The Microbiome and Urolithiasis: Current Advancements and Future Challenges.

PURPOSE OF REVIEW: The aim of this review is to explore the effect of the microbiome on urolithiasis and explore recent advances and challenges in microbiome research for urolithiasis. RECENT FINDINGS: Lack of standardization and shortcomings in study design for urinary microbiome research on urolithiasis has hampered the generalizability of results and weakened the impact of findings on clinical practice. Important study limitations include sample heterogenicity, specimen contamination, poor culture yields, and lack of shared datasets for meta-analysis. Contrary to traditional teaching, the genitourinary tract is not a sterile environment. This urinary microbiome may influence the pathogenesis of urolithiasis, although the specific mechanisms are still currently being explored. Successful investigation will depend on consistency in study design and analysis, as well as sharing data and protocols across institutions. Developing an understanding of the relationship between the urinary microbiome and urolithiasis may lead to novel approaches to mitigate stone risk.

Commentary in response to BMC Urology publication entitled "Infection-related hospitalization following ureteroscopic stone treatment: results from a surgical collaborative".

This Commentary is in response to the BMC Urology publication entitled "Infection-related hospitalization following ureteroscopic stone treatment: Results from a surgical collaborative". This study utilized a registry with prospectively recorded standardized data elements named Reducing Operative Complications from Kidney Stones, part of the Michigan Urological Surgery Improvement Collaborative, to identify risk factors of infection-related hospitalization after ureteroscopy for stone treatment. The study included 1817 primary URS procedures for urinary stones in 11 practices in Michigan. They found 43 patients (2.4%) were hospitalized with an infection-related complication and 3 patients died during their hospitalization (0.2% mortality rate). Just over 20% of patients did not have a pre-operative urinalysis or urine culture, representing a deviation from guideline recommendations. Also, in the hospitalized group, none of the 12 patients (27.9%) who had a positive pre-operative urinalysis or urine culture received pre-operative treatment. A multivariable analysis identified higher Charleston Comorbidity Index, history of recurrent urinary tract infection, increasing stone size, intraoperative complications, and fragments left in-situ as independent risk factors for hospitalization from an infection after ureteroscopy. This commentary discusses caveats to the data as well as short-comings of the study. It also reviews more broadly infection after ureteroscopy, includes findings from similar studies, and highlights guideline recommendations to reduce infection risk.

To Dust or Not To Dust: a Systematic Review of Ureteroscopic Laser Lithotripsy Techniques.

PURPOSE OF REVIEW: This review discusses factors affecting outcomes during ureteroscopy (URS) with laser lithotripsy (LL), explores specific clinical challenges to the efficacy of URS LL, and reviews the available literature comparing the dusting and basketing approaches to URS LL. RECENT FINDINGS: Data show high stone-free rates with URS LL in all locations of the urinary tract and with all stone types and sizes. Recent data comparing LL with dusting versus basketing suggest higher rates of residual fragments with dusting but less utilization of ureteral access sheaths and potentially shorter operative times. Differences in postoperative complications, re-intervention rates, and other outcome parameters are not yet clear. Interpretation of published data is problematic due to variability in laser settings, follow-up intervals, and definitions for what constitutes stone-free status. URS has overtaken shock wave lithotripsy in the last decade as the most commonly utilized surgical approach for treating urolithiasis. Two primary strategies have emerged as the most common techniques for performing LL: dusting and basketing. There is a relative paucity of data examining the difference in these techniques as it pertains to peri-operative outcomes and overall success. We attempt to synthesize this data into evidence-based and experience-based recommendations.

Clinical analysis of the PADUA and the RENAL scoring systems for renal neoplasms: a retrospective study of 245 patients undergoing laparoscopic partial nephrectomy.

