Minimally Invasive Management of Post-treatment Rectovesical Fistulae.

Objective: The aim of this study is to report our experience in minimally invasive management of rectovesical fistulae (RVFs). Materials and Methods: Between 2004 and 2021, 24 patients who underwent minimally invasive RVF repair by a single surgeon at 3 international institutions were retrospectively reviewed. Baseline demographic characteristics and perioperative and postoperative variables were collected. Complications were reported using the modified Clavien-Dindo Classification System and the European Association of Urology Complication Guidelines Panel Assessment and Recommendations. Fistula repair was defined as confirmation of fistula closure by imaging and complete resolution of fistula-related symptoms at the 12-month follow-up. Continuous variables are reported as medians and quartiles, whereas categorical variables are reported as frequencies and percentages. Results: Twenty-four patients with RVFs were treated: 22 males (91.7%) and 2 females with a median age of 66 (64.2-68) years. Twenty cases (83.3%) occurred postsurgery, three cases (12.5%) after surgery with combined radiotherapy, and one case (4.1%) after a combination of energy treatments. A robotic approach was performed in 19 patients (79%) and laparoscopic approach in 5 patients (21%). Ninety-six percent of patients had previous fecal diversions. No intraoperative complications were recorded. The median operative time was 180 (140-282) minutes, estimated blood loss was 50 (40-125) mL, and length of hospital stay was 2 (2-3) days. There were two Grade II complications and one Grade IIIb complication. All patients met criteria for repair. Conclusions: Minimally invasive management of RVFs is feasible. More studies are needed to assess the role of this approach among all RVF management options.

Minimally Invasive Management of Rectourethral Fistulae.

OBJECTIVE: To report our experience and outcomes in minimally invasive management of rectourethral fistula (RUF). METHODS: From 2004 to 2021, 15 patients who underwent minimally invasive RUF repair by a single surgeon at 2 international institutions were retrospectively reviewed. Baseline demographic characteristics, perioperative, and postoperative data were collected. Complications were reported using the modified Clavien-Dindo Classification System and the European Association of Urology Complication Panel Assesment and Recommendations. Success was defined as complete resolution of fistula-related symptoms at 12-month follow-up along with confirmation of fistula closure by imaging or cystoscopy. Categorical variables were presented as frequencies and percentages whereas continuous variables were reported as median and quartiles. RESULTS: Fifteen male patients with a median age of 71 (64-79.2) years were treated. Four cases (26.6%) occurred postsurgery, 8 cases (53.3%) occurred after energy treatments, and 3 cases (20%) after surgery combined with an energy treatment modality. A robotic and laparoscopic approach was performed in 9 (60%) and 6 (40%) patients, respectively. No intraoperative complications were reported. Median operative time was 264 (217.5-341) minutes, estimated blood loss was 175 (137.5-200) mL, and the length of hospital stay was 4 days. Nine postoperative complications were reported. All patients were followed-up for 12 months with no recurrence reported. All patients reached our criteria for successful RUF repair. CONCLUSIONS: Minimally invasive surgery could represent an efficient way to manage RUF in selected patients. More studies and treatment standardization are needed to assess the role of minimally invasive surgery in the management of RUF.

Massive Malignant Epithelioid Angiomyolipoma of the Kidney.

Renal angiomyolipomas (AMLs) are a subset of perivascular epithelioid cell neoplasms (PEComas) that are associated with tuberous sclerosis complex (TSC). Epithelioid angiomyolipomas (EAMLs) are a rare variant of AML with more aggressive propensities. EAMLs with malignant potential can be difficult to distinguish from relatively benign AMLs and other renal tumors. Although there are no established criteria for predicting EAML malignancy, there are proposed histologic parameters that are associated with higher tumor risk. EAML can be treated with surgical resection as well as mTOR inhibitors. Here, we present a unique case of a patient with a 36-cm renal EAML metastatic to the lungs that was treated with complete surgical resection of the primary lesion and mTOR inhibition.

Robotic Intracorporeal Ileal Conduit Urinary Diversion Technique.

The gold standard surgical treatment for muscle invasive bladder cancer is radical cystectomy and urinary diversion. This procedure has historically been performed as an open surgery. With the advances of robotic surgery, robotic cystectomy and urinary diversion has gained popularity with the ability to perform intracorporeal urinary diversions in addition to extirpative surgery. Herein, we detail our technique for intracorporeal ileal conduit.

