From Diagnosis to Precision Surgery: The Transformative Role of Artificial Intelligence in Urologic Imaging.

The multidisciplinary nature of artificial intelligence (AI) has allowed for rapid growth of its application in medical imaging. Artificial intelligence algorithms can augment various imaging modalities, such as X-rays, CT, and MRI, to improve image quality and generate high-resolution three-dimensional images. AI reconstruction of three-dimensional models of patient anatomy from CT or MRI scans can better enable urologists to visualize structures and accurately plan surgical approaches. AI can also be optimized to create virtual reality simulations of surgical procedures based on patient-specific data, giving urologists more hands-on experience and preparation. Recent development of artificial intelligence modalities, such as TeraRecon and Ceevra, offer rapid and efficient medical imaging analyses aimed at enhancing the provision of urologic care, notably for intraoperative guidance during robot-assisted radical prostatectomy (RARP) and partial nephrectomy.

Pelvic lymphadenectomy: Evaluating nodal stage migration and will rogers effect in bladder cancer.

INTRODUCTION: Pelvic lymphadenectomy (PLND) alongside radical cystectomy (RC), provides crucial diagnostic and therapeutic value in patients with bladder cancer. With the advent of neoadjuvant chemotherapy and prospective data supporting standard PLND, controversy remains regarding the optimal PLND extent and patient selection. Nearly 40% of patients may not receive adequate PLND, even though 25% of patients have positive lymph nodes (LN) at time of RC. We hypothesized that PLND still remains an important facet of bladder cancer treatment. To clarify the prognostic importance of nodal yield, we performed a retrospective investigation of a heterogenous population (pTanyNx/0M0) of patients undergoing RC. METHODS: From the Surveillance, Epidemiology, and End Results (SEER) program, we identified pTanyNx/0M0 bladder cancer patients undergoing RC from 2004 to 2015. Kaplan Meier curves and Cox proportional hazards models assessed cancer-specific survival. Patients were analyzed with PLND performed as the primary covariate. Survival analysis then stratified patients undergoing PLND by LN yield, both as a continuous and categorial variable (≤10, 11-20, 21-30, and >30), and T stage. RESULTS: The final cohort included pTanyNx/0M0 patients with urothelial bladder cancer (n = 12,096); median follow up was 39 (IQR: 17-77) months. PLND was performed in 81.45% of patients with a median LN yield of 14 (IQR: 7-23). Most commonly, patients had T2 disease (44.68%). After controlling for age and T stage, patients receiving PLND had improved CSS (HR = 0.56, [95% CI: 0.51-0.62]) compared to those that did not receive PLND. When grouping patients by LN yield, survival improved in a "dose dependent" manner (>30 LN: HR = 0.76, [95% CI: 0.66-0.87]). We noted similar results when stratifying patients into non-muscle-invasive (NMIBC) and muscle-invasive bladder cancer (MIBC). CONCLUSIONS: In a large contemporary series of pTanyNx/0M0 bladder cancer patients, we found a significant oncologic benefit to PLND. Higher LN yield correlated to improved CSS in non-muscle-invasive and muscle-invasive disease. Our data support the possibility of occult micrometastasis even in non-muscle-invasive disease. Additionally, in light of recent advances in adjuvant immunotherapy, our results emphasize the importance of adequate nodal yield for accurate staging and optimal treatment.

Comparison of a Valveless Trocar System and Conventional Insufflation in Pediatric Urologic Surgery.

