Patient Satisfaction with a Novel Tele-Cystoscopy Model: Expanding Access to Bladder Cancer Surveillance for Rural Patients.

Background: Tele-cystoscopy involves trained advanced practice providers performing cystoscopy with real-time interpretation by an urologist. The goal of this externally validated care model is to expand the availability of cystoscopy to underserved rural areas. Herein we report on population demographics and describe the socioeconomic benefits of tele-cystoscopy for bladder cancer surveillance. Methods: Using an IRB-approved protocol, patients were consented for dual, sequential cystoscopy wherein they experienced a standard-of-care cystoscopy along with tele-cystoscopy. Patients completed a questionnaire that contained both subjective and objective health and socioeconomic-related questions as well as a satisfaction survey. Patients were also probed about factors associated with transportation to their cystoscopy appointments including gasoline costs, travel time, and time off work. Using the Distressed Community Index, patients were ascribed an economic resource category ranging from prosperous to distressed. Results: In total, 48 patients with a mean age of 55 completed surveys after completing dual cystoscopies. Thirteen patients (27%) were uninsured and 10 patients (20%) had Medicaid as primary insurance. The tele-cystoscopy clinic saved patients an average of 235 miles and 434 min of travel time. In total, 82% of patients resided in a distressed community indicating fewer economic resources. Satisfaction results showed a mean score of 31.38 (out of 32). Conclusions: Patients were satisfied with tele-cystoscopy, noting increased access to health care and fewer disruptions impacting bladder cancer surveillance. Tele-cystoscopy may be a viable option to expand access and improve adherence to guidelines for bladder cancer surveillance, particularly benefiting patients in rural areas and those of lower socioeconomic status.

Use of a Convex Pouching System in the Postoperative Period: A National Consensus.

Convex pouching systems have been available for ostomy patients for decades; however, controversy remains over the use of convexity in the postoperative period. A group of 10 nurses and physicians with expertise caring for patients with an ostomy completed a scoping review identifying research-based evidence and gaps in our knowledge of the safety and effectiveness related to the use of a convex pouching system following ostomy surgery. Results of this scoping review demonstrated the need for a structured consensus to define best practices when selecting a pouching system that provides a secure and reliable seal around the stoma, avoids undermining and leakage of effluent from the pouching system, and contributes to optimal health-related quality of life for patients following ostomy surgery. The expert panel reached consensus on 8 statements for the use of convex products immediately after surgery and throughout the first 6 months after stoma creation, as well as describing goals in choosing the best pouching system for the patient with an ostomy.

Survey Results on Use of a Convex Pouching System in the Postoperative Period.

PURPOSE: The purpose of this study was to validate time frames for postoperative care following stoma surgery and to determine participants' current practice with convex pouching systems during the postoperative period. DESIGN: A Cross-sectional survey. SUBJECTS AND SETTING: The sample comprised 332 ostomy care specialists practicing in the United States. Most (n = 220; 66%) had more than 10 years' experience caring for patients with ostomies, 82% (n = 272) were certified WOC or ostomy care nurses (CWOCN and COCN), and 7% (n = 23) were board-certified colorectal surgeons. METHODS: A 23-item online questionnaire was created for purposes of the study. Items in the questionnaire queried professional background and experience caring for patients with an ostomy. A single item was used to identify postoperative care periods following ostomy surgery. Additional items queried current practice patterns related to use of convex pouching systems and the timing of their use. Data were collected from January 18 to February 8, 2021. RESULTS: Most respondents (n = 270; 90%) agreed with the following postoperative periods after ostomy surgery: immediate postoperative period (days 0-8); postoperative period (days 9-30); and transition phase (days 31-180). Most respondents (n = 274; 95%) indicated they would use a convex pouching system when clinically appropriate during the first 30 days following ostomy surgery and 79% (n = 228) indicated using a convex pouching system regardless of when the surgery was performed. Less than 1% (n = 2) indicated never using convexity within the first 30 days following stoma surgery, and only 3% (n = 8) indicated avoidance of convexity pouching systems in the immediate postoperative period. CONCLUSIONS: Findings indicate that use of convexity during the postoperative period is prevalent to provide a secure seal and predictable wear time.

