Prostate Cancer: Under-representation of African American Men in Research Studies Used in the Latest NCCN Guidelines.

OBJECTIVE: To evaluate racial data in studies used in current NCCN prostate cancer guidelines. These guidelines represent the latest information that informs clinical practice. Prostate cancer disproportionately affects mortality in Black patients compared to White patients at a 2.1-fold higher death rate. However, this racial disparity is not accounted for when including patients in research. METHODS: The studies referenced in the latest NCCN guidelines were evaluated for inclusion of racial demographics, and whether they properly account for the higher mortality rate of prostate cancer seen in Black patients. We then analyzed topics within prostate cancer. RESULTS: After application of exclusion criteria, 547 of 878 studies were included for analysis; of those, only 32.4% included demographic data. Overall, Black patients accounted for 472,476 (12.8%) of total patients, while 3,023,007 (81.7%) patients were White. These findings were consistent with specific areas including risk stratification (12% vs 75%), imaging and staging (11% vs 80%), treatment (16% vs 81%), recurrence (15% vs 73%), castration-sensitive prostate cancer (9% vs 84%), castration-resistant prostate cancer (8% vs 73%), and metastatic bone disease (7% vs 84%). CONCLUSION: Our analysis showed consistently that although the guidelines utilize the best research, such studies often do not report racial demographics or have patient populations that do not reflect racial differences in mortality of prostate cancer. Our study questions the generalization of these studies to Black patients. Future research should emphasize inclusion of racial demographics and recruit appropriately representative study cohorts.

Congenital Anterior Urethral Diverticulum in Identical Twins.

Congenital anterior urethral diverticulum (CAUD) is an uncommon abnormality of the male urethra. In the literature, cases of CAUD affecting both children within a set of identical twins or presenting concomitantly with another urethral condition are exceedingly rare. We describe 2 cases of CAUD in identical twins: a pair of newborns in which Twin 1A and Twin 1B both present with CAUD, and a second pair of newborns in which only Twin 2A presents with CAUD along with a partial collateral urethral duplication. In doing so, we aim to add to the incomplete literature on the embryological development of CAUD.

A 40-Year Litigation Review of Transurethral Surgeries for Benign Prostatic Hyperplasia.

OBJECTIVE: To describe litigation patterns of transurethral surgery in the treatment of benign prostatic hyperplasia including verdicts, types of lawsuits, plaintiff claims, and timing of the claims. METHODS: Data was gathered by searching for litigation cases between January 1, 1980 and December 1, 2021 in the Westlaw legal database using keywords for transurethral surgeries for benign prostatic hyperplasia. Extracted data included case type, general description of the plaintiffs and defendants, plaintiff claims, and whether the claim involved preoperative, perioperative, or postoperative management, verdict, and indemnity awards. RESULTS: The Westlaw search yielded 44 unique cases after removing duplicate and irrelevant cases. The most common surgery resulting in a lawsuit was transurethral resection of the prostate (70%) and urologists were the most frequently named defendant (80%). The most common plaintiff claims were sexual dysfunction (36%), irritative lower urinary tract symptoms (32%), and lack of consent (27%). Among malpractice cases, the verdict was in favor of the defendant in most cases (71%) and among Eighth Amendment violation cases, the verdict was in favor of the defendant in every case. The average indemnity payment was $565,845 and the highest indemnity payment was $1,020,000. CONCLUSION: Complications of transurethral surgeries and lack of consent are common reasons for patient's filing a lawsuit. Healthcare providers should ensure patient understanding of surgical risks and thoroughly document the conversation. Providers should be aware of the causes for litigation among transurethral surgeries for benign prostatic hyperplasia and of the possibility of Eighth Amendment violation lawsuits when treating prison inmates.

Isolated perinephric lymphoma: A distinct presentation of primary lymphoma.