The Financial Burden of Applying to Urology Residency in 2020.

OBJECTIVES: To determine contemporary costs of preparing for and applying for a urology residency position for the 2019-2020 American Urological Association Match. METHODS: An electronic survey was emailed to all urology residency applicants who applied to Rutgers Robert Wood Johnson Medical School during the 2019-2020 application cycle; it was sent 2 weeks after the Match results were released. We collected information on applicant demographics, interview logistics, and estimated costs incurred applying to residency. RESULTS: A total of 26% (64/242) of subjects responded, representing all 8 the American Urological Association sections, international schools, and schools without urology programs. 62% were male, 75% were single, and 52% attended public medical school. Applicants paid for the interview trail using loans (67%), family donations (50%), previous or current income (36%), and scholarships (16%). Subjects completed a median of 2 visiting student rotations (IQR 2-3), applied to 80 programs (IQR 66-99), and attended 16 interviews (IQR 13-18.75). The median cost per applicant for the 2019-2020 Match was $9725 (IQR $6134-12,564). This estimate included expenditures on application fees, visiting student rotations, interview trail travel and lodging, research, interview attire, and professional photos. Subjects who attended public medical school were likely to spend $3546.31 (95% confidence interval: 5630.71-1461.916; P < .001) more than those attending private schools. CONCLUSION: Urology residency applicants spend almost $10,000 in pursuit of a residency position. These high costs not only contribute to student debt but also may deter applicants from entering the field of urology.

The Feasibility and Efficacy of a Multi-Institutional Urology Boot Camp for Incoming Urology Residents.

OBJECTIVES: To determine the feasibility and perceived usefulness of a pre-residency urology boot camp for first and second year urology residents. METHODS: First and second year urology residents attended a multi-institutional boot camp in July 2019, which consisted of lectures, a hands-on practical, patient simulation session, and networking social event. Attendees completed a pre-course survey where they rated their comfort level in managing interpersonal, post-operative, and urology-specific scenarios on a Likert scale of 0-5. Participants completed follow-up surveys immediately and 6 months after the course regarding confidence in managing the same scenarios and the impact of boot camp on their training. RESULTS: 6 urology PGY1s (55%) and 5 PGY2s (45%) from 4 institutions attended the boot camp. On the precourse survey, PGY2s had higher average comfort scores compared to PGY1s for all post-operative scenarios besides hypotension but just 2 urology-specific scenarios, difficult Foley troubleshooting (4 vs 3, P < .01) and obstructing urolithiasis with urosepsis (3.6 vs 2.2, P = .05). Immediately after the course, 10 of 11 (91%) residents reported feeling better prepared to handle all scenarios. All participants reported they would recommend this training to other urology residents. Six months later, the majority of respondents reported using knowledge learned in boot camp on a daily basis. All agreed that it was a useful networking experience, and 63% had since contacted other residents they met at the course. CONCLUSION: A pre-residency boot camp is both feasible and valuable for first- and second-year urology residents for gaining practical medical knowledge and professional networking.

Development and validation of an objective scoring tool to evaluate surgical dissection: Dissection Assessment for Robotic Technique (DART).

Purpose: Evaluation of surgical competency has important implications for training new surgeons, accreditation, and improving patient outcomes. A method to specifically evaluate dissection performance does not yet exist. This project aimed to design a tool to assess surgical dissection quality. Methods: Delphi method was used to validate structure and content of the dissection evaluation. A multi-institutional and multi-disciplinary panel of 14 expert surgeons systematically evaluated each element of the dissection tool. Ten blinded reviewers evaluated 46 de-identified videos of pelvic lymph node and seminal vesicle dissections during the robot-assisted radical prostatectomy. Inter-rater variability was calculated using prevalence-adjusted and bias-adjusted kappa. The area under the curve from receiver operating characteristic curve was used to assess discrimination power for overall DART scores as well as domains in discriminating trainees (≤100 robotic cases) from experts (>100). Results: Four rounds of Delphi method achieved language and content validity in 27/28 elements. Use of 3- or 5-point scale remained contested; thus, both scales were evaluated during validation. The 3-point scale showed improved kappa for each domain. Experts demonstrated significantly greater total scores on both scales (3-point, p< 0.001; 5-point, p< 0.001). The ability to distinguish experience was equivalent for total score on both scales (3-point AUC= 0.92, CI 0.82-1.00, 5-point AUC= 0.92, CI 0.83-1.00). Conclusions: We present the development and validation of Dissection Assessment for Robotic Technique (DART), an objective and reproducible 3-point surgical assessment to evaluate tissue dissection. DART can effectively differentiate levels of surgeon experience and can be used in multiple surgical steps.

