the United States (US). African Americans (AAs) have up to two times the risk of bladder cancer mortality compared to Caucasians. Bladder cancer mortality increases exponentially once it invades the muscle. Geographic heterogeneity in bladder cancer mortality according to race remains to be determined. DESIGN: Analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data for 6,044 patients aged 66-85 diagnosed with clinical stage T2-T4 N0M0 bladder cancer from 1 January 2002 to 31 December 2011. Fine and Gray-competing risks regression models were used to assess the association of race with bladder cancer-specific mortality (BCSM) according to tumor registry. RESULTS: Out of 6,044 patients, 5,408 (89.5%) were Caucasian, 352 (5.82%) were non-Hispanic AA, 85 (1.4%) were Hispanic, and 199 (3.29%) were other. Of the 18 registries, AAs with bladder cancer were largely concentrated in Louisiana (19%), New Jersey (17.9%), and Georgia (17.6%). New Jersey was the only registry where AAs had increased risk of BCSM than Caucasians and only for stage T2 disease: (AHR, 1.74; 95% CI 1.22-2.47, p = 0.002). According to treatment, AAs in New Jersey had worse BCSM than Caucasians when they underwent radical cystectomy (AHR, 2.05; 95% CI 1.26-3.35, p = 0.0039) and radiotherapy or chemotherapy alone (AHR, 1.55; 95% CI 1.03-2.35, p = 0.0367). CONCLUSIONS: We observed geographic variation in bladder cancer mortality which impacted only one registry with one of the largest population of AAs. These findings support further investigation into the social determinants of race (i.e., socioeconomic status and distance to healthcare facility) and culturally centered healthcare decision making which may drive these results.

Treatment Patterns, Outcomes, and Costs Associated With Localized Upper Tract Urothelial Carcinoma.

Background: Upper tract urothelial carcinoma (UTUC) is a heterogeneous disease that presents a clinical management challenge for the urologic surgeon. We assessed treatment patterns, costs, and survival outcomes among patients with nonmetastatic UTUC. Methods: We identified 4114 patients diagnosed with nonmetastatic UTUC from 2004 to 2013 in the Survival Epidemiology, and End Results-Medicare population-based database. Patients were stratified into low- or high-risk disease groups. Median total costs from 30 days prior to diagnosis through 365 days after diagnosis were compared between groups. Overall and cancer-specific survival were evaluated using Cox proportional hazards regression. All statistical tests were 2-sided. Results: After risk stratification, 1027 (24.9%) and 3087 (75.0%) patients were classified into low- vs high-risk UTUC groups. Most patients underwent at least 1 surgical intervention (95.1%); 68.4% underwent at least 1 endoscopic intervention. Patients diagnosed with high- vs low-risk UTUC were more likely to undergo nephroureterectomy (83.6% vs 72.0%; P < .001); few patients with low-risk disease were exclusively managed endoscopically (16.9%). At 365 days after diagnosis, costs of care for high- vs low-risk UTUC were statistically significantly higher ($108 520 vs $91 233; median difference $16 704, 95% confidence interval [CI] = $11 619 to $21 778; P < .001). Those with high-risk UTUC had worse cancer-specific and overall survival compared with patients with low-risk UTUC (cancer-specific survival hazard ratio [HR] = 4.14, 95% CI = 3.19 to 5.37; overall survival HR = 1.78, 95% CI = 1.62 to 1.96). Conclusions: UTUC continues to be managed primarily with nephroureterectomy, regardless of risk stratification, and patients with high-risk UTUC have worse overall and cancer-specific survival. Substantial costs are associated with management of low- and high-risk UTUC, with the latter being more costly up to 1 year from diagnosis.

The impact of the social construct of race on outcomes among bacille Calmette-Guérin-treated patients with high-risk non-muscle-invasive bladder cancer in an equal-access setting.

BACKGROUND: The objective of this study was to describe bladder cancer outcomes as a function of race among patients with high-risk non-muscle-invasive bladder cancer (NMIBC) in an equal-access setting. METHODS: A total of 412 patients with high-risk NMIBC who received bacille Calmette-Guérin (BCG) from January 1, 2010, to December 31, 2015, were assessed. The authors used the Kaplan-Meier method to estimate event-free survival and Cox regression to determine the association between race and recurrence, progression, disease-specific, and overall survival outcomes. RESULTS: A total of 372 patients who had complete data were included in the analysis; 48 (13%) and 324 (87%) were Black and White, respectively. There was no difference in age, sex, smoking status, or Charlson Comorbidity Index by race. White patients had a higher socioeconomic status with a greater percentage of patients living above the poverty level in comparison with Black patients (median, 85% vs 77%; P < .001). A total of 360 patients (97%) received adequate induction BCG, and 145 patients (39%) received adequate maintenance BCG therapy. There was no significant difference in rates of adequate induction or maintenance BCG therapy according to race. There was no significant difference in recurrence (hazard ratio [HR], 1.53; 95% confidence interval [CI], 0.64-3.63), progression (HR, 0.77; 95% CI, 0.33-1.82), bladder cancer-specific survival (HR, 1.01; 95% CI, 0.30-3.46), or overall survival (HR, 0.97; 95% CI, 0.56-1.66) according to Black race versus White race. CONCLUSIONS: In this small study from an equal-access setting, there was no difference in the receipt of BCG or any differences in bladder cancer outcomes according to race.

