Patient perceived improvement and medication resumption rates after intradetrusor onabotulinumtoxina for idiopathic urgency urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Intradetrusor onabotulinumtoxinA (BTX-A) is a third-line therapy for overactive bladder (OAB), however several gaps exist in periprocedural care. Prior studies have demonstrated BTX-A efficacy at 2-3 weeks, but there are limited data documenting when patients should begin to note symptom improvement. The primary aim of this study was to evaluate patient-reported temporal improvement in symptoms, with secondary aim to evaluate medication resumption rates, following initial BTX-A injection. METHODS: A prospective, single-arm cohort study of patients with non-neurogenic urgency incontinence undergoing initial BTX-A injection was performed. Intradetrusor 100 units BTX-A was administered in standard 20-site template. Patients discontinued OAB medication(s) at BTX-A injection and completed a daily Patient Global Impression of Improvement (PGI-I) diary for 3 weeks. Data were collected at 1 month, including final satisfaction score, medication resumption rates, and adverse outcomes. RESULTS: Fifty-one patients were included, with 25 patients (49%) actively taking an OAB medication. Median time to first improvement was 3 days, at least "much better" (PGI-I <2) was 5 days, and maximal improvement was 7 days. Twenty of 25 patients (80%) opted to remain off OAB medications at 1 month based on symptomatic improvement following injection. Adverse outcomes included urinary tract infection in three patients (6%) and symptomatic incomplete emptying requiring temporary intermittent catheterization in two patients (4%). CONCLUSIONS: Median time to first and maximal improvement was 3 and 7 days, respectively, following initial 100 units BTX-A. Eighty percent of patients on medications opted to remain off at 1 month. These data may help further counsel patient expectations following initial BTX-A therapy.

Predictive factors of PNE success in a contemporary series: A single institution experience.

PURPOSE: Peripheral nerve evaluation (PNE) permits a trial of sacral neuromodulation to determine candidates for single stage implant. Before routine fluoroscopy, PNE success rates were 40%-50% compared to approximately 77% with staged procedures. There are limited data on PNE success rates with the use of fluoroscopy and improved techniques. We evaluated a contemporary series of PNE patients to determine predictors of PNE success and persistent functional response following permanent implantation. METHODS: A retrospective review of PNE patients at a large academic center from 2015 to 2019 was performed. Patients with urgency-frequency, urge incontinence, and/or fecal incontinence (FI) were included. Rates of permanent implant after successful PNE trial and continued improvement at ≥1 month were reviewed. Multivariable logistic regression determined predictors of PNE success and continued response at follow-up. RESULTS: A total of 102 PNE patients were included. A total of 78 patients (76.5%) were PNE responders. Predictors of PNE success included younger age (p = .014), urgency incontinence (p = .021), FI (p = .017), absence of a neurologic diagnosis (p = .04), presence of bellows and toe responses (p = .038), and perineal sensation (p = .027). A total of 68 of 78 PNE responders (87.2%) maintained optimal responses at ≥1 month. Absence of a neurologic diagnosis was predictive of persistent success at follow-up (p = .013). CONCLUSIONS: This contemporary PNE series revealed screening success equivalent to a two-staged approach. A small proportion of patients demonstrate suboptimal responses following permanent implant. Conversion from testing to permanent implant may not be the ideal outcome as it may overestimate success, and evaluation for persistent improvement should be investigated further as a more reliable indicator of successful screening.

Pathological characteristics of the large renal mass: potential implication for clinical role of renal biopsy.

