Does antithrombotic use enable earlier diagnosis of bladder cancer? A brief institutional assessment.

INTRODUCTION: Wallis et al (JAMA 2017) demonstrated use of antithrombotic medications (ATMs) is associated with increased prevalence of hematuria-related complications and subsequent bladder cancer diagnosis within 6 months. Stage of diagnosis was lacking in this highly publicized study. This study examined the association of ATM use on bladder cancer stage at the time of diagnosis. MATERIALS AND METHODS: We completed a retrospective chart review of patients with a bladder cancer diagnosis at our institution. Patient demographics and bladder cancer work up information were assessed. Patients were stratified based on use of ATMs at time diagnosis. Descriptive statistics were completed to identify association between ATM use and stage of bladder cancer diagnosis, as stratified by non-muscle invasive bladder cancer (NMIBC) versus muscle invasive bladder cancer (MIBC). RESULTS: A total of 1052 patient charts were reviewed. Eight hundred and forty-four were included and 208 excluded due to unavailability of diagnosis history. At diagnosis, 357 (42.3%) patients were taking ATMs. Patients on ATMs presented with NMIBC at similar rates as patients not taking ATMs (81.2% vs. 77.8%, p = 0.23). Subgroup analysis by ATM class similarly demonstrated no statistically significant differences in staging. CONCLUSION: While Wallis et al established that patients on blood thinners who present with hematuria are more likely to be diagnosed with genitourinary pathology, this factor does not appear to enable an earlier diagnosis of bladder cancer. Future study may assess hematuria at presentation (gross, microscopic), type of blood thinners, and low versus high risk NMIBC presentation.

Evaluation and management of female urinary incontinence.

INTRODUCTION Urinary incontinence (UI) is a common condition in all demographics of women and consists of stress UI (SUI), Urgency UI (UUI), and mixed UI (MUI). Treatment includes lifestyle modifications, medical treatment, and surgery depending on the type of UI and severity of symptoms. This review is an update on the evaluation and management of UI in women. MATERIALS AND METHODS: This review article covers the evaluation and management options for UI in women and includes the most recent guidelines from the American Urological Association (AUA) as well as recently published literature on the management of UI. RESULTS: Any evaluation of UI should include a thorough targeted history and physical, and counseling for treatment should consider patient goals and desired outcomes. For both SUI and UUI, behavioral therapy and lifestyle modifications are effective first line treatments. Patients with UUI can benefit from medical therapy which includes anticholinergics and ß3-agonist medications, as well as neuromodulation in treatment refractory patients. SUI patients may further benefit from mechanical inserts which prevent leaks, urethral bulking agents, and surgical treatments such as the mid urethral sling and autologous fascial pubovaginal sling. CONCLUSIONS: Treatment of UI in women requires a graded approach that considers patient goals and symptom severity, beginning with lifestyle and behavioral modifications before progressing to more aggressive interventions.

Management of neurogenic detrusor overactivity.

INTRODUCTION Neurogenic lower urinary tract dysfunction (NLUTD) refers to altered function of the urinary bladder, bladder outlet, and external urinary sphincter related to a confirmed neurologic disorder. Neurogenic detrusor overactivity (NDO) is a subset of NLUTD that frequently results in incontinence and may be associated with elevated bladder storage and voiding pressures resulting in upper urinary tract damage. MATERIALS AND METHODS: This article provides an update on the evaluation and management of patients with NDO. Basic bladder physiology as well as classification of NLUTD, initial urologic evaluation, and management options ranging from the most conservative to surgical interventions will be covered. RESULTS: NDO may be managed by conservative, pharmacologic, and surgical methods. Untreated or inadequately managed NDO may result in significant urologic morbidity and mortality, making careful evaluation and lifelong management necessary to optimize quality of life and prevent secondary complications. CONCLUSIONS: Patients with NDO should have life-long urologic surveillance and follow up. The extent of regular evaluation and testing should be based on the principal of risk stratification. Treatment for NDO should be considered not only for clinical symptoms such as incontinence, but also aimed at preserving renal function.

Surgical management of vaginal prolapse: current surgical concepts.