Non-invasive peripheral focused ultrasound neuromodulation of the celiac plexus ameliorates symptoms in a rat model of inflammatory bowel disease.

NEW FINDINGS: What is the central question of this study? Does peripheral non-invasive focused ultrasound targeted to the celiac plexus improve inflammatory bowel disease? What is the main finding and its importance? Peripheral non-invasive focused ultrasound targeted to the celiac plexus in a rat model of ulcerative colitis improved stool consistency and reduced stool bloodiness, which coincided with a longer and healthier colon than in animals without focused ultrasound treatment. The findings suggest that this novel neuromodulatory technology could serve as a plausible therapeutic approach for improving symptoms of inflammatory bowel disease. ABSTRACT: Individuals suffering from inflammatory bowel disease (IBD) experience significantly diminished quality of life. Here, we aim to stimulate the celiac plexus with non-invasive peripheral focused ultrasound (FUS) to modulate the enteric cholinergic anti-inflammatory pathway. This approach may have clinical utility as an efficacious IBD treatment given the non-invasive and targeted nature of this therapy. We employed the dextran sodium sulfate (DSS) model of colitis, administering lower (5%) and higher (7%) doses to rats in drinking water. FUS on the celiac plexus administered twice a day for 12 consecutive days to rats with severe IBD improved stool consistency scores from 2.2 ± 1 to 1.0 ± 0.0 with peak efficacy on day 5 and maximum reduction in gross bleeding scores from 1.8 ± 0.8 to 0.8 ± 0.8 on day 6. Similar improvements were seen in animals in the low dose DSS group, who received FUS only once daily for 12 days. Moreover, animals in the high dose DSS group receiving FUS twice daily maintained colon length (17.7 ± 2.5 cm), while rats drinking DSS without FUS exhibited marked damage and shortening of the colon (13.8 ± 0.6 cm) as expected. Inflammatory cytokines such as interleukin (IL)-1ß, IL-6, IL-17, tumour necrosis factor-α and interferon-γ were reduced with DSS but coincided with control levels after FUS, which is plausibly due to a loss of colon crypts in the former and healthier crypts in the latter. Lastly, overall, these results suggest non-invasive FUS of peripheral ganglion can deliver precision therapy to improve IBD symptomology.

Invasive Thymoma with Right Upper Lobe Endobronchial Lesion and Autoimmune Enteropathy.

Thymomas are slow-growing neoplasia arising from the epithelial cells of the thymus that usually present with respiratory symptoms, superior vena cava syndrome, or parathymic syndromes. Approximately 30% of thymomas develop myasthenia gravis. An additional 5% of patients with thymomas have other systemic syndromes, including rheumatoid arthritis, thyroiditis, red cell aplasia, systemic lupus erythematosus, and Cushing syndrome. Rarely, patients can present with diarrhea due to thymoma-associated autoimmune gastrointestinal pathologies that include Good syndrome (acquired hypogammaglobulinemia), thymoma- associated multiorgan autoimmunity, and autoimmune enteropathy. We present an uncommon and interesting case of an invasive metastatic thymoma with right upper lobe endobronchial lesion and autoimmune enteropathy in a 27-year-old female. The novelty of this case lay in the findings of extensive metastatic thymoma with right upper lobe endobronchial disease and autoimmune diarrhea.

Routine preoperative endoscopy in patients undergoing bariatric surgery.