Delaying surgery for clinical T1b-T2bN0M0 renal cell carcinoma: Oncologic implications in the COVID-19 era and beyond.

PURPOSE: During COVID-19, many operating rooms were reserved exclusively for emergent cases. As a result, many elective surgeries for renal cell carcinoma (RCC) were deferred, with an unknown impact on outcomes. Since surveillance is commonplace for small renal masses, we focused on larger, organ-confined RCCs. Our primary endpoint was pT3a upstaging and our secondary endpoint was overall survival. MATERIALS AND METHODS: We retrospectively abstracted cT1b-T2bN0M0 RCC patients from the National Cancer Database, stratifying them by clinical stage and time from diagnosis to surgery. We selected only those patients who underwent surgery. Patients were grouped by having surgery within 1 month, 1-3 months, or >3 months after diagnosis. Logistic regression models measured pT3a upstaging risk. Kaplan Meier curves and Cox proportional hazards models assessed overall survival. RESULTS: A total of 29,746 patients underwent partial or radical nephrectomy. Delaying surgery >3 months after diagnosis did not confer pT3a upstaging risk among cT1b (OR = 0.90; 95% CI: 0.77-1.05, P = 0.170), cT2a (OR = 0.90; 95% CI: 0.69-1.19, P = 0.454), or cT2b (OR = 0.96; 95% CI: 0.62-1.51, P = 0.873). In all clinical stage strata, nonclear cell RCCs were significantly less likely to be upstaged (P <0.001). A sensitivity analysis, performed for delays of <1, 1-3, 3-6, and >6 months, also showed no increase in upstaging risk. CONCLUSION: Delaying surgery up to, and even beyond, 3 months does not significantly increase risk of tumor progression in clinically localized RCC. However, if deciding to delay surgery due to COVID-19, tumor histology, growth kinetics, patient comorbidities, and hospital capacity/resources, should be considered.

Robot-Assisted Radical Cystectomy with Intracorporeal Ileal Conduit in a Patient with Situs Inversus Totalis.

Background: Situs invesus totalis is a rare congenital anomaly characterized by the mirror-image transposition of abdominal and thoracic organs. Although feasible, operating on patients with situs inversus offers unique technical challenges to the surgeon because of its rarity and the contralateral disposition of the viscera. Urologists in particular need to be aware of the genitourinary abnormalities associated with situs inversus when planning to operate. Case Presentation: We report the case of a 67-year-old man with invasive bladder cancer in the presence of situs inversus totalis (SIT) and associated bilateral duplicated ureters. This is only the second case of bladder cancer in the context of situs inversus reported in the literature and the first one managed with robot-assisted radical cystectomy and urinary diversion with an intracorporeal ileal conduit. Conclusion: In this unique case, robot-assisted radical cystectomy with intracorporeal ileal conduit in a patient with muscle-invasive bladder cancer and SIT was safely performed and we suggest to others to consider our technique of "mirror-image port placement and surgical technique" if they encounter such a patient.

Retroperitoneal Lymph Node Dissection as Primary Treatment for Men With Testicular Seminoma: Utilization and Survival Analysis Using the National Cancer Data Base, 2004-2014.

