When virtual becomes reality: short term impressions of a two-week virtual urology sub-internship program.

INTRODUCTION: The COVID-19 pandemic disrupted medical student education and posed a unique challenge for educators, especially for surgical clerkships. In response to COVID-19 rotation restrictions, we implemented a virtual urologic surgery sub-internship program and evaluated medical student impressions of the experience. MATERIALS AND METHODS: A two-week urology curriculum was created with content delivered by interactive videoconferencing. The curriculum included synchronous and individual learning with live patient clinical experiences in the outpatient clinic and operating room, lectures, departmental conferences, a suture lab, self-reflective writing exercises, and an oral presentation. Student impressions were assessed with an exit survey. Descriptive statistics were utilized to evaluate the 5-point Likert scale responses. RESULTS: A total of 40 students applied, and 18 were selected for 1 of 5 two-week rotation blocks. All students successfully passed the rotation. Of the 18 students who participated, 16 (88.9%) completed the exit survey. The overall experience was rated as "strongly positive" by 14 of 16 (87.5%) students. The learning experience was rated as 4.75 (0.45) (average (SD)). The rotation positively impacted our virtual students' plan to apply to this residency program (mean 4.81 (0.54)). All students reported they would recommend this rotation to a fellow student, and feedback regarding the self-reflection activities was positive. CONCLUSIONS: We successfully implemented a two-week virtual urology sub-internship rotation with a wide variety of clinical and educational experiences. The rotation was well received by our medical students. This is a unique experience in urology that can easily be implemented by other surgical sub-specialty programs in the future.

The Feasibility of a Health Care Application in the Treatment of Patients Undergoing Radical Cystectomy.

PURPOSE: Patients who undergo radical cystectomy of bladder cancer are at high risk for complications and hospital readmissions. Studies indicate insufficient preoperative education and perioperative monitoring. The aim of this study was to demonstrate the feasibility of implementing a health care application to provide more patient education and more thorough monitoring perioperatively. MATERIALS AND METHODS: Participants with home Wi-Fi access who were undergoing radical cystectomy were recruited for this pilot trial. Each subject was provided a tablet preloaded with the m.Care (LifeScience Technologies, Leawood, Kansas) health care application, an accelerometer and vital sign equipment. Participants were asked to watch educational videos, use the provided accelerometer and perform vital sign monitoring. RESULTS: In 1 year 20 participants enrolled in the study and 15 completed it. The most frequently viewed videos were "Ileal Conduit versus Neobladder" and "Comprehensive Care Pathway." All participants used the accelerometer and 60% kept up with syncing the data regularly. The average step count preoperatively was 5,679 reflecting a sedentary population. Step counts decreased during the inpatient stay (1,351 steps) and trended toward baseline during the postoperative period (3,156 steps). Vital signs were recorded on 85% of assigned days and generated 33 triggers for intervention. While most triggers led to repeat assessment, education and encouragement, 4 participants underwent outpatient treatment, including cultures, intravenous fluids, antibiotics or dronabinol prescription, without the need for hospital readmission. CONCLUSIONS: Providing more education and monitoring perioperatively is feasible using a health care application. Testing is warranted to determine the extent to which implementation will improve patient triaging and reduce readmissions.

Perioperative Immunonutrition Modulates Inflammatory Response after Radical Cystectomy: Results of a Pilot Randomized Controlled Clinical Trial.