Isolated perinephric lymphoma is a rare presentation of primary lymphoma. We report a case of a 77-year-old male who was incidentally found to have isolated left perinephric lymphoma. We outline the diagnostic work up and subsequent diagnosis of lymphoma as well as the considerations that guided management. Ultimately, bone marrow biopsy and PET-CT were used as diagnostic tools to assess for systemic disease and the patient was managed with observation and interval follow-up imaging.

Determining the component-based operative time learning curve for robotic-assisted radical prostatectomy.

Objectives: To determine the learning curve (LC) of total operative time and the discrete components of the robotic-assisted radical prostatectomy (RARP) for a recent robotic fellowship-trained urologic surgeon. Materials and methods: We performed a retrospective analysis of RARP procedures performed by a single new attending surgeon from August 2015 to April 2019. Patients' demographics and operative details were assessed. Total operative time was divided and prospectively recorded in 7 parts: (a) docking robot, (b) dissecting seminal vesicles (SVs) (c) dissecting endopelvic fascia (EPF), (d) incising bladder neck (BN), (e) completing the dissection, (f) lymph node dissection, and (g) urethrovesical anastomosis (UVA) and robot undocking. Cumulative sum analysis was used to ascertain the LC for total operative time and the 7 parts of the procedure. Results: One hundred twenty consecutive RARPs were performed. The LC was overcome at 25 cases for total operative time, 13 cases for docking the robot, 33 cases for dissecting SVs, 31 cases for dissecting EPF, 46 cases for incising BN, 38 cases for prostate dissection, 25 cases for lymph node dissection, and 52 cases for UVA. Total operative time was decreased 22.8% (p < 0.0001) and time for robot docking, dissecting SVs, dissecting EPF, incising BN, completing prostate dissection, lymph node dissection, and UVA were decreased 16.7%, 30.5%, 29.5%, 36.2%, 37.3%, 32.2%, and 26.9%, respectively (all p < 0.05). Conclusions: We observed a 25-case LC for a fellowship-trained urologist to achieve stable operative performance of RARP surgery. Procedural components demonstrated variable LCs including the UVA that required upward of 52 cases.

Medical malpractice in stress urinary incontinence management: A 30-year legal database review.

BACKGROUND: The purpose of this study is to investigate the most common reasons for and judicial outcomes of malpractice claims related to stress urinary incontinence (SUI) management. MATERIALS AND METHODS: Using the Westlaw database, a search was performed using the terms "medical malpractice" or "negligence" in combination with "stress incontinence" or "stress urinary incontinence" between January 1, 1990 and January 1, 2020. Extracted information included trial date, demographic information, defendant profession, procedure performed, procedure complications, alleged malpractice, trial outcome, and monetary award. Data were analyzed using descriptive statistics. RESULTS: The Westlaw search yielded 79 case results. Of the cases, 70.4% (n = 38/54) had a defense verdict, 22.2% (n = 12/54) had a plaintiff verdict, and 7.4% (n = 4/54) were settled. The most commonly implicated procedure was mid-urethral sling (63.2%, n = 36/57). Among the plaintiffs, 48.4% (n = 61/126) claimed negligence in preoperative care, 33.3% (n = 42/126) claimed negligence in surgical performance, and 18.3% (n = 23/126) claimed negligence in postoperative care. Lack of informed consent was the most common complaint related to negligence in preoperative care (42.6%, n = 26/61). The average indemnity payment was $1,253,644 for preoperative care negligence, $1,254,491 for surgical performance negligence, and $2,239,198 for postoperative care negligence. Of the defendants, 63.4% (n = 52) were gynecologists and 36.6% (n = 30) were urologists. CONCLUSIONS: Negligent preoperative care, with a particular emphasis on failure to obtain informed consent, and negligent surgical performance are the leading causes of malpractice claims during SUI management. Mid-urethral sling was the most commonly litigated procedure. This study highlights key factors to consider in minimizing malpractice risk during SUI management.

Small lymphocytic lymphoma of the prostate mimicking a PIRADS 5 lesion that resolved after systemic treatment.