INTRODUCTION: To assess whether patients with a large renal mass, treated by radical nephrectomy (RN), could have benefited from preoperative renal mass biopsy (RMB). The decision to perform partial nephrectomy (PN) for an organ-confined > 4 cm renal mass can be complex. Albeit often feasible, oncologic safety of PN in this cohort is debated. Yet, a significant portion of large renal masses that undergo RN prove benign or indolent, indicating a potential role for RMB to guide nephron preservation. MATERIALS AND METHODS: We queried prospectively maintained databases from three institutions to identify patients who underwent RN for localized > 4 cm renal mass. We excluded patients with nodal or distant metastases. Multivariable analysis assessed how clinicopathologic variables, mass anatomic complexity, and patient comorbidities related to the likelihood of harboring an indolent neoplasm. RESULTS: A total of 702 patients underwent RN for localized > 4 cm renal mass (median tumor size 7.0 cm (IQR 5.5-9.2); 12.8% (n = 90) of patients were diagnosed with oncocytoma/oncocytic neoplasm (n = 27, 3.8%) or chromophobe RCC (n = 63, 9.0%). When stratified by tumor size, indolent tumors comprised 10.1% of 4-7 cm masses, 15.6% of ≥ 7-10 cm masses, and 17.3% of ≥ 10 cm tumors. Upon multivariate analysis, younger age was associated with indolent tumors (p = 0.04, OR 0.97, 95% CI 0.94-0.99). CONCLUSIONS: Approximately 1 in 8 patients with a renal mass > 4 cm harbored benign or low risk indolent potential lesions and were associated with younger age. As such, patients with large renal masses for whom risk trade-offs between PN and RN are unclear, present a unique opportunity for greater utilization of RMB.

Advances in Ambulatory Urodynamics.

PURPOSE OF REVIEW: This manuscript reviews recent technological advances in ambulatory urodynamics. RECENT FINDINGS: Ambulatory urodynamics is currently recommended by the International Continence Society as a second-line diagnostic tool in patients with nondiagnostic traditional urodynamics. Novel techniques involving telemetric monitoring are in development, which utilize catheter-free wireless systems to address several recognized shortcomings of inoffice urodynamic studies. Current research in catheter-free bladder pressure measurements involves either an intravesical, intradetrusor, or transdetrusor approach. Real-time bladder volume estimation may be performed using ultrasonography, near-infrared spectroscopy, or bladder volume conductance measurement. Ambulatory urodynamics can measure bladder function in the "real world" setting, capturing physiological bladder filling and emptying and allowing patients to reproduce the activities that may trigger their symptoms. Telemetric devices being developed represent further advances in this field and focus upon improving diagnostic capabilities, evaluating patient response to treatment, and facilitating closed-loop bladder control with neuroprosthetic integration.

Ectopic ACTH-secreting neuroendocrine tumor: a rare etiology of a pediatric solid renal mass.

Neuroendocrine tumors (NETs) are rare tumors with varying clinical presentations. We describe the case of an 11-year-old female presenting with Cushingoid features in the setting of a left-sided flank mass. Her presentation and evaluation suggested a paraneoplastic ectopic ACTH syndrome. She underwent open left radical nephrectomy and final pathology confirming a high-grade NET with nodal metastasis. Although exceedingly rare, ACTH-secreting tumors of the kidney can cause significant morbidity and mortality and so we recommend it be included in the differential diagnosis of pediatric renal masses.

Incidence and histologic features of mixed renal tumors.

BACKGROUND AND OBJECTIVES: Guidelines for management of renal cell carcinoma (RCC) incompletely address the implications of mixed renal tumor histology. We investigate the incidence of mixed renal tumors identified at renal surgery and determine the association with pathologic features. METHODS: Institutional kidney tumor database was reviewed to identify 536 patients who underwent partial or radical nephrectomy. Clinical, demographic, and pathologic data were collected. A linear fixed effects model and logistic regression determined the association of mixed tumor histology with tumor size, stage, grade, and nephrometry score. RESULTS: Three hundred and eighteen men and 218 women with a median BMI of 31 and median tumor size of 3.5 cm were included. 469 (87.5%) patients had pathologic kidney cancer with the most common histologies being clear cell carcinoma in 343 (73.1%) patients, papillary in 81 (17.3%) patients, and chromophobe in 25 (5.3%) patients. Twenty (4.3%) patients had mixed tumors on final pathology. Clear cell RCC was the most common primary pathology in patients with mixed tumor histology (n = 14, 75%) with additional primary tumor histologies included papillary and chromophobe. When considering secondary histologies, 85% were coexistent primary renal cancers while 15% (n = 3) were benign renal tumors. No association of mixed tumor histology and adverse pathologic features was noted. CONCLUSIONS: Mixed tumor histology is an uncommon entity that is not associated with adverse features in a solitary renal mass. These results are especially relevant in discussing the role of renal mass biopsy, and provide further evidence that renal sampling is a valuable tool in the appropriate clinical context.

