Comparative Analyses and Ablation Efficiency of Thulium Fiber Laser by Stone Composition.

PURPOSE: There are limited data on ablation effects of thulium fiber laser (TFL) settings with varying stone composition. Similarly, little is known surrounding the photothermal effects of TFL lithotripsy regarding the chemical and structural changes after visible char formation. We aim to understand the TFL's ablative efficiency across various stone types and laser settings, while simultaneously investigating the photothermal effects of TFL lithotripsy. MATERIALS AND METHODS: Human specimens of calcium oxalate monohydrate, calcium oxalate dihydrate, uric acid, struvite, cystine, carbonate apatite, and brushite stones were ablated using 13 prespecified settings with the Coloplast TFL Drive. Pre- and postablation mass, ablation time, and total energy were recorded. Qualitative ablative observations were recorded at 1-minute intervals with photographs and gross description. Samples were analyzed with Fourier-transform infrared spectroscopy pre- and postablation and electron microscopy postablation to assess the photothermal effects of TFL. RESULTS: Across all settings and stone types, 0.05 J × 1000 Hz was the best numerically efficient ablation setting. When selected for more clinically relevant laser settings (ie, 10-20 W), 0.2 J × 100 Hz, short pulse was the most numerically efficient setting for calcium oxalate dihydrate, cystine, and struvite stones. Calcium oxalate monohydrate ablated with the best numerical efficiency at 0.4 J × 40 Hz, short pulse. Uric acid and carbonate apatite stones ablated with the best numerical efficiency at 0.3 J × 60 Hz, short pulse. Brushite stones ablated with the best numerical efficiency at 0.5 J × 30 Hz, short pulse. Pulse duration impacted ablation effectiveness greatly with 6/8 (75%) of inadequate ablations occurring in medium or long pulse settings. The average percent of mass lost during ablation was 57%; cystine stones averaged the highest percent mass lost at 71%. Charring was observed in 36/91 (40%) specimens. Charring was most often seen in uric acid, cystine, and brushite stones across all laser settings. Electron microscopy of char demonstrated a porous melting effect different to that of brittle fracture. Fourier-transform infrared spectroscopy of brushite char demonstrated a chemical composition change to amorphous calcium phosphate. CONCLUSIONS: We describe the optimal ablation settings based on stone composition, which may guide urologists towards more stone-specific care when using thulium laser for treating renal stones (lower energy settings would be safer for ureteral stones). For patients with unknown stone composition, lasers can be preset to target common stone types or adjusted based on visual cues. We recommend using short pulse for all TFL lithotripsy of calculi and altering the settings based on visual cues and efficiency to minimize the charring, an effect which can make the stone refractory to further dusting and fragmentation.

Atypical Presentation Delays Treatment of Pediatric Testicular Torsion.

OBJECTIVE: The aim of the study is to identify patient- and care-related factors associated with time to treatment for acute testicular torsion and the likelihood of testicular loss. METHODS: Data were retrospectively collected for patients 18 years and younger who had surgery for acute testicular torsion between April 1, 2005, and September 1, 2021. Atypical symptoms and history were defined as having abdominal, leg, or flank pain, dysuria, urinary frequency, local trauma, or not having testicular pain. The primary outcome was testicular loss. The primary process measure was time from emergency department (ED) triage to surgery. RESULTS: One hundred eleven patients were included in descriptive analysis. The rate of testicular loss was 35%. Forty-one percent of all patients reported atypical symptoms or history. Eighty-four patients had adequate data to calculate time from symptom onset to surgery and time from triage to surgery and were included in analyses of factors affecting risk of testicular loss. Sixty-eight patients had adequate data to evaluate all care-related time points and were included in analyses to determine factors affecting time from ED triage to surgery. On multivariable regression analyses, increased risk of testicular loss was associated with younger age and longer time from symptom onset to ED triage, while longer time from triage to surgery was associated with reporting atypical symptoms or history.The most frequently reported atypical symptom was abdominal pain, in 26% of patients. These patients were more likely to have nausea and/or vomiting and abdominal tenderness but equally likely to report testicular pain and swelling and have testicular findings on examination. CONCLUSIONS: Patients presenting to the ED with acute testicular torsion reporting atypical symptoms or history experience slower transit from arrival in the ED to operative management and may be at greater risk of testicular loss. Increased awareness of atypical presentations of pediatric acute testicular torsion may improve time to treatment.