OBJECTIVE: To investigate the clinical significance of preoperative aspects and dimensions used for anatomic (PADUA) and radius exophytic/endophytic nearness anterior/posterior location (RENAL) scoring systems for renal neoplasms in patients undergoing laparoscopic partial nephrectomy. METHODS: A retrospective analysis was carried out on clinical data of 245 Chinese patients with renal neoplasms undergoing laparoscopic partial nephrectomy from June 2008 to June 2012. The perioperative complications and variables, as well as PADUA and RENAL score, were compared. RESULTS: The PADUA and RENAL scoring systems were significantly associated with percent change in estimated glomerular filtration rate (P = 0.032 and P = 0.026 respectively), whereas the RENAL scoring system was also significantly associated with warm ischemia time (P = 0.032). On multivariate analysis, both scores were able to predict percent change in estimated glomerular filtration rate (PADUA, P = 0.011; RENAL, P = 0.028). There were no significant associations between the two scoring systems assessed and the occurrence of complications or tumor stage. The correlation between PADUA classification and RENAL nephrometry score was significant (P < 0.0001). Fleiss' generalized kappa was 0.69-0.89 for the various components of the PADUA score and 0.67-0.89 for the RENAL nephrometry components. CONCLUSIONS: The PADUA classification and RENAL nephrometry score are comprehensive assessment tools for delineating renal tumor anatomy. The reproducibility of the PADUA and RENAL scores is substantial, but further research is required to evaluate its performance in more accurately predicting operative and patient-related outcomes.

Complete Intraureteral Stents Decrease Urinary Symptoms Compared with Conventional Ureteral Stents: A Systematic Review and Meta-Analysis.

Introduction: Up to 80% of stent patients report urinary discomfort, negatively impacting their daily activities and quality of life. Conventional Double-J ureteral stents (DJSs) can cause adverse kidney and bladder-related symptoms. Complete intraureteral stents (CISs) may reduce bothersome bladder symptoms by reducing foreign material in the bladder. We sought to aggregate and analyze ureteral stent symptom questionnaire (USSQ) data from the available randomized controlled trials comparing CISs with conventional ureteral stents. Methods: In February 2023, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review was performed to identify studies that evaluated the use of CISs and reported outcomes using the USSQ score. Two authors (D.E.H.-G. and G.S.) independently extracted and analyzed data using Review Manager 5.41. Heterogeneity was assessed using Higgins I2%, with values >50% considered heterogeneous and analyzed with a random effects model; otherwise, a fixed effects model was used. The results are presented as the mean difference (MD) with 95% confidence intervals (CIs). We set our significance level at p = 0.05. Results: Six randomized controlled clinical trials compared CISs with DJSs, but only five trials reported the USSQ score. Among these patients, 235 had CISs, whereas the remaining 259 had DJSs or loop-tail stents and served as controls for 494 patients. Urinary symptoms scores were lower in the CIS group (MD -5.19, 95% CI: [-5.89 to -4.50], p < 0.0001). Pain scores were also lower in the CIS group (MD -1.90 [-2.63 to -1.16] p < 0.00001). General health and work performance domains were similar between the groups. A 2.5% stent failure or migration rate requiring endoscopic intervention was reported in the CIS group compared with 0.3% in the DJS group (odds ratio 4.01 [0.96-16.76] p = 0.06). Conclusions: CISs significantly decrease urinary symptoms and pain associated with conventional indwelling ureteral stents. However, further trials are needed to determine the optimal patient selection for this type of stent.

Resident-as-Teacher: Can It Be Done With an E-Learning Module?

Background Resident-as-teacher initiatives are traditionally specialty-specific and performed in-person, limiting ability to disseminate essential teaching skills to all residents. Objective The aim of this study was to develop, implement, and evaluate a resident-as-teacher interactive e-learning module on growth mindset and coaching. Methods The module was designed and implemented between August 2022 and March 2023. It was distributed to postgraduate year (PGY) 1 residents in all specialties at a large academic institution. Completion rates, Likert ratings, and answers to 2 open-ended questions were used for assessment. Descriptive statistics and 1-way analysis of variance with Sîdák correction for multiple comparisons were performed on Likert ratings. Responses to open-ended questions were evaluated using content analysis. Results The module was completed by all 277 PGY-1 residents (100%), with the evaluation completed by 276 of 277 (99.6%) residents. Mean rating of the module's relevance to the role of resident teacher was 4.06±0.90 (5-point Likert scale), with general surgery residents rating the module less favorably compared to all specialties (3.28±1.06; P<.01; 95% CI 0.26-1.30). Open-ended comments revealed that residents most liked the delivery of relevant teaching strategies and the interactive design of the module. The most common area for suggested improvement was the addition of content such as teaching in challenging situations. Time needed for design, implementation, and evaluation was 80 hours total. Conclusions An e-learning module offers an interactive platform for teaching skills and was found to be an acceptable method of instruction for residents.