PURPOSE: Poor preoperative nutritional status is associated with a higher complication rate after radical cystectomy in patients with bladder cancer. Given the short interval between diagnosis and radical cystectomy, we compared the effect of short-term specialized immunonutrition to that of a standard oral nutritional supplement on the acute inflammatory response and arginine status in patients treated with radical cystectomy. MATERIALS AND METHODS: In this prospective, randomized study in 29 men 14 received specialized immunonutrition and 15 received oral nutritional supplement. Each group drank 3 cartons per day for 5 days before and 5 days after radical cystectomy. The Th1-Th2 balance, plasma interleukin-6 and plasma amino acids were measured at baseline, intraoperatively and on postoperative days 2, 14 and 30. Body composition was measured by dual energy x-ray absorptiometry at baseline and on postoperative days 14 and 30. Differences in outcomes were assessed using the generalized linear mixed model. RESULTS: In the specialized immunonutrition group there was a 54.3% average increase in the Th1-Th2 balance according to the tumor necrosis factor-α-to-interleukin-13 ratio from baseline to intraoperative day, representing a shift toward a Th1 response. In the oral nutritional supplement group the Th1-Th2 balance decreased 4.8%. The change in the Th1-Th2 balance between the specialized immunonutrition and oral nutritional supplement groups significantly differed (p <0.027). Plasma interleukin-6 was 42.8% lower in the specialized immunonutrition group compared to the oral nutritional supplement group on postoperative day 2 (p = 0.020). In the specialized immunonutrition group plasma arginine was maintained from baseline to postoperative day 2 and yet the oral nutritional supplement group showed a 26.3% reduction from baseline to postoperative day 2 (p = 0.0003). The change in appendicular muscle loss between the groups was not statistically significant. CONCLUSIONS: Th1-to-Th2 ratios, peak interleukin-6 levels and plasma arginine suggest that consuming specialized immunonutrition counteracts the disrupted T-helper balance, lowers the inflammatory response and prevents arginine depletion due to radical cystectomy.

Radiation-induced complex anterior urinary fistulation for prostate cancer: a retrospective multicenter study from the Trauma and Urologic Reconstruction Network of Surgeons (TURNS).

PURPOSE: To characterize anterior urinary fistulae following radiotherapy for prostate cancer. METHODS: Over 10 years, 31 men were identified to have an anterior urinary fistula. A retrospective database was created to evaluate patient demographics, presentation, diagnostic procedures, operative interventions, outcomes, and complications. Comparisons between men who underwent cystectomy versus bladder-sparing surgeries were performed. RESULTS: At a median age of 73 (interquartile range (IQR) 68.5, 79) years, presenting symptoms included as follows: pubic pain (19/31, 61%), urine drainage via fistula (10/31, 32%), or a superficial wound infection (6/31, 19%). Recent instrumentation prior to diagnosis of anterior urinary fistula was reported by 18/31 (58%) at a median of 14.9 months (IQR 7.9, 103.8) after manipulation. Anterior fistula formation was either isolated to the pubic symphysis (19/31, 61%) or the thigh (12/31, 38%). Nineteen men underwent a cystectomy, whereas 12 men underwent a fistula repair. Excluding grades 1 and 2, 30- and 90-day postoperative complications were limited to four and two men, respectively, all of whom had a grade 3 complication. At 6-month follow-up, 26/31 (84%) men reported their pain had resolved. There was one fistula recurrence managed with subsequent cystectomy. CONCLUSIONS: Complex anterior urinary fistulae to the pubic symphysis and thigh are devastating yet treatable conditions. Universally, these men have a history of radiotherapy and repeated endoscopic interventions. Surgical intervention with either cystectomy or primary repair was highly successful.

Metastatic prostate cancer in the modern era of PSA screening.

INTRODUCTION: To characterize initial presentation and PSA screening status in a contemporary cohort of men treated for metastatic prostate cancer at our institution. MATERIALS AND METHODS: We reviewed records of 160 men treated for metastatic prostate cancer between 2008-2014 and assessed initial presentation, categorizing patients into four groups. Groups 1 and 2 presented with localized disease and received treatment. These men suffered biochemical recurrence late (>1 year) or earlier (<1 year), respectively, and developed metastases. Groups 3 and 4 had asymptomatic and symptomatic metastases at the outset of their diagnosis. Patients with a first PSA at age 55 or younger were considered to have guideline-directed screening. RESULTS: Complete records were available on 157 men for initial presentation and 155 men for PSA screening. Groups 1, 2, 3 and 4 included 27 (17%), 7 (5%), 69 (44%) and 54 (34%) patients, respectively. Twenty (13%) patients received guideline-directed PSA screening, 5/155 (3%) patients presented with metastases prior to age 55 with their first PSA, and 130/155 (84%) had their first PSA after age 55, of which 122/130 (94%) had metastasis at the time of diagnosis. CONCLUSION: Despite widespread screening, most men treated for metastatic prostate cancer at our institution presented with metastases rather than progressed after definitive treatment. Furthermore, 25 (16%) patients received guideline-directed PSA screening at or before age 55. These data highlight that, despite mass screening efforts, patients treated for incurable disease at our institution may not have been a result of a failed screening test, but a failure to be screened.