Background: Conventional operative insufflation uses a one-way trocar to handle instruments while maintaining pneumoperitoneum. In 2007, the AirSeal® valveless trocar insufflation system was introduced, which maintains stable pneumoperitoneum while continuously evacuating smoke. Although this device has been validated in adult patients, it has not been extensively validated in the pediatric population. Materials and Methods: A retrospective cohort study of pediatric urology patients aged 0 to 21 who underwent laparoscopic pyeloplasty between March 2016 and October 2021 was performed. Intraoperative physiologic parameters, procedure characteristics, postoperative outcomes, and demographics of each patient in whom either AirSeal insufflation system (AIS) or conventional insufflation system (CIS) was utilized were obtained from hospital records. Data were compared across the AIS and CIS cohorts. The primary outcomes were intraoperative anesthetic and physiologic parameters, including end tidal carbon dioxide, oxygen saturation, body temperature, positive inspiratory pressure, systolic blood pressure, and heart rate. Results: There were no significant differences in the anesthetic and physiologic parameters in the AIS and CIS groups. In addition, no differences in demographics, procedural characteristics, or complication rates were found between the cohorts. Conclusion: The AirSeal valveless trocar insufflation system demonstrates comparable intraoperative anesthetic and physiologic outcomes compared to conventional one-way valve insufflation in pediatric laparoscopic pyeloplasty. Certain surgeon-related qualitative metrics are underappreciated in this study, however, including improved visualization with vigorous suctioning and pressure maintenance with frequent instrument exchanges. Surgeon experience may mask the benefits of these characteristics as it pertains to quantitative surgical outcomes such as estimated blood loss, operative time, and perioperative complications.

The Boot Camp Model in Urology: Preparing PGY1 Urology Interns for Practice.

PURPOSE OF REVIEW: The purpose of this review is to highlight literature regarding resident boot camps published across surgical specialties with a focus on urology. Herein, we discuss different boot camp iterations, their results, and the integration of simulation into their curriculum. We review program elements such as curriculum, course length, and efficacy as well as areas for continued investigation. RECENT FINDINGS: The field of urology has grown in both the breadth of knowledge and the complexity of procedures. With urology now being an integrated surgical subspecialty, interns often start on the urology service despite limited experience navigating this unique specialty. The boot camp model is one method by which interns and junior residents participate in consolidated training programs to best prepare them for a patient-facing role and the day-to-day demands of residency. Urology programs, both in the USA and abroad, have begun integrating boot camps into their training programs with positive results. Urology boot camps can be a valuable part of training programs for interns to quickly establish medical knowledge, skills, and efficiency. Boot camps should be easily accessible, have sufficient support from institutions, and provide effective training through various methods such as didactics and simulation.

Annual trends of cystectomy complications: A contemporary analysis of the NSQIP database.

INTRODUCTION: Despite significant morbidity, radical cystectomy (RC) is standard of care for muscle invasive bladder cancer, certain high-risk nonmuscle invasive tumors and after failure of intravesical or trimodal therapy. Modern efforts have hastened the recovery after this surgery without impact on overall complication rates. Our primary aim was to examine changes in complication rates of RC over time. METHODS: The National Surgical Quality Improvement Program database included 11,351 RC from 2006 to 2018 for nondisseminated bladder cancer. Baseline characteristics and complication rates were studied across time periods: 2006 to 2011, 2012 to 2014, and 2015 to 2018. Thirty-day complications, readmissions, and mortality were identified. RESULTS: Overall complication rates decreased over time (56.5%, 57.4%, 50.6%, P < 0.01). Infectious complications were stable, including UTIs (10.1%, 8.8%, 8.3% respectively, P = 0.11) and sepsis (10.4%, 8.8%, 8.7% respectively, P = 0.20). On multivariable analysis, ASA≥3 (OR 1.399, 95% CI 1.279-1.530) was associated with increased complications, while procedures in 2015 to 2018 (OR 0.825, 95% CI 0.722-0.942), laparoscopic/robotic approach (OR 0.555, 95%CI 0.494-0.622), and ileal conduit (OR 0.796, 95% CI 0.719-0.882) were associated with decreased complication rates. Other outcomes of interest included mean length of stay (LOS), which decreased over time (10.5, 9.8, 8.6 days, respectively, P < 0.01) and readmission (20.0%, 21.3%, 21.0%, respectively, P = 0.84) and mortality rates were stable (2.7%, 1.7%, 2.0%, respectively, P = 0.13). CONCLUSION: Decreased early complications and LOS after RC over time may reflect beneficial effects of recent advances in bladder cancer treatment such as enhanced recovery after surgery protocols and minimally invasive techniques. Further opportunities to improve long term outcomes, readmissions and infection rates are needed.

Pelvic radiation-induced urinary strictures: etiology and management of a challenging disease.

Radiation is a common treatment modality for pelvic malignancies. While it can be effective at cancer control, downstream effects can manifest months to years after treatment, leaving patients with significant morbidity. Within urology, a particularly difficult post-radiation consequence is urinary tract stricture, either of the urethra, bladder neck, or ureter. In this review, we will discuss the mechanism of radiation damage and treatment options for these potentially devastating urinary sequelae.