Program Directors' Perspectives on Residency Applications in the Post‒United States Medical Licensing Examination Step 1 Era: A Case for Standardized Letters of Recommendation?

INTRODUCTION: The United States Medical Licensing Examination (USMLE) Step 1 test evolved into a key metric utilized by program directors (PDs) in assessing candidates for residency. The transition to a USMLE Step 1 binary pass/fail scoring system has resulted in a loss of an important objective assessment. With national movements toward pass/fail systems for clerkship grading and trends toward abandonment of class ranking, assessing residency applications has become increasingly challenging. METHODS: The Society of Academic Urologists convened a task force to, in part, assess the perspectives of urology PDs regarding the importance of various aspects of a residency application for predicting clinical performance. An anonymous survey was disseminated to all urology PDs in the US. Perspectives on 11 potential application predictors of clinical performance and demographics were recorded. Descriptive statistics characterized PD responses. Friedman test and pairwise Wilcoxon tests were used to evaluate the relative ranks assigned to application elements by PDs. RESULTS: There was a 60.5% response rate (89/147). Letters of recommendation (LORs) were ranked as the most important predictor, with a mean rank of 2.39, median of 2 (IQR 1-3). Clerkship grades and USMLE Step 1 were comparable and ranked second. Medical school reputation ranked the lowest. There was significant subjective heterogeneity among categories; however, this was less so for LORs, which predominated as the most important factor among application elements (P < .001). CONCLUSIONS: To our knowledge, this is the largest sample size assessing PD perspectives on application factors that predict clinical performance. The second (clerkship grades) and third (USLME Step 1) most important factors moving toward binary pass/fail systems create an opportunity for actionable change to improve assessment objectivity. Our data demonstrate LORs to be the most important factor of residency applications, making a compelling argument for moving toward a standardized LOR to maximize this tool, mitigate bias, and improve interreviewer reliability.

Comparison of laparoendoscopic single site (LESS) and conventional laparoscopic donor nephrectomy at a single institution.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Most transplant centres harvest living donor kidneys via a conventional laparoscopic surgical approach. Laparoendoscopic single-site donor nephrectomy (LESS-DN) is a relatively novel minimally invasive approach that allows the surgery to be performed via a single incision. This technique may be advantageous in decreasing surgical morbidity and improving cosmetic outcomes, thus plausibly reducing the barriers to kidney donation. The study demonstrates the safety and feasibility of LESS-DN in a large consecutive series of kidney donors. Comparative analysis between LDN and LESS-DN showed that there was a significant decrease in intra-operative blood loss and allograft warm ischaemia time in the LESS-DN group, but also a significant increase in operating time. Other peri-operative outcomes were similar between the two approaches. Evaluation of the LESS-DN cases alone revealed that, the operating times did not significantly change through the course of the series. Using this outcome as a surrogate for technical difficulty suggests a relatively shallow learning curve for LESS-DN. OBJECTIVE: To present a comparative analysis of peri-operative outcomes for >200 cases of conventional laparoscopic donor nephrectomy (LDN) and laparoendoscopic single site donor nephrectomy (LESS-DN). PATIENTS AND METHODS: From 2006 to 2011, 213 donor nephrectomies were performed by two surgeons (R.E.L and W.A.M.) at a tertiary transplant centre. The approach changed from conventional LDN to LESS-DN over the course of the series. The two approaches were compared retrospectively and evaluated for differences in peri-operative outcomes. Statistical significance was assessed using Student's t-test and chi-squared analysis. RESULTS: A total of 111 patients underwent LDN and 102 patients underwent LESS-DN. Total operating time was significantly longer in the LESS-DN group (206.1 vs 181.9 min, P < 0.001), but LESS-DN resulted in less intra-operative blood loss (61.5 mL vs 85.9 mL, P < 0.001) and shorter warm ischaemia times (4.4 vs 5.0 min, P = 0.01). There were no significant differences in analgesic requirements, subjective pain scores, length of hospital stay, postoperative graft function, or donor's postoperative glomerular filtration rate between the two approaches. Complication rates were low regardless of the approach, and there were no major complications (>grade II) in the LESS-DN group. CONCLUSIONS: In experienced hands, LESS-DN results in peri-operative outcomes similar to those of conventional LDN without compromising donor safety, while providing a desirable cosmetic result. For surgeons familiar with LDN, transitioning to the LESS approach using this technique appears to have a relatively short learning curve.