Optimizing Telemedicine Technologic Infrastructure with Animal Models: A Case in Telecystoscopy.

Background: Rapid evolution of telemedicine technology requires procedures in telemedicine to adapt frequently. An example in urology, telecystoscopy, allows certified advanced practice providers to perform cystoscopy, endoscopic examination of the bladder, in rural areas with real-time interpretation and guidance by an off-site urologist. We have previously shown the technological infrastructure for optimized video quality. Introduction: Newer models of cystoscope and coder/decoder (codec) are available with anticipation that components used in our original model will become unavailable. Our objective is to assess the diagnostic ability of two cystoscopes (Storz, Wolf) with old (SX20) and new (DX70) codecs. Materials and Methods: A single urologist performed flexible cystoscopy on an ex vivo porcine bladder. Combinations of cystoscope (Storz vs. Wolf), codec (SX20 vs. DX70), and internet transmission speed were used to create eight distinct recordings. Deidentified videos were reviewed by expert urologist reviewers via electronic survey with questions on video quality and diagnostic ability. A logistic regression model was used to assess the ability to make a diagnosis. Results: Eight transmitted cystoscopy videos were reviewed by 16 urologists. Despite new technology, the Storz cystoscope combined with the SX20 codec (the original combination) provides the best diagnostic capacity. Discussion: Technical infrastructure must be routinely validated to assess the component impact on overall quality because newer is not always better. Should the SX20 become obsolete, ex vivo animal models are safe, inexpensive anatomic models for testing. Conclusions: As technology continues to evolve, procedures in telemedicine must critically scrutinize the impact of new technologic components to uphold quality.

Telehealth Management of Urostomy Postoperative Complications: A Case Study.

BACKGROUND: Surgical creation of a urostomy with or without radical cystectomy is a common urologic procedure. Despite advances in techniques, ostomy and surgical-related postoperative complications are prevalent and may impair physical recovery and health quality of life. Restrictions in face-to-face clinic visits created by the coronavirus disease-2019 (COVID-19) pandemic have dramatically altered care for patients with a new urostomy. CASE: This case report describes our management approaches using telemedicine and complementary communication strategies during the recent COVID-19 pandemic for a patient with multiple complex chronic conditions and multiple stoma and related postoperative complications. CONCLUSIONS: Despite challenges imposed during the COVID-19 pandemic, we were able to manage multiple surgical- and ostomy-related complications using a combination of telecommunication techniques that mitigated the need for routine and urgent postoperative clinic visits, hospital readmission, or unplanned visits to an emergency department. The new onset use of telemedicine approaches (telephone, televideo, and direct telemedicine) and various Health Insurance and Portability and Accountability Act-secure platforms due to pandemic conditions can improve access to care.

Blinded Comparison of Clarity, Proficiency and Diagnostic Capability of Tele-Cystoscopy Compared to Traditional Cystoscopy: A Pilot Study.

PURPOSE: In order to expand the availability of cystoscopy to underserved areas we have proposed using advanced practice providers to perform cystoscopy with real-time interpretation by the urologist on a telemedicine platform, termed "tele-cystoscopy." The purpose of this study is to have blinded external reviewers retrospectively compare multisite, prospectively collected video data from tele-cystoscopy with the video of traditional cystoscopy in terms of video clarity, practitioner proficiency and diagnostic capability. MATERIALS AND METHODS: Each patient underwent tele-cystoscopy by a trained advanced practice provider and traditional cystoscopy with an onsite urologist. Prospectively collected tele-cystoscopy transmitted video, tele-cystoscopy onsite video and traditional cystoscopy video were de-identified and blinded to external reviewers. Each video was evaluated and rated twice by independent reviewers and diagnostic agreement was quantified. RESULTS: Six tele-cystoscopy encounters were reviewed for a total of 36 assessments. Video clarity, defined by speed of transmission and image resolution, was better for onsite compared to transmitted tele-cystoscopy. Practitioner proficiency for thoroughness of inspection was rated at 92% for tele-cystoscopy and 100% for traditional cystoscopy. Confidence in identification of an abnormality was equivalent. Four of 6 videos had 100% agreement between reviewers for next action taken, indicating high diagnostic agreement. Additionally, provider performing cystoscopy and location did not statistically influence the ability to make a diagnosis or action taken. CONCLUSIONS: This model has excellent completeness of examination, equivalent ability to identify abnormalities and external validation of action taken. This pilot study demonstrates that tele-cystoscopy may expand access to bladder cancer surveillance.