Prostatic PIRADS 4 and 5 lesions on multiparametric MRI typically represent adenocarcinoma with small lymphocytic lymphoma being a rare pathological finding. We report a case of small lymphocytic lymphoma masquerading as PIRADS 4 and 5 lesions with associated lymphadenopathy in a 69-year-old male on active surveillance for low-risk prostate cancer that was subsequently confirmed on targeted and systematic prostate biopsy. Following treatment of lymphoma with ibrutinib, there was complete resolution of the PIRADS lesions on follow-up mpMRI.

Finding the Next Resident Physicians in the COVID-19 Global Pandemic: An Applicant Survey on the 2020 Virtual Urology Residency Match.

OBJECTIVE: To assess interviewing applicant perceptions of a virtual urology residency interview in the setting of changes mandated by COVID-19 and to determine applicant preference for virtual or in person interviews. Applicant perceptions of multiple interview components were queried to identify program specific and interview modality specific strengths or weaknesses in the 2020 to 2021 Urology Match. METHODS: A 12 question multiple choice and free text survey was emailed to 66 virtually interviewed applicants for open residency positions at a metropolitan training program after conclusion of interviews. Items of interest included interview type preference, overall interview impression, and recommendations for improvement. RESULTS: A total of 50 of 66 (76%) applicants completed the survey corresponding to approximately 11% of the 2020 national urology applicant pool. A total of 49 of 50 (96%) respondents assessed faculty interaction and the virtual platform positively. A total of 38 of 50 (76%) was satisfied with their resident interaction and 32 of 50 (64%) applicants stated they were able to satisfactorily evaluate the site and program. Ultimately, 39 of 50 (78%) respondents would have preferred an in person interview to our virtual interview. Respondents cited challenges in assessing program culture and program physical site virtually. CONCLUSION: The majority of survey respondents indicated a preference for in person interviews. A smaller proportion of applicants preferred virtual interviews citing their convenience and lower cost. Efforts to improve the virtual interview experience may focus on improving applicant-resident interaction and remote site assessment.

Evolving case of emphysematous pyelonephritis in a second renal allograft.

Emphysematous pyelonephritis is an acute necrotizing infection with gas in the kidney that portends a poor prognosis. Patients present with sepsis, requiring fluid resuscitation, glucose control, and broad-spectrum antibiotics. Surgical intervention ranges from relief of urinary obstruction (nephrostomy tube or stent), percutaneous drainage or nephrectomy. We present a 51-year-old second kidney transplant recipient diabetic male, suffering from sepsis of unknown etiology which was subsequently revealed to be due to emphysematous pyelonephritis. Percutaneous drainage was performed initially followed by renal transplant nephrectomy after no improvement of his clinical status. Herein, we describe the clinical course and escalation in management.

Review of Priapism Litigation in the United States.

OBJECTIVES: To review medical malpractice trends and to identify the most common claims filed against medical providers for the management of patients with priapism. METHODS: Using the Westlaw legal database, a search was done for the keyword "priapism" between July 1, 1980 and July 1, 2020. Cases were evaluated for plaintiff demographics, reasons for filing claims, management outcomes, legal verdicts and awards and further categorized based upon the timing of the alleged malpractice. RESULTS: Alleged negligence during the pre-management period was cited in 30 cases. Administration of psychotropic medications was the most common reasons for filing pre-management claims 22/56 (39.3%). Delay in care accounted for 18/56 (32.1%) and complications of surgery were 5/56 (8.9%) of claims. The majority of the completed cases were in favor of the defendants (39/47; 83.0%). There was no association between type of health care provider or timing of alleged malpractice and ultimate verdict. CONCLUSIONS: Prescribing psychoactive medications without warning of the adverse effect profile is the most common reason for claims filed against providers with trazodone as the leading medication. Medical providers should ensure that patients are well informed of this adverse effect prior to prescription. Regardless, the majority of medical malpractice cases carry a verdict in favor of the defendant.