Ergonomic Considerations in Urologic Surgery.

PURPOSE OF REVIEW: This paper aims to discuss the various work-related musculoskeletal disorders (WRMDs) among urologists and provide an overview of the latest recommendations to improve awareness of ergonomic principles that can be applied in the operating room, with special consideration of challenges faced during pregnancy. RECENT FINDINGS: Urologists suffer from a large burden of WRMDs. The main drivers of pain associated with the various surgical approaches include repetitive movements, static and awkward body positions, and the use of burdensome equipment. Pregnant surgeons are at an even greater risk of WRMDs and face high rates of pregnancy complications. Laparoscopy, endoscopy, robot-assisted surgeries, and open surgeries present unique ergonomic challenges for the practicing urologist. Proper posture and equipment use, optimal operating room setup, intraoperative stretching breaks, and an emphasis on teaching ergonomic principles can reduce the risk of WRMDs. Surgeons are also at increased risk of WRMDs during pregnancy but may continue to operate while taking measures to limit physical exertion and fatigue. Improving awareness of and incorporating ergonomic principles early in a urologist's career may reduce the risk of injury and improve operative performance and longevity.

Rare case of an isolated scaphoid congenital megalourethra: before and after reconstruction.

Congenital megalourethra, first described in 1955, is a rare urethral anomaly resulting from dysgenesis of the penile corpus spongiosum, with or without corpus cavernosum involvement, leading to dilatation of the penile urethra. Presentations come in two forms, scaphoid and fusiform, with the former being more common and resulting from deficient or absent corpus spongiosum. Fusiform types are much rarer, and consist of absence of both the corpus spongiosum and cavernosum.3 Here, we present a case involving the surgical correction of an isolated scaphoid-type congenital megalourethra with significantly improved postoperative cosmetic and functional outcomes.

Urology Virtual Education Programs During the COVID-19 Pandemic.

PURPOSE OF REVIEW: This article aims to describe the impact of the COVID-19 pandemic on American urology trainees, with a focus on virtual learning initiatives. RECENT FINDINGS: Urological education was forced to rapidly adapt to the COVID-19 pandemic in 2020. Significant challenges included quarantines, redeployment of residents and faculty, and suspension of regularly scheduled conferences. In response, urologists across the country adopted web-based platforms to develop virtual lecture series to fill the gap. Popular programs for residents included UCSF's COViD (Collaborative Online Video Didactics) series and the New York Section of the American Urological Association's EMPIRE (Educational Multi-institutional Program for Instructing REsidents) series. Virtual education programs have enabled urology trainees to pursue their education during the pandemic. While the long-term impact of the pandemic on urology training remains unknown, some good may be found in the innovative solutions that have arisen in urology education.

Gastrointestinal Tract Pathology in a BALB/c Niemann-Pick Disease Type C1 Null Mouse Model.

BACKGROUND: Niemann-Pick disease, type C (NPC) is a rare lysosomal storage disorder characterized by progressive neurodegeneration, splenomegaly, hepatomegaly, and early death. NPC is caused by mutations in either the NPC1 or NPC2 gene. Impaired NPC function leads to defective intracellular transport of unesterified cholesterol and its accumulation in late endosomes and lysosomes. A high frequency of Crohn disease has been reported in NPC1 patients, suggesting that gastrointestinal tract pathology may become a more prominent clinical issue if effective therapies are developed to slow the neurodegeneration. The Npc1 nih mouse model on a BALB/c background replicates the hepatic and neurological disease observed in NPC1 patients. Thus, we sought to characterize the gastrointestinal tract pathology in this model to determine whether it can serve as a model of Crohn disease in NPC1. METHODS: We analyzed the gastrointestinal tract and isolated macrophages of BALB/cJ cNctr-Npc1m1N/J (Npc1-/-) mouse model to determine whether there was any Crohn-like pathology or inflammatory cell activation. We also evaluated temporal changes in the microbiota by 16S rRNA sequencing of fecal samples to determine whether there were changes consistent with Crohn disease. RESULTS: Relative to controls, Npc1 mutant mice demonstrate increased inflammation and crypt abscesses in the gastrointestinal tract; however, the observed pathological changes are significantly less than those observed in other Crohn disease mouse models. Analysis of Npc1 mutant macrophages demonstrated an increased response to lipopolysaccharides and delayed bactericidal activity; both of which are pathological features of Crohn disease. Analysis of the bacterial microbiota does not mimic what is reported in Crohn disease in either human or mouse models. We did observe significant increases in cyanobacteria and epsilon-proteobacteria. The increase in epsilon-proteobacteria may be related to altered cholesterol homeostasis since cholesterol is known to promote growth of this bacterial subgroup. CONCLUSIONS: Macrophage dysfunction in the BALB/c Npc1-/- mouse is similar to that observed in other Crohn disease models. However, neither the degree of pathology nor the microbiota changes are typical of Crohn disease. Thus, this mouse model is not a good model system for Crohn disease pathology reported in NPC1 patients.