BACKGROUND: The role of routine preoperative endoscopy before primary weight loss surgery remains controversial. OBJECTIVE: We reviewed our experience to determine the frequency of abnormal findings in patients undergoing routine preoperative endoscopy before bariatric surgery. SETTING: A tertiary level, academic-affiliated bariatric surgery practice. METHODS: A retrospective chart review was performed between July 2014 and June 2016 of patients undergoing routine preoperative endoscopy before primary bariatric surgery. Variables evaluated included preendoscopy symptoms, planned bariatric surgical procedure, abnormal findings on endoscopy, and changes in planned bariatric surgical procedure after endoscopy. RESULTS: A total of 631 patients met inclusion criteria. Of patients, 72% (457) were female. The median age was 44 (interquartile range 36-55). The median body mass index was 46 (interquartile range 42-51). Most patients had no preendoscopy clinical symptoms (61.3%). The most frequent abnormal findings included esophagitis (26.5%), hiatal hernia (27.1%), gastric ulcer (4.9%), and biopsy-proven Barrett's esophagus (4.6%). Although patients with preoperative symptoms were more likely to have abnormal findings on endoscopy, there were no significant differences in rates of Barrett's esophagus in patients with (5.3%) or without (4.1%) symptoms. Of the total cohort, 18.4% had a change in their planned operation after endoscopy results. CONCLUSION: The findings in our large series suggest selective screening in symptomatic patients only may lead to failure of discovery of foregut pathology that should prompt consideration for changes in the planned bariatric surgical procedure. Further study is necessary to see if our findings have broad applicability.

An Update on Minimally Invasive Surgery for Benign Prostatic Hyperplasia: Techniques, Risks, and Efficacy.

Benign prostatic hyperplasia (BPH), a common cause of lower urinary tract symptoms in the elderly male population, has conventionally treated by transurethral resection of the prostate (TURP). During recent years, newer minimally invasive therapies (MITs) have entered the playing field and challenged TURP with their convenience, lack of sexual side effects, and overall safety. The present paper provides an update on the more heavily studied and most recent MITs, analyzing their mechanism of action, tolerability, and efficacy in clinical practice. Particularly, robust clinical data have propelled UroLift and Rezuum to the forefront in the armamentarium of minimally invasive BPH treatment. Newer mechanical therapies such as the temporary implantable nitinol device, ClearRing, ZenFlow Spring, and Butterfly are appealing options as they forego cutting, ablation, heating, or removing prostatic tissue. It is obvious that there is wide variation in the degree of clinical readiness of each modality and only time and long-term, multicenter studies will decide which of these therapies are accepted by the patient and urologist.

Techniques for Optimizing Surgical Scars, Part 3: Erythema, Hyperpigmentation, and Hypopigmentation.

Surgical management of benign or malignant cutaneous tumors may result in noticeable scars that are of great concern to patients, regardless of sex, age, or ethnicity. Techniques to optimize surgical scars are discussed in this three-part review. Part 3 focuses on scar revision for erythema, hyperpigmentation, and hypopigmentation. Scar revision options for erythematous scars include moist exposed burn ointment (MEBO), onion extract, silicone, methyl aminolevulinate-photodynamic therapy (MAL-PDT), pulsed dye laser, intense pulsed light (IPL), and nonablative fractional lasers. Hyperpigmented scars may be treated with tyrosinase inhibitors, IPL, and nonablative fractional lasers. Hypopigmented scars may be treated with needle dermabrasion, medical tattoos, autologous cell transplantation, prostaglandin analogues, retinoids, calcineurin inhibitors, excimer laser, and nonablative fractional lasers.

Techniques for Optimizing Surgical Scars, Part 2: Hypertrophic Scars and Keloids.

Surgical management of benign or malignant cutaneous tumors may result in noticeable scars that are of great concern to patients, regardless of sex, age, or ethnicity. Techniques to optimize surgical scars are discussed in this three-part review. Part 2 focuses on scar revision for hypertrophic and keloids scars. Scar revision options for hypertrophic and keloid scars include corticosteroids, bleomycin, fluorouracil, verapamil, avotermin, hydrogel scaffold, nonablative fractional lasers, ablative and fractional ablative lasers, pulsed dye laser (PDL), flurandrenolide tape, imiquimod, onion extract, silicone, and scar massage.

Techniques for Optimizing Surgical Scars, Part 1: Wound Healing and Depressed/Atrophic Scars.

Surgical management of benign or malignant cutaneous tumors may result in noticeable scars that are of great concern to patients, regardless of sex, age, or ethnicity. Techniques to optimize surgical scars are discussed in this three-part review. In part 1, an overview of the importance of preoperative planning, intraoperative technique, and pathophysiology of wound healing is followed by a discussion of scar revision options for depressed/atrophic scars. Scar revision options for these scars include dermabrasion, needling and subcision, punch excision and grafts, fillers, nonablative fractional lasers, ablative and fractional ablative lasers, and platelet-rich plasma (PRP). This review examines the scar revision outcomes for each technique, discusses potential adverse effects, and highlights the importance of further studies to optimize postsurgical scar revision.