Wound Complication Rates after Inguinal Lymph Node Dissection: Contemporary Analysis of the NSQIP Database.

BACKGROUND: Inguinal lymph node dissection (ILND) is used for diagnosis and treatment in penile cancer (PC), vulvar cancer (VC), and melanomas draining to the inguinal lymph nodes. However, ILND is often characterized by its morbidity and high wound complication rate. Consequently, we aimed to characterize wound complication rates after ILND. STUDY DESIGN: The NSQIP database was queried for ILND performed from 2005 to 2018 for melanoma, PC, or VC. Thirty-day wound complications included wound disruption and superficial, deep, and organ-space surgical site infection. Multivariable logistic regression was performed with covariates, including cancer type, age, American Society of Anesthesiologists score ≥3, BMI ≥30, smoking history, diabetes, operative time, and concomitant pelvic lymph node dissection. RESULTS: A total of 1,099 patients had an ILND with 92, 115, and 892 ILNDs performed for PC, VC, and melanoma, respectively. Wound complications occurred in 161 (14.6%) patients, including 12 (13.0%), 17(14.8%), and 132 (14.8%) patients with PC, VC, and melanoma, respectively. Median length of stay was 1 day (interquartile range 0 to 3 days), and median operative time was 152 minutes (interquartile 83 to 192 minutes). Readmission rate was 12.7%. Wound complications were associated with longer operative time per 10 minutes (odds ratio 1.038, 95% CI 1.019 to 1.056, p < 0.001), BMI ≥30 (odds ratio 1.976, 95% CI 1.386 to 2.818, p < 0.001), and concomitant pelvic lymph node dissection (odds ratio 1.561, 95% CI 1.056 to 2.306, p = 0.025). CONCLUSIONS: Predictors of wound complications after ILND include BMI ≥30, longer operative time, and concomitant pelvic lymph node dissection. There have been efforts to decrease ILND complication rates, including minimally invasive techniques and modified templates, which are not captured by NSQIP, and such approaches may be considered especially for those with increased complication risks.

Preference Signaling in the 2022 Urology Residency Match - The Applicant Perspective.

OBJECTIVE: To evaluate the applicant experience with preference signaling during the 2022 Urology Residency Match. METHODS: An anonymous electronic survey was emailed to all urology residency applicants who applied to Rutgers Robert Wood Johnson Medical School during the 2021-2022 application cycle. The survey collected information regarding applicant demographics, applicant characteristics, preference signal destinations, match outcomes, and attitude towards preference signaling. RESULTS: A total of 601 applicants applied to the 2022 Urology Residency Match, 283 of which applied to the urology residency program at Rutgers Robert Wood Johnson Medical School. Of the 283 applicants, 53 (19%) responded to our survey. Rate of interview for preference signaled programs was 54.23%, with a significantly lower rate of interview for comparative, non-signaled programs (40.54%; P = .001). Of respondents, 14.29%, 26.19%, and 35.71% matched to their home program, a program they signaled, or a program where they completed an away rotation, respectively. 96% of applicants favored continuation of the preference signaling program. CONCLUSION: Our study suggests preference signaling in the 2022 Urology Match may have been an effective method of expressing interest in a program. Respondents of our survey overwhelmingly favor continuation of the program in future urology matches. However, it may not address the underlying, growing problem of the increasing application burden on applicants and programs alike. We encourage more comprehensive studies to further clarify the effects of preference signaling on the Urology Match.

Survival of nonseminomatous germ cell tumors in pediatric patients and young adults - A stage group stratified analysis.