Cost Implications of Routine Preoperative Blood Typing and Crossmatching Prior to Robot-Assisted Laparoscopic Partial Nephrectomy.

INTRODUCTION: The surgical treatment of small renal masses has shifted from open to minimally invasive approaches. Preoperative blood typing and product orders often mirror the practices of the open era. We aim to define the rate of transfusion after robot-assisted partial laparoscopic nephrectomy (RAPN) at an academic medical center and the costs associated with current practice. METHODS: A retrospective review of an institutional database was utilized to identify patients who underwent RAPN and transfusion of blood products. Patient, tumor and operative variables were identified. RESULTS: From 2008 to 2021, 804 patients underwent RAPN, with 9 (1.1%) patients requiring a transfusion. Comparison of the transfused group with nontransfused patients yielded a significant difference in mean operative blood loss (527.8 ml vs 162.5 ml, p <0.0001), R.E.N.A.L. (for radius, exophytic/endophytic, nearness of tumor to collecting system, anterior/posterior, location relative to polar line) nephrometry score (7.1 vs 5.9, p <0.05), hemoglobin (11.3 gm/dl vs 13.9 gm/dl, p <0.05) and hematocrit (34.2% vs 41.4%, p <0.05). The variables associated with transfusion on univariate analysis were examined for predictive capacity using logistic regression. Operative blood loss (p <0.05), nephrometry score (p=0.05), hemoglobin (p <0.05) and hematocrit (p <0.05) remained associated with a transfusion. The hospital charge for blood typing and crossmatching was $1,320 USD per patient. CONCLUSIONS: With the maturity of RAPN techniques and outcomes, the extent of preoperative testing related to blood products should evolve to better reflect current procedural risks. Prioritizing testing resources for patients at increased complication risk can be based on predictive factors.

Intensive preoperative ostomy education for the radical cystectomy patient.

OBJECTIVES: Patients undergoing radical cystectomy with ileal conduit formation usually receive training on the use of their stoma during their initial hospitalization - while actively recovering from surgery - often with little follow-up or reinforcement. Many of these patients are not equipped to deal with these significant body changes, which can lead to additional clinic visits, stoma-related complications, and decreased patient satisfaction/health-related quality of life (HRQOL). In an effort to improve patient education, we sought to evaluate the feasibility of implementing a preoperative comprehensive stoma education session termed the "stoma bootcamp" for patients scheduled for a radical cystectomy and ileal conduit (RCIC). We tracked patient related outcomes to determine its impact. METHODS: We performed a longitudinal, quality-improvement feasibility study at the University of Kansas Health System. All patients who were scheduled to undergo a RCIC for bladder cancer were offered enrollment into the study at their preoperative clinic visit. The "stoma boot camp" consisted of a 3-hour group session within 2 weeks of the surgery date. Patients were given a short presentation by residents and advanced practice providers regarding the operation, recovery, and expectations for their post-operative care. Ostomy nurses then demonstrated basic urostomy care - pouching, sizing, emptying - along with trouble-shooting tips for common ostomy problems. Measurements of HRQOL questionnaires were completed at the initial visit, after "boot camp," and at defined time points after surgery for 12 weeks. This included using an ostomy adjustment score. Length of stay, unplanned stoma-related interventions, and re-admissions within 30 days were also tracked. RESULTS: In this initial pilot program, 51 patients participated in the stoma bootcamp. The patients had an average ostomy adjustment score (OAS) of 150.4 (95% CI 142.0, 158.8) at discharge from the hospital, and these high OAS levels persisted throughout the 12 weeks of follow-up data without any significant decline. Short-form 36 (SF-36) scores demonstrated numerical improvements in each individual category at the 6-week mark above baseline. These improvements persisted at the 12-week mark. CONCLUSIONS: In this study we were able to establish the feasibility of implementing a preoperative comprehensive stoma education session for patients scheduled for a RCIC. Additionally, we were able to document favorable HRQOL data and improved ostomy adjustment scores surrounding the education session.

Postoperative Outcomes After Radical Cystectomy in Patients With Prior Pelvic Radiation.