Tele-Urology During COVID-19: Rapid Implementation of Remote Video Visits.

INTRODUCTION: COVID-19 has brought unprecedented challenges to the delivery of urological care. Following rapid implementation of remote video visits at our tertiary academic medical center serving a large rural population we describe and assess our experience with planned video visits and ongoing scheduling efforts. METHODS: Patients scheduled for video visits between April 14 and April 27, 2020 were included. Prospective and retrospective data were collected on patient and clinical characteristics as well as telemedicine outcomes. Multivariable logistic regression was performed to evaluate factors influencing video visit success. Concurrently scheduling data were collected from a separate cohort regarding patient access to technology and willingness to participate in video visits. RESULTS: A total of 209 patients were included with an overall video visit success rate of 67%. Of video visits that failed (69) reasons included no-show (35%), inability to connect to the telemedicine platform (23%) and lack of Internet access (10%). Nearly half of failed video visits (46.4%) were completed as phone visits. After adjustment for patient demographics commercial insurance was significantly associated with video visit success. In assessment of scheduling outcomes 179 patients were contacted to offer video visits. Of these patients 6.7% reported not having Internet access. Of those with Internet access 87% agreed to proceed with a video visit in lieu of visiting in person. CONCLUSIONS: Our experience indicates that rapid implementation of video telemedicine is feasible and highly accepted by patients. Efforts focused on standardized pre-visit patient education may further optimize successful telemedicine visits.

Understanding Advanced Prostate Cancer Decision Making Utilizing an Interactive Decision Aid.

BACKGROUND: Prostate cancer is the most commonly diagnosed cancer and the second leading cause of cancer deaths among men in the United States. Patients with advanced prostate cancer are vulnerable to difficult treatment decisions because of the nature of their disease. OBJECTIVE: The aims of this study were to describe and understand the lived experience of patients with advanced prostate cancer and their decision partners who utilized an interactive decision aid, DecisionKEYS, to make informed, shared treatment decisions. METHODS: This qualitative study uses a phenomenological approach that included a sample of 35 pairs of patients and their decision partners (16 pairs reflected patients with <6 months since their diagnosis of metastatic castration-resistant prostate cancer; 19 pairs reflected patients with >6 months since their diagnosis of metastatic castration-resistant prostate cancer). Qualitative analysis of semistructured interviews was conducted describing the lived experience of patients with advanced prostate cancer and their decision partners using an interactive decision aid. RESULTS: Three major themes emerged: (1) the decision aid facilitated understanding of treatment options; (2) quality of life was more important than quantity of life; and (3) contact with healthcare providers greatly influenced decisions. CONCLUSIONS: Participants believed the decision aid helped them become more aware of their personal values, assisted in their treatment decision making, and facilitated an interactive patient-healthcare provider relationship. IMPLICATIONS FOR PRACTICE: Decision aids assist patients, decision partners, and healthcare providers make satisfying treatment decisions that affect quality/quantity of life. These findings are important for understanding the experiences of patients who have to make difficult decisions.

Care of the patient undergoing radical cystectomy with a robotic approach.