Hypertension is the primary component of metabolic syndrome associated with pathologic features of kidney cancer.

PURPOSE: To determine whether individual and/or cumulative components of metabolic syndrome (obesity, hypertension, dyslipidemia, and hyperglycemia) are associated with pathologic features of kidney cancer. PATIENTS AND METHODS: A review of our kidney tumor database identified 462 patients who underwent partial or radical nephrectomy for renal cell carcinoma. The NCEP ATP-III criteria were used to define metabolic syndrome (MetS). Linear fixed effects modeling and ordinal logistic regression examined the relationship between MetS (individual and cumulative components) and pathologic characteristics. RESULTS: Two hundred and seventy-eight men and 184 women with a median age of 58 years, BMI of 31 kg/m2, tumor size of 3.7 cm, and nephrometry score of 6 were included. Ninety-seven (21 %) patients met NCEP ATP-III criteria for MetS. Hypertension was the only individual component of MetS associated with pathologic features of kidney cancer including increased tumor size [geometric mean ratio 1.17 (1.05-1.32), P = 0.03], higher tumor grade [OR 1.49 (1.03-2.17), P = 0.04], increasing nephrometry score [OR 1.77 (1.28-2.48), P = 0.001], and non-clear cell histology [OR 1.42 (1.01-2.02), P = 0.05]. Furthermore, combinations of MetS components were associated with increased tumor grade (P = 0.02), tumor stage (P = 0.02), nephrometry score (P ≤ 0.001), and non-clear cell histology (P = 0.02), only when hypertension was included. CONCLUSION: MetS is composed of four risk factors each implicated in carcinogenesis. We identified hypertension as the primary component associated with specific pathologic features of kidney cancer. Further studies are necessary to elucidate whether the effect of hypertension is a function of severity and/or chronicity.

Adherent perinephric fat at minimally invasive partial nephrectomy is associated with adverse peri-operative outcomes and malignant renal histology.

OBJECTIVES: To predict adherent perinephric fat (APF) at minimally invasive partial nephrectomy (MIPN) using the Mayo adhesive probability (MAP) score and to determine the impact of MAP score and APF on MIPN outcomes. PATIENTS AND METHODS: A total of 245 patients undergoing MIPN were included in the study. The presence of APF was determined through keywords in operating notes, and radiographic data were obtained from preoperative cross-sectional imaging. Posterior fat thickness was measured between the renal capsule and the posterior abdominal wall at the level of the renal vein. Perinephric stranding was graded on a 0-3 severity scale. RESULTS: The study included 123 men and 122 women, with a median age of 55 years, body mass index of 31.7, tumour size of 2.7 cm and nephrometry score of 6. The median posterior fat thickness was 1.79 cm and MAP score 2.63. In all, 26 patients (10.6%) had evidence of APF at the time of renal surgery. Factors predictive of APF included increasing age (P = 0.001), male gender (P = 0.045), perinephric stranding (P = 0.002), posterior fat thickness (P < 0.001) and MAP score (P < 0.001). APF was associated with adverse pathological and peri-operative outcomes including malignant renal histology (P = 0.04), longer operating time (P = 0.005) and greater estimated blood loss (EBL; P = 0.025). CONCLUSIONS: Specific clinical and radiographic factors predict APF at MIPN. The presence of APF is associated with adverse peri-operative outcomes including longer operating time and greater EBL. APF was also associated with renal malignancy on final pathology, but further studies are necessary to elucidate the precise underlying mechanism.

