The Balance between Open and Robotic Training among Graduating Urology Residents-Does Surgical Technique Need Monitoring?

PURPOSE: A minimum number of index procedures is required for graduation. Without thresholds for surgical technique, it is unclear if robotic and open learning is balanced. We assessed the distribution of robotic and open surgeries performed by residents upon graduation. MATERIALS AND METHODS: Voluntary Accreditation Council for Graduate Medical Education resident case logs from 11 institutions were de-identified and trends in robotic and open major surgeries were compared using Wilcoxon rank sum and 2-sample t-tests. RESULTS: A total of 89,199 major cases were recorded by 209 graduates from 2011 to 2017. The median proportion of robotic cases increased from 2011 to 2017 in reconstruction (4.7% to 15.2%), oncology (27.5% to 54.2%) and pediatrics (0% to 10.9%) (all values p <0.001). Robotic and open cases remained most divergent in reconstruction, with a median of 12 robotic (IQR 9-19) to 70 open cases (IQR 55-106) being performed by residents in 2017. Similar observations occurred in pediatrics. In oncology the number of robotic procedures superseded that of open in 2016 and rose to a median of 148 robotic (IQR 108-214) to 121 open cases (IQR 90-169) in 2017, with the driver being robotic prostatectomy. Substantial differences in surgical technique were observed between institutions and among graduates from the same institution. CONCLUSIONS: Although robotic volume is increasing, the balance of surgical technique and the pace of change differ in reconstruction, oncology and pediatrics, as well as among individual institutions and graduates themselves. This raises questions about whether more specific guidelines are needed to ensure equity and standardization in training.

Identifying appropriate patients for early salvage radiotherapy after prostatectomy.

PURPOSE: It remains unclear whether relapsed prostate specific antigen at postprostatectomy salvage radiotherapy impacts outcomes as long it is 1.0 ng/ml or less. MATERIALS AND METHODS: We performed a retrospective cohort study of 197 patients treated with salvage radiotherapy in the setting of detectable relapsed prostate specific antigen 1.0 ng/ml or less. Patients were excluded from analysis if they had lymph node involvement or received androgen deprivation therapy. Freedom from prostate specific antigen progression after salvage radiotherapy was analyzed by a Cox regression model. RESULTS: Median relapsed prostate specific antigen was 0.33 ng/ml (range 0.07 to 1.0). There was 86% freedom from prostate specific antigen progression at a median followup of 52 months. Relapsed prostate specific antigen (HR 1.9, p = 0.004), Gleason score 8-10 (HR 5.2, p <0.001) and negative margin status (HR 2.0, p = 0.02) were independently associated with an increased risk of prostate specific antigen progression after salvage radiotherapy. We identified interaction between relapsed prostate specific antigen and Gleason score (p = 0.04) but not margin status. A significant association was noted between higher relapsed prostate specific antigen and prostate specific antigen progression after salvage radiotherapy in patients with Gleason score 8-10 but not 7 or less. In patients with Gleason score 8-10 the rate of freedom from prostate specific antigen progression at 53 months was 77% vs 26% when salvage radiotherapy was initiated at a relapsed prostate specific antigen of 0.33 or less vs 0.34 to 1.0 ng/ml (log rank p = 0.003). CONCLUSIONS: Different relapsed prostate specific antigen thresholds for unsuccessful salvage radiotherapy may exist based on Gleason score. These data suggest that patients with Gleason score 8-10 should be offered salvage radiotherapy at the earliest detectable relapsed prostate specific antigen, even 0.33 ng/ml or less. Those with Gleason score 7 or less may have the opportunity to be followed with serial prostate specific antigen measurements to improve risk stratification, and delay and/or avoid the potential toxicity of salvage radiotherapy.

Race and Age-Related PSA Testing Disparities in Spinal Cord Injured Men: Analysis of National Veterans Health Administration Data.