INTRODUCTION Pelvic organ prolapse (POP) is a condition defined by a loss of structural integrity within the vagina and often results in symptoms which greatly interfere with quality of life in women. POP is expected to increase in prevalence over the coming years, and the number of patients undergoing surgery for POP is expected to increase by up to 13%. Two categories of surgery for POP include obliterative and reconstructive surgery. Patient health status, goals, and desired outcomes must be carefully considered when selecting a surgical approach, as obliterative surgeries result in an inability to have sexual intercourse postoperatively. MATERIALS AND METHODS: This review article covers the role of traditional native tissue repairs, surgical options and techniques for vaginal and abdominal reconstruction for POP and the associated complications, and considerations for prevention and management of post-cystectomy vaginal prolapse. RESULTS: Studies comparing native and augmented anterior repairs demonstrate better anatomic outcomes in patients with mesh at the cost of more surgical complications, while different procedures for posterior repair result in similar improvements in symptoms and quality of life. In the management of apical prolapse, vaginal obliterative repair, namely colpocleisis, results in very low risk of recurrence at the cost of the impossibility of having sexual intercourse postoperatively. Reconstructive procedures preserve vaginal length along with the ability to have intercourse, but show higher failure rates over time. They can be divided into vaginal approaches which include sacrospinous ligament fixation (SSLF) and uterosacral vaginal vault suspension (USVS), and the abdominal approach which primarily includes abdominal sacrocolpopexy (ASC). There is evidence that ASC confers a distinct advantage over vaginal approaches with respect to symptom recurrence, sexual function, and quality of life. Patients who have had radical cystectomy for bladder cancer are at an increased risk of POP, and may benefit from preventative measures and prophylactic repair during surgery. Importantly, the success rates of POP surgery vary depending on whether anatomic or clinical definitions of success are used, with success rates improving when metrics such as the presence of symptoms are incorporated. CONCLUSIONS: The surgical management of POP should greatly take into account the postoperative goals of every patient, as different approaches result in different sexual and quality of life outcomes. It is important to consider clinical metrics in the evaluation of success for POP surgery as opposed to using exclusively anatomic criteria. Preoperative counseling is critical in managing expectations and increasing patient satisfaction postoperatively.

Management of urinary incontinence following treatment of prostate disease.

INTRODUCTION Men who undergo treatment for prostate disease are at increased risk of urinary incontinence (UI). UI has a known negative impact on patient quality of life. Once a thorough evaluation has been performed, there are effective modalities for treatment that can be tailored to the patient. MATERIALS AND METHODS: This review article provides the most recent evidence-based work up and management for men with incontinence after prostate treatment (IPT). Etiology, prophylactic measures, work up, surgical treatments, and patient considerations will be covered. The more recent adjustable balloon device is included in this publication as well as more traditional treatments like the artificial urinary sphincter (AUS) and male urethral sling. RESULTS: IPT can result from treatment of either benign or malignant prostate disease whether surgery or radiotherapy are utilized. Stress urinary incontinence (SUI), urge urinary incontinence (UUI), or mixed urinary incontinence (MUI) are all possibilities. SUI after radical prostatectomy (RP) is the most common form of IPT. Patient education and implementation of pelvic therapy as well as modern surgical techniques have greatly improved continence results. AUS remains the gold standard of SUI treatment with the broadest category of patient eligibility. Patients experiencing UUI should be treated according to the overactive bladder guidelines. CONCLUSIONS: For men with IPT, it is crucial to first take a thorough patient history and delineate the exact nature of UI symptoms which will determine the options for management. Patient factors and preferences must also be taken into consideration when ultimately choosing the appropriate intervention.

The use of individualized 3D-printed models on trainee and patient education, and surgical planning for robotic partial nephrectomies.