Virtual grand rounds as a novel means for applicants and programs to connect in the era of COVID-19.

BACKGROUND: COVID-19 has disrupted the 2020-2021 residency application cycle with the cancellation of away rotations and in-person interviews. This study seeks to investigate the feasibility and utility of video conferencing technology (VCT) as an opportunity for applicants to interact with faculty from outside programs. METHODS: 18 prospective urology applicants were randomized to 6 urology programs to give a virtual grand rounds (VGR) talk. Presentations were recorded and analyzed to determine audience engagement. Students were surveyed regarding perceived utility of VGR. Faculty were surveyed to determine system usability of VCT and ability to evaluate the applicant. RESULTS: 17 students completed the survey, reporting a 100% satisfaction rate with VGR. A majority felt this was a useful way to learn about outside programs. 85 physicians completed the faculty survey, with nearly half feeling confident in their ability to evaluate the applicant. Video transcription data shows sessions were interactive with minimal distractions. CONCLUSIONS: VGR can be a useful means for medical students to express interest in programs as well as an additional marker for faculty to evaluate applicants.

A 30-Year Review of Cystectomy Litigation.

INTRODUCTION: Annually the U.S. spends approximately $55.6 billion on malpractice and medical liability, with urology ranked 11th out of 25 specialties for number of malpractice claims. Our objective was to identify common causes for filing claims associated with cystectomy as well as corresponding payout outcomes. METHODS: Using the Westlaw® legal database, a search was conducted using the keywords, "cystectomy," "cystoprostatectomy" and "bladder removal" between January 1, 1990 and January 1, 2020. Each case was evaluated for plaintiff demographics, alleged malpractice claim, defendant specialty, resulting clinical outcome, resulting legal outcome including verdict and monetary award. Alleged malpractice claims were further subdivided based on whether the claimed negligence of duty was preoperative, perioperative or postoperative. Data were analyzed using Microsoft® Office Excel®. RESULTS: After accounting for irrelevant and duplicate cases the Westlaw search returned 42 unique cases. The most common indication for cystectomy was bladder cancer (69%). Preoperative negligence resulted in the highest average payout ($2,062,204.00) and accounted for 76% of filed claims, with delay in diagnosis accounting for the most common complaint (47%). Urologists made up the highest percentage of defendants sued, at 62%. CONCLUSIONS: The bulk of alleged malpractice in cystectomy cases is due to preoperative negligence, most predominantly in the delay of cancer diagnosis. Alleged cases of preoperative negligence also return the highest award for the plaintiff. This study sheds light on areas of concern that urologists should be aware of associated with cystectomy litigation.

Video-Based Coaching as an Educational Platform for Urological Residency Training: A Pilot Study.

INTRODUCTION: Surgical experience requires skills traditionally taught through real-time operating room education and a variety of supplemental educational strategies. Video-based coaching is a modality that may offer potential advantages of immediate, direct and targeted feedback. The objective of this study was to demonstrate and evaluate the utility and educational value of video-based coaching in urology by conducting a qualitative analysis with a coding schema. METHODS: Residents and attendings were recorded operating during randomly selected cases in the operating room. Video-based coaching sessions were held during urology grand rounds and required residents to describe a selected portion of the operating room video and attendings to provide teaching points. Audio recordings from the operating room and video-based coaching sessions were reviewed by 2 independent coders. A coding scale classifying surgical educational goals into 5 categories (information, operative technique, questioning, response to resident interaction and unrelated commenting) was used to identify the interactions and was adjusted for time. RESULTS: Four urological cases were selected for recording. In the video-based coaching sessions compared to the operating room, attendings made more teaching points per hour, provided more information to residents (mean teaching points 7.7 for video-based coaching vs 2.9 for operating room, p <0.005), emphasized operative skills and technique (mean teaching points 10.5 for video-based coaching vs 4.1 for operating room, p <0.005), and were more likely to ask open-ended discussion leading questions (mean teaching points 28.5 for video-based coaching vs 4.4 for operating room, p <0.05). CONCLUSIONS: Video-based coaching delivered in short time frames offers an easily implementable additional learning opportunity for resident education to further enhance skills learned in the urological operating room.