Background: Prostate-specific antigen (PSA) testing remains controversial due to the debate about overdetection and overtreatment. Given the lack of published data regarding PSA testing rates in the population with spinal cord injury (SCI) within the US Department of Veterans Affairs (VA), there is concern for potential disparities and overtesting in this patient population. In this study, we sought to identify and evaluate national PSA testing rates in veterans with SCI. Methods: Using the VA Informatics and Computing Infrastructure Corporate Data Warehouse, we extracted PSA testing data for all individuals with a diagnosis of SCI. Testing rates were calculated, analyzed by race and age, and stratified according to published American Urological Association guideline groupings for PSA testing. Results: We identified 45,274 veterans at 129 VA medical centers with a diagnosis of SCI who had records of PSA testing in 2000 through 2017. Veterans who were only tested prior to SCI diagnosis were excluded. Final cohort data analysis included 37,243 veterans who cumulatively underwent 261,125 post-SCI PSA tests during the given time frame. Significant differences were found between African American veterans and other races veterans for all age groups (0.47 vs 0.46 tests per year, respectively, aged ≤ 39 years; 0.83 vs 0.77 tests per year, respectively, aged 40-54 years; 1.04 vs 1.00 tests per year, respectively, aged 55-69 years; and 1.08 vs 0.90 tests per year, respectively, aged ≥ 70 years; P < .001). Conclusions: Significant differences exist in rates of PSA testing in persons with SCI based on age and race. High rates of testing were found in all age groups, especially for African American veterans aged ≥ 70 years.

Bilateral Ureteral Obstruction Secondary to Papillary Necrosis From Non-Steroidal Anti-Inflammatory Drug Use in an Adult Patient.

Prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs) is known to cause renal papillary necrosis and, in rare cases, can cause sloughing of renal papillae with subsequent ureteral obstruction. We report the first documented case of an adult patient presenting with bilateral ureteral obstructions, secondary to bilateral papillary necrosis from chronic NSAID use. He subsequently underwent bilateral ureteral stent placement with rapid recovery of renal function.

Impact of Perioperative Blood Transfusions on the Outcomes of Patients Undergoing Kidney Cancer Surgery: A Systematic Review and Pooled Analysis.

The aim of the present study is to systematically review current evidence regarding the association between perioperative blood transfusions (PBT) and oncological outcomes of patients with renal cell carcinoma undergoing nephrectomy procedures. A computerized bibliographic search was conducted to identify pertinent studies. The Population, Intervention, Comparator, Outcome (PICO) study design approach was used to define study eligibility according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria. Only 7 studies were deemed fully eligible for analysis. Most series included both open and laparoscopic cases. The rate of PBT varied between 9.6% and 76.6%, and the median number of transfused units was 2 for most of the studies. At pooled analysis, a statistically significant association was found between PBT and disease recurrence (HR, 1.79; 95% CI, 1.32-2.41; P < .001), cancer-specific mortality (HR, 1.62; 95% CI, 1.29-2.05; P ≤ .001), and all-cause mortality (HR, 1.45; 95% CI, 1.25-1.69; P < .001). Current evidence suggests that indeed the use of PBT may be associated with worse oncologic outcomes in patients with renal cell carcinoma undergoing nephrectomy procedures. Although presents findings should be interpreted within the intrinsic limitations of this type of pooled analysis, they emphasize the need for evidence-based strategies to minimize the use of PBT during kidney cancer surgery.

The role of surgery in the management of metastatic kidney cancer: an evidence-based collaborative review.

The current manuscript aims to provide an up to date evidence based analysis on the status of surgery in the metastatic renal cell carcinoma setting. It includes the role of surgery in the primary tumor as well as recent perspective on the surgical management of metastatic disease.

A Phase II Study to Prevent Radiation-induced Rectal Injury With Lovastatin.