3D printing is a growing tool in surgical education to visualize and teach complex procedures. Previous studies demonstrating the usefulness of 3D models as teaching tools for partial nephrectomy used highly detailed models costing between $250 and 1000. We aimed to create thorough, inexpensive 3D models to accelerate learning for trainees and increase health literacy in patients. Patient-specific, cost-effective ($30-50) 3D models of the affected urologic structures were created using pre-operative imaging of 40 patients undergoing partial nephrectomy at Thomas Jefferson University Hospital (TJUH) between July 2020 and May 2021. Patients undergoing surgery filled out a survey before and after seeing the model to assess patient understanding of their kidney, pathophysiology, surgical procedure, and risks of surgery. Three urological residents, one fellow, and six attendings filled out separate surveys to assess their surgical plan and confidence before and after seeing the model. In a third survey, they ranked how much the model helped their comprehension and confidence during surgery. Patient understanding of all four subjects significantly improved after seeing the 3D model (P < 0.001). The urology residents (P < 0.001) and fellow (P < 0.001) reported significantly increased self-confidence after interacting with the model. Attending surgeon confidence increased significantly after seeing the 3D model (P < 0.01) as well. Cost-effective 3D models are effective learning tools and assist with the evaluation of patients presenting with renal masses, and increase patient, resident, and fellow understanding in partial nephrectomies. Further research should continue to explore the utility of inexpensive models in other urologic procedures.

Volumetric Quantitative Contrast-enhanced Ultrasonography Evaluation of Complex Renal Cysts: An Adjunctive Metric to the Bosniak Classification System to Predict Malignancy.

BACKGROUND: Management of complex renal cysts is guided by the Bosniak classification system, which may be inadequate for risk stratification of patients for intervention. Fractional tumor vascularity (FV) calculated from volumetric contrast-enhanced ultrasound (CEUS) images may provide additional useful information. OBJECTIVE: To evaluate CEUS and FV calculation for risk stratification of patients with complex renal cysts. DESIGN, SETTING, AND PARTICIPANTS: This was a pilot prospective study with institutional review board approval involving patients undergoing surgery for Bosniak IIF-IV complex renal cysts. CEUS was performed preoperatively on the day of surgery with two-dimensional (2D) and three-dimensional (3D) imaging and sulfur hexafluoride lipid-type A microspheres as the ultrasound contrast agent. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A custom MATLAB program was used to select regions of interest on CEUS scans. FV was calculated according to FV = 1 - (total nonenhancing area/total lesion area). We assessed the ability of 2D- and 3D-derived percentage FV (2DFV%, and 3DFV%) and Bosniak classification schemes (pre-2019 [P2019B] and post-2019 [B2019]) to predict malignancy, aggressive histology, and upstaging on surgical pathology. Performance was assessed as area under the receiver operating characteristic curve (AUC). RESULTS AND LIMITATIONS: Twenty eligible patients were included in final analysis, of whom 85% (n = 17) had Bosniak IV cysts and 85% (n = 17) had malignant disease on final pathology. Four (24%) of the malignant lesions were International Society of Urological Pathology grade 3-4. The AUC for predicting malignancy was 0.980, 0.824, 0.863, and 0.824 with P2019B, B2019, 2DFV%, and 3DFV%, respectively. When the Bosniak classification was combined with FV%, three models had an AUC of 1, while the combined 2DFV% + B2019 model had AUC of 0.980. CONCLUSIONS: FV is a novel metric for evaluating complex cystic renal masses and enhances the ability of the Bosniak classification system to predict malignancy. This metric may serve as an adjunct in risk stratification for surgical intervention. Further prospective evaluation is warranted. PATIENT SUMMARY: Cysts in the kidney are currently classified using a scheme called the Bosniak system. We assessed measurement of the percentage of vascular tissue (called fractional vascularity) in cysts on a special type of ultrasound scan. This promising test adds information when combined with the Bosniak system and can help in guiding appropriate treatment.

Palliative Endoscopic Treatment of Metastatic Uveal Melanoma to the Upper and Lower Urinary Tract.

We report a rare case of uveal melanoma demonstrating simultaneous metastatic foci to the upper and lower urinary tract. A 60-year-old woman, with metastatic uveal melanoma, was referred for incidental right hydronephrosis. Diagnostic cystoscopy and ureteroscopy confirmed the diagnosis of metastatic malignant melanoma to the bladder and kidney. Both tumor resection and coagulation were possible with the neodymium/holmium laser combination. The goals of treatment in metastatic patients should be cessation of hematuria and relief of obstruction with preservation of functional renal reserve while minimizing morbidity.