Impact of a Preoperative Safety Checklist on Perioperative Quality Outcomes and Operative Efficiency.

INTRODUCTION: Additional preoperative safety checklist requirements at Penn State Health were recently implemented on the morning of surgery. We evaluate whether this added safety policy impacted reported adverse patient safety events and institutional operating room performance indicators. METHODS: Key operating room performance indicators from fiscal years 2016 through 2019 quarter 2 were reviewed. Additional attestation requirements by the attending surgeon were implemented at start of fiscal year 2018 (July 1, 2017). All reported perioperative patient safety events during this time were reviewed with events classified into one of 8 select categories. RESULTS: Total operative case volume was 49,894 cases in fiscal years 2016 and 2017, and 36,533 in fiscal years 2018 and 2019 through quarter 2 (p <0.10). Mean operating room use was 81% in both groups (p <0.46). First case on time start rates decreased from 79.5% to 58%, respectively (p <0.0001). Mean turnover time between cases also increased from 35 minutes to 40 minutes, respectively (p <0.0001). There were 252 patient events (0.51%) in fiscal years 2016 and 2017 compared to 94 (0.26%) events in fiscal years 2018 and 2019 through quarter 2 following implementation of the surgical safety checklist (p <0.0001). The number of incomplete preoperative checklists (39 vs 14, p=0.008) and missing/incomplete patient identification bands (15 vs 2, p=0.004) were also decreased between fiscal years 2016 and 2017, and fiscal years 2018 and 2019 through quarter 2, respectively. CONCLUSIONS: A day-of-surgery safety checklist decreased the number of reported patient safety events but with a negative impact on standard metrics of operating room productivity for 18 months following implementation. Further study is necessary to determine if these effects persist over time.

Endoscopic Closure of a Large Rectovesical Fistula Following Robotic Prostatectomy.

Background: Rectovesical fistulae (RVF) are uncommon complications of pelvic surgeries and are a potential cause of significant morbidity. RVF are not typically closed endoscopically but rather require reoperative surgery of the lower pelvis with closure of tract, interposition of fat or omentum, and possible permanent bowel diversion. We present a unique case of a rectovesical fistula developing after robotic prostatectomy that was managed by multimodal multistage endoscopic therapy as an alternative to conventional operative repair. Case Presentation: A healthy 78-year-old Caucasian man underwent a robot-assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection for high-risk adenocarcinoma of the prostate. The patient's postoperative course was complicated by an unrecognized rectal injury culminating in emergent exploration, abdominal washout, creation of a diverting loop transverse colostomy, and resultant development of a large rectovesical fistula. Given the patient's hostile abdomen and desire for conservative management the fistula was managed through a combined cystoscopic and endoscopic procedure that utilized suturing and clipping to close the fistula. This novel technique was followed by a series of three subsequent endoscopic procedures that enabled us to gradually downsize the fistula over time and ultimately achieve complete closure. The patient's colostomy was eventually reversed with return of bowel continuity. Conclusion: Although uncommon, RVF are significant complications of pelvic surgery. The presence of abdominal/pelvic adhesions from previous surgeries or patient comorbidities can make open surgical repair extremely challenging or impracticable. Therefore, it is important to recognize and consider the use of endoscopic techniques as potential options for closure of rectovesical fistula in certain situations.

Incidence and preoperative predictors for major complications following radical nephroureterectomy.