PURPOSE: Physician reported symptomatic late rectal injury occurs in about 5% to 25% of patients treated with radiation therapy for prostate cancer, depending on the treatment technique. Patients, however, report clinically meaningful declines in bowel/rectal function regardless of the technique used. Lovastatin has been shown to protect mice from late radiation injury. This study was designed to determine if lovastatin might reduce the incidence of late rectal injury in patients receiving radiation therapy for prostate cancer. MATERIALS AND METHODS: Patients with adenocarcinoma of the prostate receiving radiotherapy with curative intent were eligible. A portion of the rectum had to receive at least 60 Gy. Gastrointestinal functioning was assessed using both physician-reported and patient-reported instruments at baseline and at prescribed intervals during and after treatment. Lovastatin (20 to 80 mg/d) was started on day 1 of radiation and continued for 12 months. Patients were followed for an additional 12 months. The primary endpoint was physician-reported rectal toxicity ≥grade 2 during the first 2 years after treatment. RESULTS: A total of 20/53 (38%) patients developed grade 2 or higher toxicity during the 2-year follow-up period. Seventeen patients had 1 or more unresolved gastrointestinal symptom at the end of 2 years, 3 (6%) of which were grade 2 and none were of higher grade. CONCLUSIONS: The primary endpoint of the study was not met. Lovastatin, as administered in this trial, did not reduce the incidence of grade 2 or higher rectal toxicity compared with historical controls.

Prophylactic radical cystectomy for the management of keratinizing squamous metaplasia of the bladder in a man with tetraplegia.

BACKGROUND/OBJECTIVE: To report a case of keratinizing squamous metaplasia of the bladder treated with radical cystectomy. DESIGN: Case report and discussion of management options. METHODS: Keratinizing squamous metaplasia of the bladder is a rare entity that can result from chronic irritative stimuli involving the bladder. It is considered a premalignant condition associated with invasive squamous cell carcinoma. A case report is presented describing the diagnosis and management of keratinizing squamous metaplasia of the bladder in a tetraplegic man with a chronic indwelling urinary catheter. RESULTS: Radical cystectomy with an Indiana continent reservoir was performed after cystoscopy with biopsy confirmed keratinizing squamous metaplasia. Final pathology revealed focal erosion and diffuse keratinizing squamous metaplasia of the bladder with prostatic adenocarcinoma as an incidental finding. CONCLUSIONS: Patients with spinal cord injury who use indwelling catheters for bladder management are at higher risk of developing keratinizing squamous metaplasia. Surveillance for early detection of this entity is recommended. Prophylactic cystectomy is sometimes warranted; however, observation and frequent cystoscopic surveillance to identify potential malignant transformation can be an alternative strategy. An interdisciplinary approach is recommended before consideration of bladder resection.

Prostate Cancer in Transgender Women: Incidence, Etiopathogenesis, and Management Challenges.

OBJECTIVE: To critically analyze the available evidence regarding the incidence, etiopathogenesis, and management of prostate cancer (CaP) in transgender women. In addition, this article aims to present a recent case report of a transgender woman with a unique presentation at the author's institution. MATERIALS AND METHODS: An electronic nonsystematic literature search was performed to identify pertinent studies. PubMed search engine was queried by using the following search terms: "prostate cancer," "male to female transsexual," "transgender patient," "androgen + prostate cancer," "estrogen therapy + prostate cancer," and "health care barrier." In addition, a clinical case managed at our institution was reviewed and critically discussed. RESULTS: Including our case, there have been only 10 documented cases of CaP in transgender women. Additionally, an emerging body of literature has questioned the role of androgens in the development of CaP and suggested that estrogen therapy may not be as protective as initially thought. Therefore, the current evidence suggests that the transgender woman should be screened for CaP the same as a nontransgender men. Barriers to care in the transgender female population include accessing resources, medical knowledge deficits, ethics of transition-related medical care, diagnosing vs pathologizing transgender patients, financial restrictions of the patient, and health system determinants. CONCLUSION: Although rare, CaP in transgender women has been documented. Both the mechanism and the impact of receiving a bilateral orchiectomy on disease development are unclear. Future study is needed to examine these factors, and to further shape the treatment and screening regimen for these patients.