Vitamin D levels in Smith-Lemli-Opitz syndrome.

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive congenital malformation syndrome caused by mutations in the 7-dehydrocholesterol reductase gene. This inborn error of cholesterol synthesis leads to elevated concentrations of 7-dehydrocholesterol (7-DHC). 7-DHC also serves as the precursor for vitamin D synthesis. Limited data is available on vitamin D levels in individuals with SLOS. Due to elevated concentrations of 7-DHC, we hypothesized that vitamin D status would be abnormal and possibly reach toxic levels in patients with SLOS. Through a retrospective analysis of medical records between 1998 and 2006, we assessed markers of vitamin D and calcium metabolism from 53 pediatric SLOS patients and 867 pediatric patients who were admitted to the NIH Clinical Center (NIHCC) during the same time period. SLOS patients had significantly higher levels of 25(OH)D (48.06 ± 19.53 ng/ml, p < 0.01) across all seasons in comparison to the NIHCC pediatric patients (30.51 ± 16.14 ng/ml). Controlling for season and age of blood draw, 25(OH)D levels were, on average, 15.96 ng/ml (95%CI 13.95-17.90) higher in SLOS patients. Although, mean calcium values for both patient cohorts never exceeded the normal clinical reference range (8.6-10.2 mg/dl), the levels were higher in the SLOS cohort (9.49 ± 0.56 mg/dl, p < 0.01) compared to the NIHCC patients (9.25 ± 0.68 mg/dl). Overall, in comparison to the control cohort, individuals with SLOS have significantly higher concentrations of 25(OH)D that may be explained by elevated concentrations of serum 7-DHC. Despite the elevated vitamin D levels, there was no laboratory or clinical evidence of vitamin D toxicity.

The New York Section EMPIRE Collaborative: Piloting a Multi-Institutional, Simulation-Based Surgical Skills Boot Camp for Junior Urology Residents.

INTRODUCTION: Since the integration of the intern year into urology residencies, programs are mandated to introduce fundamental skills to junior residents. Our goal was to assess the impact of one such program: the 2023 New York Section of the AUA (NYS-AUA) EMPIRE (Educational Multi-institutional Program for Instructing REsidents) Boot Camp. METHODS: Junior urology residents from all 10 NYS-AUA institutions attended a free EMPIRE Boot Camp on June 9, 2023. The seminar covered procedural skills including urethral catheterization, cystoscopy, renal and bladder ultrasound, transrectal prostate ultrasound with biopsy, and an introduction to robotics/laparoscopy. Sessions focused on urologic emergencies and postoperative scenarios. Participants completed questionnaires before, immediately after, and 6 months post course, assessing comfort with procedures and overall program quality using a 5-point Likert scale and free text responses. t Tests compared pre and immediate/6-month post scores. RESULTS: Forty junior residents, along with faculty and resident instructors from all 10 NYS-AUA programs, participated. Of the 40 trainees, 35 (87.5%) completed pre- and immediate post-boot camp surveys, while 23 (57.5%) responded to the 6-month follow-up survey. Ratings showed significant improvement in comfort with basic urologic technical skills for 13 out of 14 domains (93%) immediately after the course and at the 6-month mark. Attendees reported notably higher comfort levels in managing obstructive pyelonephritis (P = .003) and postoperative complications (P = .001) following didactic sessions. CONCLUSIONS: A skills-based, free collaborative urology boot camp for junior residents is feasible and can be effective. Trainees reported improved comfort performing certain technical skills and managing urologic emergencies both immediately after the course and at 6 months of follow-up.