Association of Residents' Medical School Reputation and Urology Residency Program Ranking.

INTRODUCTION: The Urology Residency Match process is a highly competitive application process that evaluates coursework performance, standardized examination scores, research productivity, quality of letter of recommendations, and participation in away rotations. With recent changes to medical school grading metrics, lack of in-person interviews, and examination scorings, less objective metrics are available to stratify applicants. We characterized the association of urology residents' medical school and urology residency program rankings. METHODS: Using publicly available resources, all urology residents from 2016 to 2022 were identified. Their medical school and urology residency rankings were determined from 2022 US News and World Reports and Doximity urology residency reputation. Ordinal logistic regression modeling was used to determine the association between medical school and residency rankings. RESULTS: A total of 2,306 successfully matched residents were identified from 2016 to 2022. There was positive association between urology program and medical school ranking (P < .001). Within each urology program tier over the last 7 years, there was no significant change over time in the proportions of urology residents by medical school rankings (P >0.05). A consistent proportion of matched residents from higher ranked medical schools matched into top ranked urology programs, while a consistent proportion of applicants from lower ranked medical schools matched into lower ranked urology programs across each application cycle from 2016 to 2022 (P < .05). CONCLUSIONS: We observed that over the last 7 years trainees from higher ranked medical schools were more commonly represented in top urology programs while lower ranked urology programs were overrepresented by residents from lower ranked medical schools.

Impact of the Virtual Interview Format on Urology Residency Interviews: A Survey of Program Directors.

INTRODUCTION: Our objective is to assess the impact of the virtual interview (VI) format on urology residency interviews during the COVID-19 pandemic from the perspectives of program directors (PDs). METHODS: An anonymous survey was sent to PDs of American Council for Graduate Medical Education-accredited urology residency programs. Questions were designed to evaluate how VIs affected programs' assessment of applicants, interview logistics, and overall perspectives regarding in-person and virtual interviews. RESULTS: A total of 42 PDs (31%) responded to our survey. VIs negatively affected programs' ability to assess applicants' fit with their residency program (71%), commitment to urology along with their ability to function as a resident (67%), and personality and communication skills (71%) when compared to in-person interviews. Fifty percent of PDs reported that they relied more heavily on objective metrics when ranking applicants, compared to prior years. VIs were more economical than in-person interviews for all participating programs, with each program saving an average of $3,135 in interview-related costs. Additionally, 33% of PDs reported that VIs were less time-consuming when compared to in-person interviews, with 26% of PDs reporting that they were able to interview more applicants. Only 19% of PDs reported that VIs were better than in-person interviews. Given the option, 60% of PDs intend on hosting both virtual and in-person interviews moving forward, while 9% and 31% of programs intend to exclusively host virtual and in-person interviews, respectively. CONCLUSIONS: PDs perceived VIs to be less reliable than in-person interviews for subjective evaluation of applicants; however, many PDs still desire to integrate VIs in future application cycles.

Robot-assisted laparoscopic excision of a pelvic extragastrointestinal stromal tumor: a case report and literature review.