BACKGROUND: Radical nephroureterectomy (RNU) is the referent standard for managing bulky, invasive, or high grade upper-tract urothelial carcinoma (UTUC). The UTUC patient population, however, generally harbor medical comorbidities thereby placing them at risk of surgical complications. This study reviews a large international cohort of RNU patients to define the risk of major complications and preoperative factors associated with their occurrence. METHODS: Patients undergoing RNU at 14 academic medical centers between 2002 and 2015 were retrospectively reviewed. Preoperative clinical, demographic, operative, and comorbidity indices were recorded. The modified Clavien-Dindo index was used to grade complications occurring within 30 days of surgery. The association between preoperative variables and major complications occurring after RNU was determined by multivariable logistic regression. RESULTS: One thousand two hundred and sixty-six patients (707 men; 559 women) with a median age of 70 years and BMI of 27 kg/m2 were included. Over three-quarters of the cohort was white, 50.1% had baseline chronic kidney disease (CKD) ≥ stage III, 22.4% had a Charlson comorbidity index (CCI) score >5, and 17.1% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2. Overall, 413 (32.6%) experienced a complication including 103 (8.1%) with a major event. Specific distribution of major complications included 49 Clavien III, 44 Clavien IV, and 10 Clavien V. On univariate analysis, patient age (P=0.006), hypertension (P=0.002), diabetes mellitus (P=0.023), CKD stage (P<0.001), American Society of Anesthesiologists (ASA) score (P=0.022), ECOG (P<0.001), and CCI (P<0.001) all were associated with major complications. On multivariate analysis, ECOG ≥2 (OR 2.38, 95% CI, 1.46-3.90), P=0.001), CCI >5 (OR 3.45, 95% CI, 1.41-8.33, P=0.007), and CKD stage ≥3 (OR 3.64, P=0.008) were independently associated with major complications. CONCLUSIONS: Major complications following RNU occurred in almost 10% of patients. Impaired preoperative performance status and baseline CKD are preoperative variables associated with these major post-surgical adverse event. These easily measurable indices warrant consideration and discussion prior to proceeding with RNU.

A preoperative nomogram to predict major complications after robot assisted partial nephrectomy (UroCCR-57 study).

OBJECTIVE: To generate a nomogram based on preoperative parameters to predict the occurrence of a major complication within 30-days of robotic partial nephrectomy. MATERIALS AND METHODS: The study included 1,342 patients with a clinically localized renal tumor who underwent robotic partial nephrectomy (RPN) between 2010 and 2017 at 7 academic centers. The primary outcome was the major complication rate. A multivariable logistic regression model was fitted to predict the risk of major complications after RPN. Model-derived coefficients were used to calculate the risk of major complications. Local regression smoothing technique was used to plot the observed rate against the predicted risk of major complications. RESULTS: In multivariate logistic regression, male gender (odds ratio [OR]: 2.93; P = 0.03), Charlson comorbidity index (OR: 1.13; P = 0.05), ECOG PS (OR: 1.66; P = 0.02), low hospital volume (P < 0.05), and high RENAL score (OR: 4.73; P = 0.01) were significant predictors of major postoperative complications. A preoperative nomogram incorporating these risk factors was constructed with an area under curve of 75%. CONCLUSIONS: Using standard preoperative variables from this multi-institutional RPN experience, we constructed and validated a nomogram to predict postoperative complications after RPN. We believe this tool can be relevant to help weighing treatment options for a more tailored management of patients with small renal masses.

Longitudinal Rupture of Distal Corpus Cavernosum With Concomitant Urethral Injury: An Uncommon Result of a Common Mechanism.

Fracture of the penis is a well-recognized yet relatively uncommon urologic event. Forceful, blunt trauma with lateral bending of the penis in an erect state typically results in a transverse rupture of the tunica albuginea of the corpus cavernosum. Longitudinal tears of the corpus cavernosum are by themselves considered infrequent. We present a rare case of a patient with longitudinal rupture of the distal corpus cavernosum with concomitant extension to the corpus spongiosum causing partial urethral disruption as a result of trauma during sexual intercourse.