Radical cystectomy or cystoprostatectomy with urinary diversion is the gold standard for the treatment of muscle-invasive bladder cancer. Cystectomy can be through an open or robotic-assisted laparoscopic approach. Advances in laparoscopy, robotic surgery, and urological oncology have made it possible for select surgeons to perform nerve-sparing robotic-assisted laparoscopic radical cystoprostatectomy. Advantages of robotic surgery may be minimal blood loss, shorter hospital stay, quicker recovery, and possibly more precise and rapid removal of the bladder depending on the experience and expertise of the surgeon. Appropriate patient selection and thorough pre-operative evaluation, however, are key in maximizing positive surgical outcomes. The experience at the University of Virginia with robotic-assisted laparoscopic radical cystectomy will be discussed.

Robotic-assisted laparoscopic cystectomy with ileal conduit for urinary diversion.

This case demonstrates the need for flexibility when approaching major abdominal surgery through a robotic approach. While the case was initiated with robotic technology, it ultimately had to be converted to an open procedure for reasons of patient safety and to ensure a good surgical outcome.

Robotic prostatectomy surgery.

Despite the minimally invasive nature of the robotic prostatectomy procedure, there are still many cultural, environmental, and social issues that must be addressed. The following case study emphasizes that patient education is key to successful outcomes following robotic prostatectomy.

Care of the patient undergoing robotic-assisted prostatectomy.

Prostate cancer has many treatment options. In addition to open retropubic and perineal approaches to radical prostatectomy, laparoscopic robotic prostatectomy is available as a newer surgical option. Potential advantages of robotic surgery include reduced pain and trauma, less blood loss, reduced infection risk, shorter hospital stay, faster recovery, and less scarring (Intuitive Surgical, 2005). A variety of nursing care considerations involving pre-operative education and preparation, intra-operative and immediate postoperative care issues, and long-term followup must be understood to meet the needs of a robotic surgical patient. Patient selection is very important to optimize a positive surgical outcome. Just as certain criteria make a good surgical candidate, there are factors that could complicate the surgery or adversely affect recovery.

NMP-22 for bladder cancer screening and surveillance.

In 2004, more than 56,000 Americans will be diagnosed with bladder cancer (American Cancer Society, 2004). Urethrocystoscopy is considered the gold standard for bladder cancer diagnosis, but it is not a screening test. Researchers have been challenged to develop a noninvasive urine test that reliably differentiates hematuria associated with bladder cancer from that associated with nonmalignant etiologies. Several well-established and some novel tests for bladder cancer screening diagnosis and surveillance, including urinalysis, voided cytology, and the Nuclear Matrix Protein 22 (NMP-22) assay, one of a growing number of assays developed as a specific, sensitive noninvasive test for bladder cancer, are reviewed. Until the sensitivity of the NMP-22 is improved, or another urine assay emerges that provides significantly greater sensitivity while maintaining adequate specificity, urethrocystoscopy will remain the reference test for detecting and diagnosing bladder cancer and its recurrence.

The next generation of medications for kidney transplant patients.

Transplant pharmacotherapy evolves as new agents are investigated and approved for use. Clinical immunosuppression has been plagued with maintaining a balance between rejection of the transplanted organ and complications of over-immunosuppression, including infection and malignancy. Clinicians must understand current immunosuppressive regimens and their associated effects when caring for transplant patients. While all transplant patients receive some form of immunosuppressive therapy, the combinations and choices increase as new drugs are developed. In the critical and acute care settings, newly transplanted patients will likely receive induction therapy. The goal of induction therapy is to increase long-term patient and allograft survival while preventing or reducing rejection episodes. Several agents are available for induction therapy, and each transplant center designs its own protocol. The foundation for maintenance therapy rests on the combining immunosuppressives to prevent rejection through a variety of pathways. An understanding of the mechanism of action and additive effects of a drug allows practitioners to optimize therapy while decreasing adverse effects. Immunosuppressive therapy offers potential for reducing detrimental patient outcomes and improving allograft survival. It is well established that repeated rejection episodes correlate with poor long-term graft survival. Challenges facing researchers and clinicians focus on improved patient outcomes and options to address financial constraints of transplantation.