OBJECTIVE: To compare complication rates, perioperative outcomes, and survival after radical cystectomy (RC) in patients with prior abdominal or pelvic radiation therapy (RT) vs those without an RT history. MATERIALS AND METHODS: We retrospectively reviewed patients undergoing RC for urothelial carcinoma between January 2008 and January 2016. Patients were stratified by receipt of RT, and differences in complications (any, minor, and major) at 30 and 90 days, as well as estimated blood loss, length of surgery, length of hospital stay, and pathologic stage, were compared. Recurrence-free, cancer-specific, and overall survival were compared using the Kaplan-Meier method and log-rank test. RESULTS: We identified 518 patients who underwent RC between 2008 and 2016. Of these patients, 55 (11%) had a history of RT. There were no significant differences in complication rates (66% vs 69%, P= .80) between patients who did not and patients who did have a history of RT. Similarly, there were no differences in any perioperative or pathologic outcome by receipt of prior RT (all P>.05). Meanwhile, at a median follow-up of 26 (interquartile range 13-46) months among patients alive at last follow-up, no differences in survival were observed by prior RT (P= .08). CONCLUSION: Among patients with a history of prior abdominal or pelvic RT treated at a tertiary referral center, there was no difference in complication rates, perioperative, or pathologic outcomes. Importantly, no differences in survival were noted by prior RT receipt. Therefore, our data support the use of RC, when indicated, in patients with a prior history of abdominal or pelvic RT.

The July Effect in Radical Cystectomy: Mortality, Morbidity, and Efficiency.

Background: The "July effect" is the potential effect that new and recently promoted residents have on patient care during the first months of the academic year. Literature suggests that the July effect may worsen patient outcomes and lead to systemic inefficiencies. Objective: We evaluate the July effect on mortality, morbidity, and efficiency outcomes in patients undergoing radical cystectomy. Methods: A chart review was performed in patients who underwent radical cystectomy between January 2008 and April 2012. Demographic information was abstracted from patient charts and outcomes compared between operations performed in July, September, and November (first month of each resident's university rotation) to the remainder of the year. Outcomes of interest included mortality, complications, and markers of efficiency (operative time, length of hospital stay, and estimated blood loss). Results: Two hundred and fifty one patients were included in the analysis. There were no major differences in mortality or morbidity between the July, September, November group and the rest of the year. Multivariable analysis demonstrates a trend for operations performed in the months of July, September, and November to be associated with longer OR times 2.06 (0.99-4.27), p = 0.053. Length of hospital stay and estimated blood loss were no different between the two groups. Conclusions: These data demonstrate no increase in mortality or morbidity during the early academic period. Additionally, while there is a trend for OR time to be longer in the early group, length of hospital stay and estimated blood loss were no different. These data may be used as an impetus to continue to investigate technical/clinical teaching practices, strategies to assess resident progression, and to initiate protocols to support residents early in the academic year in efforts to prevent inefficiencies.

Effects of Immunonutrition for Cystectomy on Immune Response and Infection Rates: A Pilot Randomized Controlled Clinical Trial.

UNLABELLED: After radical cystectomy (RC), patients are at risk for complications including infections. The expansion of myeloid-derived suppressor cells (MDSCs) after surgery may contribute to the lower resistance to infection. Immune response and postoperative complications were compared in men consuming either specialized immunonutrition (SIM; n=14) or an oral nutrition supplement (ONS; n=15) before and after RC. MDSC count (Lin- CD11b+ CD33+) was significantly different between the groups over time (p=0.005) and significantly lower in SIM 2 d after RC (p<0.001). MDSC count expansion from surgery to 2 d after RC showed a weak association with an increase in infection rate 90 d after surgery (p=0.061). Neutrophil:lymphocyte ratio was significantly lower in SIM compared with ONS 3h after the first incision (p=0.039). Participants receiving SIM had a 33% reduction in postoperative complication rate (95% confidence interval [CI], 1-64; p=0.060) and a 39% reduction in infection rate (95% CI, 8-70; p=0.027) during late-phase recovery. The small sample size limits the study findings. PATIENT SUMMARY: Results show that the immune response to surgery and late infection rates differ between radical cystectomy patients receiving specialized immunonutrition versus oral nutrition supplement in the perioperative period. TRIAL REGISTRATION: ClinicalTrials.gov NCT01868087.

Genetic polymorphisms of human flavin monooxygenase 3 in sulindac-mediated primary chemoprevention of familial adenomatous polyposis.