Is sarcopenia and sarcopenic obesity associated with clinical and pathological outcomes in patients undergoing radical nephroureterectomy?

PURPOSE: To investigate the association between sarcopenia and sarcopenic obesity on clinical, perioperative, and oncologic outcomes in patients with upper-tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU). METHODS: Retrospective review of our institutional UTUC database was performed to identify all patients who underwent radical nephroureterectomy from 2002-2016. Skeletal Muscle Index (SMI) was measured at the L3 vertebral level and standardized according to patient height (cm2/m2). Sarcopenia was defined as<55cm2/m2 for men and<39cm2/m2 for women. Sarcopenic obesity was also assessed in patients with BMI>30kg/m2. Unadjusted logistic regression and Wilcoxon rank sum tests examined the relationship between sarcopenia and variables. RESULTS: A total of 100 patients (66 men and 34 women) with a mean age of 68 years, BMI of 30, Charlson comorbidity index of 4.0, tumor size of 3.5, and SMI of 50.8cm2/m2 were included. Furthermore, 42 patients (42%) were sarcopenic, and 18 patients (18%) had sarcopenic obesity. Median EBL was 150ml, OR duration was 322 minutes, and length of stay was 5.0 days. Sarcopenia was associated with several clinical factors including decreasing BMI, male sex, and coronary artery disease, albeit without association with any perioperative or oncologic outcomes. Sarcopenic obesity was similarly associated with several clinical variables including male sex, diabetes mellitus, hyperlipidemia, as well as increased EBL (P = 0.047) and non-bladder cancer disease relapse (P = 0.049). CONCLUSIONS: This contemporary cohort of patients undergoing RNU highlights the association of nonmodifiable risk factors with sarcopenia and disease relapse with sarcopenic obesity. Larger studies are necessary to further validate these observations.

Predicting morbidity after robotic partial nephrectomy: The effect of tumor, environment, and patient-related factors.

PURPOSE: To investigate the effect of tumor and nontumor related parameters on perioperative outcomes of robotic partial nephrectomy (RPN). PATIENTS AND METHODS: Patients who underwent RPN for a localized renal tumor at 2 institutions between June 2010 and November 2016 were reviewed. RENAL and Mayo adhesive probability (MAP) scores were calculated and information on comorbid conditions including ASA score, performance status, Charlson's comorbidity index (CCI), and history of cardiovascular disease was collected. Correlations between each variable and warm ischemia time, estimated blood loss (EBL), operative time, change in estimated glomerular filtration rate, and length of hospital stay were assessed. Logistic regression analyses were performed to identify the best predictors of overall complications, major complications, risk of conversion, and Trifecta achievement. RESULTS: A total of 500 patients were included. RENAL score was found to have a statistically significant (P<0.05) correlation with warm ischemia time, EBL, and change in estimated glomerular filtration rate. MAP score showed significant association (P<0.05) with operative time and EBL. CCI had a significant correlation (P<0.05) with length of hospital stay and postoperative complications. In multivariable analyses, MAP score as a continuous variable (OR = 7.66; P<0.001) and MAP risk group stratification (OR = 3.29; P = 0.005) were independent predictors of the risk of conversion. Major complications were significantly associated with the cardiovascular disease in both univariable (OR = 2.35; P = 0.01) and multivariable analysis (OR = 4.52, P = 0.01). Finally, the MAP score as a continuous variable was an independent factor of Trifecta achievement (OR = 0.56; P = 0.04). CONCLUSION: Patients related factors were the most important determinants of postoperative complications after RPN. RENAL and MAP scores had some influence on intraoperative parameters.

Incarcerated Right Lateral Trocar-Site Hernia as a Rare Complication of Robot-Assisted Laparoscopic Prostatectomy.