Antimicrobial Prophylaxis for Percutaneous Nephrolithotomy: Contemporary Practice Patterns.

Background: Updated in 2019, the American Urological Association's (AUA) Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis outlines prophylaxis for percutaneous nephrolithotomy (PCNL). Recent studies have challenged these recommendations. We hypothesized that endourologists do not routinely follow the AUA's statement on antibiotic use during PCNL and assessed their prescribing patterns. Methods: A 24-question survey was distributed to members of the Endourological Society. The primary outcome was adherence to the AUA's recommendations. Two multiple logistic regression analyses were performed with demographics and antibiotic preference as predictors of following the AUA. Results: A total of 51.4% of endourologists follow the AUA Best Practice Statement for antimicrobial prophylaxis of uncomplicated PCNL. No demographic data were predictive of following the AUA. 90.9% and 83.6% reported they have "never" used the first-line recommendation options of metronidazole and aztreonam, respectively. Preferred antibiotics were cephalosporins (uncomplicated 60%, complicated 52.6%), fluoroquinolones (13.3%, 7.2%), aminoglycosides (12.7%, 17.8%), penicillins (7.9%, 11.2%), carbapenems (0.6%, 0.7%), trimethoprim-sulfamethoxazole (2.4%, 5.9%), fosfomycin (0.6%, 0.7%), nitrofurantoin (2.4%, 2.6%), aztreonam (0%, 0.7%), and clindamycin (0%, 0.7%). For uncomplicated PCNL, 63.1% prescribe ≤24 hours of perioperative antibiotics. For complicated PCNL, 16.2% prescribe ≤24 hours of perioperative antibiotics, while 20.4% begin antibiotics 7 or more days prior. Conclusions: Nearly half of respondents do not follow the AUA's recommendations for antibiotic choice for PCNL. Few endourologists prescribe 7 days of preoperative antibiotics for complicated PCNL despite supporting data. Metronidazole and aztreonam are rarely used as a first-line antibiotic choice for PCNL and their roles needs to be further evaluated as first-line prophylaxis recommendations. Updates on antibiotic recommendations for PCNL are needed based on current literature, antimicrobial stewardship, and contemporary practice patterns.

The Impact of the Virtual Interview on Candidate Experience and Outcomes: Society of Academic Urologists National Survey of Interns Who Participated in the 2020-2021 Urology Match.

OBJECTIVE: To examine retrospective experiences with the virtual interview (VI) process among postgraduate year 1 (PGY1) urology residents who participated in the 2020-2021 American Urologic Association (AUA) Match cycle. METHODS: A 27-question survey created by a Society of Academic Urologists Taskforce on VI was distributed to PGY1 residents from 105 institutions between February 1, 2022 and March 7, 2022. The survey asked respondents to reflect on the VI process, cost concerns, and how experiences at their current program aligned with prior VI representation. RESULTS: A total of 116 PGY-1 residents completed the survey. The majority felt the VI represented the following domains well: (1) institution/program culture and strengths (74%), (2) representation of all faculty/disciplines (74%), (3) resident quality of life (62%), (4) personal fit (66%), (5) quality of surgical training and volume (63%), and (6) opportunities to meet residents (60%). Approximately 71% of respondents did not match at their home program or a program they visited in-person. Within this cohort, 13% agreed important aspects of their current program were not translated virtually, and they would not have prioritized the program had they been able to visit in-person. In total, 61% ranked programs they ordinarily might not have listed during an in-person interview season. Overall, 25% deemed financial costs a "very important" consideration during the VI process. CONCLUSION: The majority of PGY1 urology residents reported key components of their current program translated well from the VI process. This platform offers a method of overcoming conventional geographic and financial barriers associated with the in-person interview process.

Survival outcomes in patients with muscle invasive bladder cancer undergoing radical vs. partial cystectomy.