Litigation Patterns in Oncologic Nephrectomies: A 30-Year Review.

Introduction: The litigious environment encompassing the medical-legal domain is an increasing concern for surgical fields, with urology being no exception. The objective of our study was to systematically review, evaluate, and summarize the factors associated with oncologic nephrectomy litigation to determine possible factors contributing to verdicts or settlements. Materials and Methods: Publicly available verdict reports were retrieved using the Westlaw® legal database (Reuters). Cases were identified using the search term "nephrectomy" with dates ranging from January 1, 1990 to July 1, 2019. Each case was evaluated by two independent reviewers for defendant specialty, alleged breach in treatment, resulting complications, verdict outcomes, and indemnity payment. Complications were determined to be preoperative, perioperative, and postoperative. Data were analyzed using SPSS software to produce the descriptive statistics. Results: After accounting for duplicates and irrelevant cases, a total of 103 cases were analyzed with more than three-fourths being radical nephrectomies (78%). The most common claim was preoperative negligence (48%); however, negligence in perioperative care received the highest average monetary payment of $5,493,151. Forty-one percent of cases were perioperative with the majority being attributed to vascular injury (46%). The type of perioperative negligence claims and its average payment were found to be statistically significant (p = 0.042). Overall, 57% of cases denied the plaintiff's claims, whereas 28% were awarded. Conclusions: Our data show that although the highest number of cases were caused by preoperative negligence, perioperative negligence accounts for the highest settlement awards. This review provides insights into stages of management in the surgical management of renal cell cancer patients that may be subject to litigation.

Aquablation for the Treatment of Benign Prostatic Hyperplasia in a Large Volume Prostate with an Intravesical Median Lobe.

Background: Aquablation is a relatively new minimally invasive technology for the treatment of benign prostatic hyperplasia (BPH) that has shown significant promise in its clinical efficacy and utility. Larger prostates or prostates with a median lobe are a common limitation to other minimally invasive treatment options. There is evidence that Aquablation maintains efficacy for larger prostates and prostates with an intravesical median lobe. Herein, we describe 3-month follow-up results for a patient who underwent Aquablation for a large prostate with a significant intravesical median lobe. Case: Our patient is a 72-year-old man with lower urinary tract symptoms secondary to BPH refractory to pharmacotherapy. Patient underwent Aquablation of the prostate, which was 110 cc in volume and had a large intravesical median lobe component. At 3-month follow-up patient had reduction in his AUA-SS from 21 to 12, improvement in uroflow from 8.2 to 16 mL/second, and improvement in postvoid residual from 90 to 13 mL. Conclusion: Aquablation has been shown to be efficacious for the treatment of BPH in patients with large prostates and intravesical median lobes. This case report further demonstrates effective treatment for patients who fit this profile.

Persistent Lower Urinary Tract Symptoms After Prostatic Urethral Lift Successfully Treated with Water Jet Ablation of the Prostate: A Case Report and Review of the Literature.

Background: We describe a patient who underwent waterjet ablation of the prostate after an unsuccessful prostatic urethral lift (PUL) procedure. Case Presentation: After PUL, our patient had incomplete bladder emptying with a postvoid residual of 600 mL. Urodynamic study of the bladder suggested detrusor underactivity. Our patient was motivated to undergo a salvage bladder outlet surgery. At 3 months after Aquablation, he reported complete resolution of bothersome lower urinary tract symptoms (LUTS). Conclusion: This case report illustrates return of volitional voiding and significant improvement in LUTS after salvage bladder outlet treatment with waterjet ablation of the prostate.