A 61-year-old male presented with long standing urinary frequency and the sensation of incomplete emptying. Computed tomography (CT) revealed a 9.5 cm x 7.9 cm x 6.9 cm pelvic mass behind the bladder and abutting the rectum. The mass was excised using a robotic-assisted laparoscopic approach. Pathologic examination of the mass demonstrated an extragastrointestinal stromal tumor (EGIST), an extremely rare entity. To the best of our knowledge, this is the first EGIST to be found in the rectovesicular pouch of a male and the first to be resected robotically. Our case adds to the understanding of EGISTs and their possible origin and demonstrates that robotic-assisted resection of large pelvic masses can be safe and potentially curative.

Innovative Approaches to Battling Resident Burnout in a Urology Residency Program.

INTRODUCTION: Data suggest many U.S. physicians experience burnout, affecting up to 65% of U.S. urology resident physicians. We implemented a multifaceted Urology Resident Wellness Curriculum and measured its effect on burnout reported among our trainees. METHODS: We created a 5-pronged Resident Wellness Curriculum: 1) faculty-sponsored Resident Wellness Fund, 2) social groups between 1 faculty and 2-3 trainees, 3) one-on-one structured mentorship, 4) resident-organized social outings using the Resident Wellness Fund, and 5) wellness education. We administered 2 validated burnout questionnaires, the Maslach Burnout Index-Human Services Survey and the Expanded Mayo Physician Well Being Index, to our resident physicians at 4 time points, immediately before and following curriculum implementation. At study conclusion, resident physicians were asked to rank the most meaningful interventions. RESULTS: At 4 timepoints over 3 academic years, 54 completed instruments were collected from 32 unique resident physicians. Initial Maslach Burnout Index survey data indicated high levels of Depersonalization and Emotional Exhaustion with moderate levels of Personal Accomplishment. Over the study period, there was improvement in Depersonalization from high to moderate (28% decrease, p=0.04), improvement in Emotional Exhaustion from high to moderate (20% decrease, p=0.15) and preserved moderate Personal Accomplishment. The average Physician Well Being Index score decreased by 52% (p=0.006), demonstrating decreased levels of distress. Resident-organized social outings were ranked as the most meaningful intervention, with 63% of participants ranking it first. CONCLUSIONS: Rates of urology resident physician burnout were observed to be high at baseline, but improved significantly after introduction of a purposeful Resident Wellness Curriculum.

Education Time Out and Debrief: Structured Implementation of Perioperative Resident Technical Education Discussion.

BACKGROUND: We designed a model for pre- and postoperative discussions between faculty and trainees to maximize educational yield of cases and accelerate residents' technical development. We sought to study its effect on surgical education via participant perceptions and longitudinal validated performance evaluations. STUDY DESIGN: Our model included preoperative collaborative technical goal-setting, specific to the resident, or "Time Out," and immediate postoperative granular feedback guided by validated evaluation tools, or "Debrief." We encouraged routine use for two 3-month rotations. We administered surveys with Likert scale and open-ended questions before and after implementation to assess adoption and perceptions. Likert scale survey data were analyzed using Mann-Whitney U tests; reported time durations were analyzed using t-tests. At 2 time points per rotation, designated faculty evaluated participating residents using the Objective Structured Assessment of Technical Skills (OSATS) for open/endoscopic cases or Global Evaluative Assessment of Robotic Skills (GEARS). OSATS and GEARS data were analyzed using paired t-tests. RESULTS: Before our intervention, we noted significant differences between attending and resident physicians' perceptions of the frequency, importance, and challenges of perioperative educational discussions. After our intervention, these disparities resolved. In addition, participants reported significantly improved satisfaction with pre- and postoperative educational discussions (p = 0.01). Use of the model did not require increased time per participants' report. Paired GEARS/OSATS were completed for 9 trainees during the intervention, with faculty ratings revealing significant improvement in resident technical skills (p = 0.03). CONCLUSIONS: Our structured model for perioperative educational discussions, consisting of the preoperative "Education Time Out" and postoperative "Education Debrief," significantly improved faculty and resident satisfaction and was associated with measurable improvements in resident technical skills without requiring significantly more time.

Para-aortic haemangioma mimics paraganglioma on MRI.