PURPOSE: While radical cystectomy (RC) is the standard of care for muscle invasive bladder cancer (MIBC), partial cystectomy (PC) is an effective alternative in select patients. We sought to examine differences in survival for RC and PC in a hospital-based registry. MATERIAL AND METHODS: We identified patients diagnosed with cT2-4 bladder cancer who underwent RC or PC from 2003 to 2015 in the National Cancer Database (NCDB). Using inverse probability treatment weighting (IPTW) to control for known confounders, we compared the primary outcome of overall survival (OS) in patients who underwent RC vs. PC. Kaplan-Meier survival analysis, univariable and multivariable Cox proportional hazards modeling were used. We performed a secondary survival analysis for a subcohort of patients with cT2, cN0, tumor size ≤5 cm, and no concurrent carcinoma in situ (CIS), who may be optimal candidates for PC. RESULTS: A total of 22,534 patients met inclusion criteria, of which 6.9% (1,457) underwent PC. RC had longer median OS than PC (67.8 vs. 54.1 months) and on Cox regression analysis (HR 0.88, 95% CI, 0.80-0.95, P = 0.002). However, in our subcohort, there was no difference in OS between RC and PC (HR 1.02, 95% CI, 0.9-1.2, P = 0.74). PC was associated with increased time from surgery to any systemic therapy or death in the subcohort. CONCLUSIONS: Among patients with clinically organ-confined MIBC, PC appears to afford similar survival outcomes to RC in a large national data set. The safety and tolerability of PC may warrant consideration in highly selected patients.

Understanding the Urology Program Directors Perspective on the Current Resident Selection Process: The Society of Academic Urologists National Survey of Urology Program Directors.

OBJECTIVE: The traditional residency selection process was altered dramatically by the SARS CoV-2 (COVID-19) pandemic. For the 2020-2021 application cycle in-person interviews were transitioned to the virtual format. What was thought to be a temporary transition has now become the new standard with continued endorsement from the Association of American Medical Colleges (AAMC) and the Society of Academic Urologists (SAU) for virtual interviews (VI). We sought to assess the perceived efficacy and satisfaction of the VI format from the urology residency program director's (PDs) perspective. DESIGN: A designated SAU Taskforce on "Optimizing the Applicant Experience in the Virtual Interview Era" developed and refined a survey composed of 69 questions on VI and was distributed to all urology program directors (PD) of member institutions of the SAU. The survey focused on candidate selection, faculty preparation, and interview day logistics. PDs were also asked to reflect on the impact of VI on their match results, recruitment of underrepresented minorities and female gender, and what their preference would be for future applications cycles. PARTICIPANTS: Urology residency PDs (84.7% response rate) between January 13, 2022 - February 10, 2022 were included in the study. RESULTS: Most programs interviewed a total of 36 to 50 applicants (80%), with an average of 10 to 20 applicants per interview day. The top 3 ranked criteria for interview selection reported by urology PDs surveyed included letters of recommendation, clerkship grades, and USMLE Step 1 score. The most common areas of formal training for faculty interviewers were diversity, equity and inclusion (55%), implicit bias (66%), and review of the SAU guidelines on illegal questions (83%). Over half (61.4%) of PDs believed that they were able to accurately represent their training program through the virtual platform, while 51% felt that VI did not afford similar assessments of applicant as in-person interviews. Two-thirds of PDs believed the VI platform improve access for all applicants to attend interviews. Focusing on the impact of the VI platform for recruitment of underrepresented minorities (URM) and female gender applicants, 15% and 24% reported improved visibility respectively for their program, and 24% and 11% reported increased ability to interview URM and female gender applicants respectively. Overall, in-person interviews were reported to be preferred by 42%, and 51% of PDs desired VIs to be included in future years. CONCLUSIONS: PDs opinion and role of the VIs into the future is variable. Despite uniform agreement of cost savings and belief that VI platform improves access for all, only half of PDs expressed interest of the VI format being continued in some form. PDs note limitation of VI in the ability to comprehensively assess applicants as well as the in-person format. Many programs have begun to incorporate vital training in the areas of diversity equity and inclusion bias, and illegal questions. There is a role for continued development and research on ways to optimize virtual interviews.