PURPOSE: Sulindac is a nonsteroidal anti-inflammatory drug (NSAID) effective in regressing adenomas in patients with familial adenomatous polyposis (FAP). However, a recent randomized trial showed that sulindac, when compared with placebo, failed to prevent the development of adenomatous polyps in genotypically positive but phenotypically negative FAP patients. The present study determined whether polymorphisms in the gene encoding flavin monooxygenase 3 (FMO3), a hepatic microsomal enzyme that inactivates sulindac, played a role in determining the efficacy of sulindac in preventing polyposis in this cohort of FAP patients. EXPERIMENTAL DESIGN: Genotyping was performed on seven established FMO3 polymorphisms previously shown to have functional relevance-M66I, P153L, E158K, V257M, E305X, E308G, and R492W-in 21 and 20 FAP patients, who received sulindac and placebo, respectively. RESULTS: None of the 41 patients exhibited heterozygous or homozygous M66I and R492W variant alleles, or homozygous P153L, V257M, and E305X variant alleles. Among sulindac-treated patients who did not develop adenomas ("responders"), 4 (33%) were homozygous for E158K and 2 (17%) were homozygous for E308G variant alleles. In contrast, none of the patients on sulindac who developed adenomas ("nonresponders") exhibited homozygosity for either of the two variant alleles. In addition, polymorphisms in the E158K or E308G allele were associated with a significant reduction in mucosal prostanoid levels in patients treated with sulindac. CONCLUSIONS: Polymorphisms in FMO3, particularly at the E158K and E308G loci, may reduce activity in catabolizing sulindac and result in an increased efficacy to prevent polyposis in FAP.

Alvimopan in an Enhanced Recovery Program Following Radical Cystectomy.

Background: Radical cystectomy (RC) carries a high complication rate, including post-operative ileus. Alvimopan is an FDA approved peripherally acting µ-opioid receptor antagonist that has shown favorable results for improved recovery of gastro-intestinal function resulting in decreased hospital length of stay. Many enhanced recovery pathways (ERP) have been published demonstrating improved outcomes with decreased hospital stay and morbidity. Objective: We evaluated the addition of alvimopan to an ERP in patients undergoing RC. Methods: Patients undergoing RC at our institution during the implementation phase of alvimopan to our established ERP were retrospectively reviewed. Effect of alvimopan as it related to the use of nasogastric tubes, time to initiation of regular diet, and length of hospital stay was assessed using Chi-squared and Student's T-tests. Linear regression was performed for univariate analysis and binary logistic regression was performed as a multivariate assessment of the effect of alvimopan. Results: Between July 2011 and January 2013, 80 patients were identified who underwent RC under the ERP (34 alvimopan and 46 standard care). Age, sex, neoadjuvant chemotherapy, surgical technique (open vs. robotic), and type of urinary diversion were not different between groups. Alvimopan was associated with a reduction in mean time to regular diet (5.3 vs 4.1 days, p <  0.01) and a reduction in mean length of hospital stay (6.9 vs 5.7 days, p = 0.01). After controlling for other variables, alvimopan usage predicted for shorter time to regular diet and total hospital stay. Conclusions: Alvimopan may help to improve time to regular diet and decrease hospital stay in patients on an enhanced recovery pathway.

Use of full-length metallic stents in malignant ureteral obstruction.

INTRODUCTION: Malignant ureteral obstruction (MUO) has traditionally been a difficult problem to manage. Indwelling ureteral stents have a failure rate up to 50%, necessitating the placement of percutaneous nephrostomy (PCN) drainage, which has associated complications and impacts on quality of life. Recently, metallic ureteral stents have emerged as a treatment for extrinsic ureteral obstruction. We present our initial experience using Resonance (Cook Urologic, Spencer, IN) full-length metallic stents for MUO. MATERIALS AND METHODS: 20 patients (27 renal units) with advanced cancers and MUO were treated with metallic stents. Patients were followed prospectively to evaluate for recurrent obstruction. Perioperative morbidity and overall mortality were recorded. RESULTS: The mean patient age was 49.9 years (SD 18.9). The primary malignancies causing MUO were gastrointestinal (8), gynecologic (6), genitourinary (2), or other (4). All but two renal units had been previously treated with traditional stents. Eight out of 20 (40%) patients required further intervention for their MUO. Mean time to failure for the metallic stents was 7.4 months (222 days). Two patients required conversion to percutaneous drainage. Five patients required change to traditional stents (3) or removal of metallic stents. At the last follow-up, sixteen patients had died. Fourteen of the sixteen patients died with functioning metallic stents in place, although one patient who initially had bilateral metallic stent placements had a left stent removed due to migration. Of the remaining four living patients, two have functioning metallic stents at a mean follow-up of 42 months. DISCUSSION: MUO remains a difficult clinical problem in a group of patients with a high mortality. While metallic stents ultimately have a failure rate similar to that of traditional stents, the mean time to failure is longer. Therefore, metallic stents may benefit patients with MUO, because the longer dwell time may eliminate the need for more frequent stent changes or further interventions.