Background: Trocar-site hernia (TSH) is an uncommon complication following laparoscopic surgery and a potential cause of significant morbidity if bowel incarceration or strangulation occurs. Lateral trocar sites are intrinsically less susceptible to hernia development and traditionally do not mandate fascial closure. We present an unusual case involving an incarcerated TSH from a 12-mm right lateral port after robotic prostatectomy. Case Presentation: The patient is a 76-year-old man with localized intermediate risk, high-volume prostate cancer who underwent a robot-assisted, laparoscopic prostatectomy. He developed generalized malaise and no flatus or bowel movements at 7 days postoperatively. Cross-sectional imaging revealed small bowel dilatation with a transition point along the right lateral 12-mm trocar site. A minilaparotomy (extension of lateral port incision) confirmed incarcerated but viable small bowel. This was reduced and fascia closed without surgical resection. Conclusion: While rare, TSH is an important clinical entity to recognize after minimally invasive surgery. It is critical to properly review trocar technique and maintain a low threshold for close postoperative follow-up, if there is clinical concern for a trocar hernia.

Longitudinal Gender Disparity in Female Urology Resident Primary Authorship at an American Urological Association Sectional Meeting.

OBJECTIVE: To further evaluate the academic representation of female urology residents in the United States, we reviewed abstracts from the Mid-Atlantic American Urological Association (MA-AUA) sectional meetings to determine if the recent increase in the number of female urology residents mirrored an increase in this group's abstract authorship. MATERIALS AND METHODS: Full text abstracts from the MA-AUA meetings were analyzed from 2008 to 2014 excluding 1 joint section meeting. First-author gender was determined by querying publicly available institutional websites, social media platforms, and the U.S. News & World Report. First-author gender was indeterminable in 10 abstracts based on search criteria and these were excluded. Individual abstracts were broadly categorized based on keywords into 1 of several topics. Chi-square statistical tests examined the relationship between first-authorship gender, publication year, and abstract category. RESULTS: The number of female urology residents in the MA-AUA increased over the study period. A total of 484 abstracts were analyzed. Three hundred ninety-three abstracts (81%) included a male first-author, whereas 81 abstracts (17%) included a female first-author. Female first-authorship ranged from 13% to 25% annually. Comparison of male-to-female first-authorship was statistically significant in all years evaluated (P <.001). There was a statistically significant difference between male and female first-authorship in all topic categories (P <.01), except Education/Other (P = .56). CONCLUSION: Despite continued gains and increasing female representation in urology, these data highlight significantly fewer female first-authors at the regional Mid-Atlantic section meetings. Larger studies are necessary to identify contributing factors and further areas for improvement toward decreasing gender imbalances within the academic community.

Synchronous Primary Renal Lymphoma and Renal Cell Carcinoma: Collision Tumors in the Same Kidney.

Background: Primary renal lymphoma (PRL) is an exceptionally rare disease with under 50 reported cases in the literature. PRL is an aggressive condition that can present with nonspecific symptoms and local invasion mimicking renal cell carcinoma (RCC). We present an unusual case involving a collision tumor between PRL and RCC. Case Presentation: The patient is a 62-year-old immunosuppressed man with an incidental left renal mass on cross-sectional imaging. Renal mass biopsy confirmed clear cell type RCC. He underwent robot-assisted, laparoscopic left radical nephrectomy for presumed RCC without evidence for extrarenal disease or discernable lymphadenopathy. Final pathology revealed a collision tumor, including PRL and RCC. Conclusion: To our knowledge, this is the first reported case within the literature describing a collision tumor between PRL and RCC. Although rare, it is important to consider PRL in the differential diagnosis of a solid renal mass, especially in patients with a prior history of transplantation and/or chronic immunosuppression.

Splenogonadal fusion: a rare etiology of solid testicular mass.

A 35-year-old man presented with a painless left scrotal mass. Pathologic examination after orchiectomy revealed splenogonadal fusion. Splenogonadal fusion is an exceptionally rare, typically benign, congenital anomaly. Splenogonadal fusion should be included in the differential diagnosis of a left-sided testicular mass.