Association of Patient and Imaging-Related Factors With False Negative MRI-Targeted Prostate Biopsies of Suspicious PI-RADS 4 and 5 Lesions.

OBJECTIVE: To investigate specific imaging and patient-related factors associated with a false negative (FN) MRI-targeted prostate fusion biopsies (TBx) of suspicious MRI lesions. METHODS: Retrospective study of men with PI-RADS 4 or 5 lesions November, 2015-December 2020 with TBx and systematic biopsy (SBx) performed. Only FN and true positive (TP) targeted lesions were included. FN biopsy was defined as a negative TBx with a positive systematic core in the ROI or perilesional sextant. Logistic regression was used to determine the association of patient and imaging-specific factors with the probability of a FN TBx. RESULTS: 361 PI-RADS 4 or 5 lesions in 304 patients, including 67 FN (19%) and 294 TP (81%) were included. There was a significant inverse association between lesion size (OR: 0.94, P-value: .02), presence of a suspicious DRE (OR: 0.36, P-value: .02) and PSA density (OR: 0.01, P-value: .004) on the probability of obtaining a FN TBx. There was no association between age, biopsy indication, use of an enema before MRI, prostate size, or discrepant US and MRI segmentation volumes on the probability of a FN TBx. CONCLUSION: In this cohort, SBx detected 19% of csPCa missed on TBx. Smaller PI-RADS 4/5 lesions, lower PSAD values, and a normal DRE were all associated with an increased probability of a FN TBx.

Predicting Sepsis in Patients with Ureteral Stones in the Emergency Department.

Background: In the absence of overt infection signs, clinical criteria for early intervention in patients with ureteral stones are poorly defined. We aimed to develop a model that can identify patients who are at risk for developing sepsis if discharged home from the emergency department (ED). Materials and Methods: We retrospectively reviewed patients between January 2010 and December 2019 who were discharged from the ED after diagnosis of ureteral stones. The primary outcome was sepsis requiring urgent surgical decompression. We used multivariable logistic regression to identify predictors of sepsis. We refined the model using backward stepwise regression with a threshold p-value of 0.05. Results: We identified 1331 patients who were discharged from the ED with ureteral stones. Of these patients, 22 (2%) subsequently developed sepsis requiring urgent decompression. In the initial multivariable model, female gender (odds ratio [OR]: 2.82, p = 0.039) and urine white blood cells (WBCs) (OR: 1.02 per cell count, p < 0.001) were predictive of sepsis. After performing backward stepwise regression, female gender, urine WBCs, and leukocytosis (WBCs >15,000/mm3) met criteria for inclusion in the model. A logistic model including these variables predicted sepsis with an internally cross-validated area under the curve (AUC) of 0.79. Among patients with urine cultures completed in the ED, rates of sepsis were 9% in patients with positive cultures and 1% in patients with negative cultures (p < 0.001). Antibiotic usage was not protective against developing sepsis. Conclusions: Sepsis is a rare complication among patients with ureteral stones selected for conservative management. The presence of elevated urine WBCs and female gender can help identify patients who are at risk of developing sepsis. Patients with risk factors should be managed with an increased index of suspicion for infection and may benefit from early intervention to reduce the risk of sepsis. Sepsis is more common in patients with positive urine cultures.

The Impact of Visiting Rotations on the Urology Residency Match: Insights and Perspectives From the 2021-2022 Applicants.

OBJECTIVE: To survey 2022 Urology Residency Match applicants on their away rotation experiences to better understand the impact of pandemic changes, including the one in-person away rotation limit, on interviews and match outcomes. METHODS: An anonymous post-match online survey was distributed to applicants of study-participating institutions. Data was prospectively collected regarding respondent demographics, away rotation experiences, interviews, utilization of preference signaling, and overall match outcomes. RESULTS: In total, 230 applicants completed the survey. Respondents prioritized geography (28.1%), program reputation (26.1%), and early notification (25.6%) as the top factors in determining whether to accept a rotation offer. The majority (93%) participated in a single away rotation, with nearly all respondents being offered a virtual interview from the program where they completed a visiting clerkship. Of those who declined away rotation offers, 56% were not offered an interview at the program they declined an offer from. The majority matched at either their home institution (20.8%), a program where they submitted a preference signal (22.2%), or a program where they completed an in-person away rotation (13%). Despite 46.3% of respondents reporting that their match outcome was negatively affected by the ability to rotate at only one away rotation, the majority were satisfied (70%) with their rotation selection based on match results. CONCLUSIONS: For applicants, participation in visiting rotations plays a significant role in the match process. Further research regarding mechanisms to optimize the away rotation application process is needed as the capacity to do visiting electives expands in the post-pandemic environment.