BACKGROUND: The role of retroperitoneal lymph node dissection (RPLND) as first-line treatment for testicular seminoma is less well defined than for testicular nonseminomatous germ-cell tumors. We describe utilization of primary RPLND in the United States and report on overall survival (OS) after surgery for these men. PATIENTS AND METHODS: Using 2004-2014 data from the National Cancer Data Base, we identified 62,727 men with primary testicular cancer, 31,068 of whom were diagnosed as having seminoma. After excluding men with benign, non-germ cell, and nonseminomatous germ-cell tumor histologies, those who did not undergo RPLND, those where clinical stage and survival data were unavailable, and those with testicular seminoma who underwent RPLND in the postchemotherapy setting (n = 47), 365 men comprised our final cohort. Descriptive statistics were used to summarize clinical and demographic factors. The Kaplan-Meier method was used to determine OS. RESULTS: A total of 365 men with testicular seminoma underwent primary RPLND. At a median follow-up of 4.1 years, there were 16 deaths in the entire cohort. Five-year OS was 94.2%. Subset analysis of men with stage I and IIA/B disease who underwent primary RPLND revealed 5-year OS rates of 97.3% and 92.0%, respectively (P = .035). OS did not significantly differ in patients with stage IIA versus IIB disease (91.8% vs. 92.3%, respectively, P = .907). CONCLUSION: Although RPLND is rarely used as primary therapy in testicular seminoma, OS rates appear to be comparable to rates reported in the literature for primary chemotherapy or radiotherapy. Ongoing prospective trials will clarify the role of RPLND in the management of testicular seminoma.

Characterization of a learning curve for robotic cystectomy with intracorporeal urinary diversion at two institutions using the cumulative sum (CUSUM) method.

INTRODUCTION: Robotic cystectomy with intracorporeal urinary diversion (RCID) is a technically challenging procedure. It is understood that this approach has a learning curve; however, limited studies have characterized this learning curve. The cumulative sum (CUSUM) method plots the learning curve. The aim of this study was to use the CUSUM approach to investigate the number of cases required to reach a consistent, desired performance level for RCID. MATERIALS AND METHODS: Retrospective study of the first 27 and 28 RCID cases performed by two new fellowship trained faculty at two separate institutions from November 2014 to January 2018. Total operating time was calculated and the CUSUM method was used to describe the learning curve, the number of cases needed for a consistent performance level. RESULTS: Twenty-seven and 28 patients were reviewed from two institutions (A and B), with 8 and 7 females, 19 and 21 males and an average age of 66.7 and 67.6 years, respectively. Twelve and ten cases, respectively, had final pathology of stage T3 bladder cancer or higher. The CUSUM curve demonstrated a learning curve of 10 and 11 cases, respectively, when the curve transitioned from steady improvement in OR times (upward slope of curve) to a relative steady state of OR times (plateau of curve). The average lymph node yield, rate of ureteral stricture, and positive margins were also examined with no learning curve noted. CONCLUSION: In RCID, approximately 10 cases were required by robotically trained new faculty to reach a steady-state level of performance.

Cytoreductive prostatectomy in metastatic prostate cancer: current knowledge and future directions.

The current standard of care for patients with metastatic prostate cancer is systemic androgen deprivation therapy, and addressing the primary tumor has been reserved for patients with localized disease. However, emerging data has called into question the universality of this paradigm. Recent studies have found treatment of the primary tumor in patients with metastatic disease not only can provide the patient with symptomatic relief but also may provide a survival benefit. The potential biological and clinical benefit for cytoreductive surgery has been also been suggested in several translational models. Thus, PubMed electronic database was queried for publications on patients with metastatic prostate cancer who underwent cytoreductive prostatectomy, using keywords including: cytoreductive prostatectomy, radical prostatectomy, metastatic prostate cancer. In this review we examine literature regarding feasibility of cytoreductive prostatectomy, oncologic outcomes, and future directions including the ongoing clinical trials in this arena. While the retrospective data is encouraging, results of these ongoing prospective trials are needed before this option is offered to patients as a reasonably safe treatment with demonstrated benefits to survival and quality of life.

Effect of alvimopan on gastrointestinal recovery and length of hospital stay after retroperitoneal lymph node dissection for testicular cancer.