Metastatic prostate cancer in the modern era of PSA screening

ABSTRACT Introduction To characterize initial presentation and PSA screening status in a contemporary cohort of men treated for metastatic prostate cancer at our institution. Materials and methods We reviewed records of 160 men treated for metastatic prostate cancer between 2008-2014 and assessed initial presentation, categorizing patients into four groups. Groups 1 and 2 presented with localized disease and received treatment. These men suffered biochemical recurrence late (>1 year) or earlier (<1 year), respectively, and developed metastases. Groups 3 and 4 had asymptomatic and symptomatic metastases at the outset of their diagnosis. Patients with a first PSA at age 55 or younger were considered to have guideline-directed screening. Results Complete records were available on 157 men for initial presentation and 155 men for PSA screening. Groups 1, 2, 3 and 4 included 27 (17%), 7 (5%), 69 (44%) and 54 (34%) patients, respectively. Twenty (13%) patients received guideline-directed PSA screening, 5/155 (3%) patients presented with metastases prior to age 55 with their first PSA, and 130/155 (84%) had their first PSA after age 55, of which 122/130 (94%) had metastasis at the time of diagnosis. Conclusion Despite widespread screening, most men treated for metastatic prostate cancer at our institution presented with metastases rather than progressed after definitive treatment. Furthermore, 25 (16%) patients received guideline-directed PSA screening at or before age 55. These data highlight that, despite mass screening efforts, patients treated for incurable disease at our institution may not have been a result of a failed screening test, but a failure to be screened.

Patients with malignant hyperthermia demonstrate an altered calcium control mechanism in B lymphocytes.

BACKGROUND: Altered Ca2+ homeostasis in skeletal muscle is a key molecular event triggering malignant hyperthermia (MH) in malignant hyperthermia-susceptible (MHS) individuals. Genetic studies have shown that mutations in the type 1 ryanodine receptor (RYR1) are associated with MH susceptibility. Because human B lymphocytes express the RYR1, it is hypothesized that Ca2+ homeostasis in B lymphocytes is altered in MHS individuals. METHODS: This study investigated the Ca2+ response of B cells to caffeine and 4-chloro-m-cresol in 13 MHS and 21 MH-negative (MHN) individuals who had been diagnosed by caffeine halothane contracture test (CHCT) and 18 healthy volunteers. Changes in [Ca2+]i in B cells were measured directly in fluo-3 loaded cells using a dual-color flow cytometric technique. Further, B cell phenotype was correlated with CHCT results in a family with the Val2168Met (G6502A) mutation. RESULTS: Caffeine-induced (50 mm) increases in [Ca2+]i in B cells were significantly greater in MHS than in MHN (P = 0.0004), control (P = 0.0001) or non-MHS (MHN and control) individuals (P < 0.0001). The 4-chloro-m-cresol-induced (400 microm) increases in [Ca2+]i were also significantly different between MHS and controls (P = 0.003) or between MHS and non-MHS (MHN and control) individuals (P = 0.0078). A study of a family with the Val2168Met mutation demonstrated expression of the RYR1 mRNA mutant in B cells from the family members with MHS phenotype and a clear segregation of genotype with B-cell phenotype. CONCLUSION: The Ca2+ responses to caffeine or 4-chloro-m-cresol in B lymphocytes showed significant differences between MHS and MHN (or control) individuals. Although the molecular mechanisms of these alterations are currently undetermined, the results suggest that the enhanced Ca2+ responses are associated with mutations in the RYR1 gene in some MHS individuals.