Pediatric Penile Non-Involuting Congenital Hemangioma With an Associated Pyogenic Granuloma: Surgical Management of a Rare Vascular Anomaly.

Vascular anomalies include both tumors and malformations. Infantile hemangiomas are the most common benign vascular tumor of infancy that proliferate after birth and eventually involute. By contrast, congenital hemangiomas are formed at birth and are categorized into three groups: rapidly involuting, partially-involuting, and non-involuting congenital hemangiomas (NICH). NICH do not regress and grow with age. Pyogenic granulomas, another acquired vascular tumor, develop over vascular lesions and cause bleeding. Primary treatment options for NICH and pyogenic granulomas are surgical resection. Here, we report a case of a NICH with a co-existing pyogenic granuloma involving the penile shaft and scrotum treated surgically.

Overcoming Immune Resistance in Prostate Cancer: Challenges and Advances.

The use of immunotherapy has become a critical treatment modality in many advanced cancers. However, immunotherapy in prostate cancer has not been met with similar success. Multiple interrelated mechanisms, such as low tumor mutational burden, immunosuppressive cells, and impaired cellular immunity, appear to subvert the immune system, creating an immunosuppressive tumor microenvironment and leading to lower treatment efficacy in advanced prostate cancer. The lethality of metastatic castrate-resistant prostate cancer is driven by the lack of therapeutic regimens capable of generating durable responses. Multiple strategies are currently being tested to overcome immune resistance including combining various classes of treatment modalities. Several completed and ongoing trials have shown that combining vaccines or checkpoint inhibitors with hormonal therapy, radiotherapy, antibody-drug conjugates, chimeric antigen receptor T cell therapy, or chemotherapy may enhance immune responses and induce long-lasting clinical responses without significant toxicity. Here, we review the current state of immunotherapy for prostate cancer, as well as tumor-specific mechanisms underlying therapeutic resistance, with a comprehensive look at the current preclinical and clinical immunotherapeutic strategies aimed at overcoming the immunosuppressive tumor microenvironment and impaired cellular immunity that have largely limited the utility of immunotherapy in advanced prostate cancer.

Virtual Urology Education in the Epicenter of COVID-19: Development and Outcomes of the Educational Multi-Institutional Program for Instructing REsidents (EMPIRE) Lecture Series.

INTRODUCTION: Sustaining resident education efforts during the height of the COVID-19 pandemic required innovative, virtual didactic programs. This article reviews the authors' collaborative experience with launching the Educational Multi-institutional Program for Instructing REsidents (EMPIRE) lecture series in the New York Section of the American Urological Association. METHODS: From April 13, 2020 to May 29, 2020, there were 68 EMPIRE lectures delivered via Zoom videoconferencing that were based on a variety of topics highlighted in the AUA Core Curriculum. Tracking tools from Zoom, Google Analytics from the New York Section website and YouTube Analytics were used to assess participant access of didactic materials. Additionally, a survey regarding the content and impact of the series was distributed and advertised to those who had attended the lecture series. RESULTS: The average number of participants was 159±68 per lecture (range 77 to 334) and the recordings received 9,086 total video views (range 42 to 443 views per video) at the time of survey completion. The survey received 170 total responses. The majority of speakers (77%) and participants (58%) were from the New York Section. Half of the participants were residents (50%) and others were attending urologists (35%), fellows (5%), medical students (9%), and advanced practice providers (1%). Survey respondents reported consistently high ratings of the EMPIRE series. Overall, 99% of respondents said that they would recommend the EMPIRE series to a colleague and 98% requested that the series continue after COVID-19 abates. CONCLUSIONS: The EMPIRE didactic series was well received, with the majority of participants positively endorsing its value. Further initiatives pertaining to virtual education for urology trainees should continue to be explored.