OBJECTIVE: Alvimopan use has reduced the length of hospital stay in patients undergoing major abdominal surgeries and radical cystectomy. Retroperitoneal lymph node dissection for testicular cancer may be associated with delayed gastrointestinal recovery prolonging hospital length of stay. We evaluate whether alvimopan is associated with enhanced gastrointestinal recovery and shorter hospital length of stay in men undergoing retroperitoneal lymph node dissection for testicular cancer. MATERIALS AND METHODS: From 2010 to 2016, 29 patients underwent open, transperitoneal bilateral template retroperitoneal lymph node dissection. Data for patients who received alvimopan were prospectively collected and compared to a historical cohort of patients who did not receive alvimopan. Primary outcome measures were length of stay and recovery of gastrointestinal function. Descriptive statistics were reported. Time-to-event outcomes were evaluated using cumulative incidence curves and log rank test. Factors associated with length of stay were analyzed for correlation using multiple linear regression. RESULTS: Of 29 men undergoing retroperitoneal lymph node dissection, eight received alvimopan and 21 did not. The two cohorts were well matched, with no significant differences. In the alvimopan cohort compared with those who did not receive alvimopan median time to return of flatus was 2 versus 4 days (p=0.0002), and median time to first bowel movement was 2.5 versus 5 days (p=0.046), respectively. Median length of stay in the alvimopan cohort was 4 days versus 6 days in those who did not receive alvimopan (p=0.074). In adjusted analyses, receipt of alvimopan did not influence length of stay. CONCLUSION: Alvimopan may facilitate gastrointestinal recovery after retroperitoneal lymph node dissection for testicular cancer. Whether this translates into reduced length of stay needs to be determined by randomized controlled trials using larger cohorts. LEVEL OF EVIDENCE: 3b.

Management of Postradical Prostatectomy Urinary Incontinence: A Review.

Postprostatectomy urinary incontinence has a significant impact on the quality of life of patients who undergo radical prostatectomy. Stress and overflow incontinence may result from the procedure, with sphincteric incompetence and detrusor hypocontractility implicating their development, respectively. In many cases, treatment begins with conservative approaches, including pelvic floor muscle training or biofeedback. Pharmacotherapy can be used to treat overactive bladder. For stress incontinence, transurethral bulking agents are utilized in select patients; however, artificial urinary sphincter and male slings are the most efficacious options with good success rates. In this review, the various treatment modalities are critically discussed with special emphasis on safety and efficacy.

Androgen deprivation therapy for the treatment of prostate cancer: a focus on pharmacokinetics.

INTRODUCTION: Medical therapy has undergone many changes as our understanding of prostate cancer cell biology has improved. Androgen deprivation therapy (ADT) remains the mainstay of therapy for metastatic disease. Metastatic castrate-resistant prostate cancer (CRPC) is an important concern since we are unable to stop progression with currently available agents. Areas covered: Pharmacologic ADT is the most commonly used treatment for metastatic prostate cancer. Multiple agents are available for both first-line and second-line use: antiandrogens, estrogens, luteinizing hormone-releasing hormone agonists/antagonists, and CYP17 inhibitors. With adoption of these drugs, it is important to consider their pharmacokinetic and pharmacodynamic properties. Many undergo metabolism through cytochrome P450. Levels may be altered with co-administration of drugs acting as enzyme inhibitors or inducers. Understanding mechanism of action, metabolism, and excretion of these drugs allows clinicians to provide the best therapeutic care while minimizing adverse events. Expert opinion: Many men with metastatic prostate cancer will progress to castration resistance. An understanding of resistance mechanisms at the cellular level has revealed new drug targets with hopes of halting or reversing progression of metastatic disease. Second-line agents, traditionally reserved for CRPC, are being studied in metastatic castrate-sensitive prostate cancer, and may offer practice-changing evidence supporting their use.

Pharmacokinetic drug evaluation of atezolizumab for the treatment of locally advanced or metastatic urothelial carcinoma.

INTRODUCTION: Muscle invasive bladder cancer (MIBC) is difficult to manage for patients who progress during or after initial chemotherapy regimens. Current regimens offer low response rates with high toxicities. The advent of immune checkpoint inhibitors may represent a new opportunity for effective management of these patients. Areas covered: Atezolizumab is an engineered humanized monoclonal immunoglobulin G1 antibody that binds selectively to PD-L1 and prevents its interaction with PD-1 and B7-1. It is administered intravenously and is given every 3 weeks as long as there is no evidence of tumor progression. Phase I trials confirmed antitumor activity of atezolizumab in patients with advanced or metastatic urothelial carcinoma. Phase II trials showed an improved response rate and a longer durable response than current conventional therapy. Phase III trials are currently underway with an estimated accrual end date of 2017. Expert opinion: MIBC is a high-risk disease, and after progression on current chemotherapy regimens, second-line treatments leave much to be desired. Emerging evidence of efficacy and safety and a recent accelerated approval by the FDA presents atezolizumab as a promising treatment option. Current clinical challenges include the details of disease progression and determining where immune checkpoint inhibition will reside in the treatment algorithm.