Here, we report a case of a 70-year-old man referred for an incidentally discovered left renal lesion with peri-aortic lymphadenopathy following a CT scan for back pain. A follow-up MRI scan demonstrated a Bosniak IIF left renal cyst and a T2-hyperintense para-aortic lesion concerning for extra-adrenal paraganglioma (EAP). [131I] Metaiodobenzylguanidine scintigraphy of the para-aortic lesion and urine catecholamines were equivocal. The mass was resected via a robotic approach. Histological examination revealed a haemangioma. Haemangiomas are benign vascular tumours frequently identified on imaging of the liver. Intra-abdominal haemangiomas outside of the liver, however, are rare and may have imaging characteristics that mimic EAP.

Adrenocortical neoplasm of uncertain malignant potential with a myelolipomatous component.

Macroscopic fat inside an adrenal lesion on CT is pathognomonic for myelolipoma, a benign neoplasm. Without macroscopic fat, it can be difficult to discern the nature of an indeterminate adrenal mass on imaging. One possible diagnosis for an indeterminate lesion without macroscopic fat is an adrenal oncocytic neoplasm (AON). Despite its typical benign presentation cases of malignant AON have been reported. Patients with malignant AON are often not surgical candidates and survival for unresected disease is 20%-35%. We present the third report of an AON of uncertain malignant potential (AONUMP) associated with a macroscopic fatty component with the largest reported size and longest duration of follow-up in the literature. This report details diagnostic and therapeutic challenges posed by AONUMP. This case highlights how pathognomonic radiographical findings associated with benign myelolipoma might mask rare, potentially malignant, lipomatous tumours.

Comparison of Urologic Transfers to Academic Medical Centers: A Multi-institutional Perspective.

OBJECTIVE: To examine urologic transfers and rate of tertiary center interventions from 4 geographically distinct academic medical centers. METHODS: Four academic medical centers were selected for this study including Baylor College of Medicine, University of Alabama at Birmingham, University of Kentucky, and University of Pennsylvania Hospital (Penn). Baylor College of Medicine and Penn primarily service large metropolitan city centers and University of Kentucky and University of Alabama at Birmingham primarily service large rural populations. Transfer logs were pulled for each institution over a 2-year period, and a retrospective chart review was performed to evaluate transfer diagnosis and need for procedural management upon admission. Date of transfer, transfer diagnosis, and interventions performed during tertiary center admission were extracted from the transfer log data sets. The transfer diagnosis was categorized into 1 of 11 mutually exclusive categories. RESULTS: Overall, 984 urologic transfers were included. Sixty-nine percent (682/984) of patients were transferred to the 2 rural centers, and 30.7% (302/984) were transferred to the 2 metropolitan centers. The most common reason for transfer was nephrolithiasis at 26% (256 of 984 transfers). The overall surgical intervention rate for all urologic transfers in this study was 44.4% (437 of 984 total transfers). Rural center transfers had a lower rate of surgical intervention than metropolitan centers (42.7% vs 48.3%) as well as a markedly higher number of total transfers during the study period (682 vs 302). CONCLUSION: Given that a majority of patients did not require surgical intervention, methods for avoiding unnecessary urologic transfers are warranted.

Robotic-assisted laparoscopic resection of a primary renal neuroendocrine carcinoma.

Primary renal neuroendocrine carcinomas (RNC) are extremely rare urological neoplasms, with fewer than 100 cases reported in the literature. There are no established protocols concerning diagnosis and treatment, and there is no definitive data on prognosis. Here, we report the findings of a 54-year-old woman who presented with intermittent back pain due to a large mass, which was initially suspected to be a renal cell or upper tract urothelial carcinoma. The patient underwent robotic-assisted laparoscopic nephrectomy and lymph node dissection without complications. Pathology revealed an RNC with local metastases to para-aortic lymph nodes without evidence of another primary origin. Subsequent surveillance showed no evidence of disease until 48-month follow-up imaging revealed a liver lesion suspicious for possible metastatic cancer. This report represents the second documented usage of robot-assisted laparoscopic nephrectomy for RNC and the longest follow-up in the literature. We review the diagnosis, treatment and follow-up of patients with RNC.