INTRODUCTION: Testicular germ cell tumors, particularly nonseminomatous germ cell tumors (NSGCT), comprise the most common solid malignancy in male children and younger adults. While these patients experience excellent survival outcomes, few studies have characterized their survival by age. Thus, we aimed to characterize the relative survival of NSGCT by age, stratifying patients by stage group. METHODS: Using the Surveillance Epidemiology and End Results (SEER) database, we divided patients with NSGCT into pediatric patients and adolescents (<19 years), young adults (19-30 years), and older adults (>30 years). Survival analysis, using Cox proportional hazards models and Kaplan Meier curves, described overall and cancer-specific survival (CSS) of each age category for Stage I-III NSGCT by stage group. RESULTS: A total of 14,786 patients met inclusion criteria and comprised the age groups <19 years (N=1,287), 19 to 30 years (N=7,729), and >30 years (N=5,770). Stage group distribution at presentation was similar between each group. Survival analysis demonstrated no differences in cancer-specific survival (CSS) among Stage I or II NSGCT. However, among Stage III tumors, multivariable models noted worse CSS in patients >30 years (HR=3.35 (95%CI: 1.45-7.73), P=0.005) and those 19-30 years (HR=2.28 (95%CI: 0.99-5.21), P=0.053) compared to pediatric and adolescent patients. CONCLUSIONS: Younger NSGCT patients experience excellent oncologic outcomes compared to their older counterparts. These survival differences by age group are largely driven by differential survival among Stage III neoplasms. Furthermore, our report lends additional evidence that age is an important prognostic factor in advanced NSGCT, including pediatric and adolescent patients.

The Urologist and the Appendix: A Review of Appendiceal Use in Genitourinary Reconstructive Surgery.

Recently, genitourinary reconstruction has experienced a renaissance. Over the past several years, there has been an expansion of the literature regarding the use of buccal mucosa for the repair of complex ureteral strictures and other pathologies. The appendix has been an available graft utilized for the repair of ureteral stricture disease and has been infrequently reported since the early 1900s. This review serves to highlight the use of the appendix for reconstruction in urology, particularly focusing on the anatomy and physiology of the appendix, historical use, and current applications, particularly in robotic upper tract reconstruction.

The Expanding Use of Buccal Mucosal Grafts in Urologic Surgery.

The advent and success of buccal mucosal grafts as a substitution material in the urinary tract has changed the landscape of reconstructive urology. Due to its ease to harvest, low morbidity, and advantageous properties, there has been a growing number of applications for buccal mucosal grafts in upper and lower urinary tract reconstruction as well as genital reconstruction. In this article, we review the historical application and the evolution of buccal mucosal grafts and provide an up-to-date review on its utilization in urologic procedures.

Improving The Match: Use of Preference Signaling to Optimize the Urology Match Interview Process.

OBJECTIVES: To outline the principles and premise, pros and cons of the use of preference signaling (PS) in the Urology Match. METHODS: PS is a standardized system in which a student may send a signal or token to a particular program to demonstrate genuine interest in advance of application review and interview selection. The available literature of the use of PS in other fields was assessed and applied to the unique construct of the Urology Match. Potential benefits and challenges are discussed and a process and timeline for implementation are presented. RESULTS: PS requires a limited number of signals to maintain value, a transparent system to disclose and distribute signals and continuous data assessment for optimization. It standardizes pre interview communication and highlights for programs which applicants have sincere interest although it does not directly address application overload. CONCLUSION: PS is a viable and equitable method for applicants to indicate interest directly, confidentially and intentionally indicate interest in a program which can allow a program to maximize scarce resources such as time and interview slots in the match process.

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.

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.

Abrogation of survival disparity between Black and White individuals after the USPSTF's 2012 prostate-specific antigen-based prostate cancer screening recommendation.

BACKGROUND: In May 2012, the US Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA)-based screening for prostate cancer (PCa), assigning it a grade D. This decision then was modified in 2018 to a grade C for men aged 55 to 69 years. The authors hypothesized that changes in screening practices would reduce survival outcomes for both Black and White men but maintain racial discrepancies in outcomes. METHODS: Using the Surveillance, Epidemiology, and End Results database, the authors examined PCa-specific survival based on race and year of diagnosis. The period between January 2010 and December 2012 was categorized as the pre-USPSTF era, whereas the period between January 2014 and December 2016 was classified as the post-USPSTF era. The year 2013 was considered the transition year and was excluded from the analysis. RESULTS: A total of 49,388 men were identified in the pre-USPSTF era who were diagnosed with PCa, approximately 83.7% of whom were White and 16.3% of whom were Black. In the post-USPSTF era, a total of 41,829 men were diagnosed with PCa, approximately 82.7% of whom were White and 17.3% of whom were Black. When compared with the pre-USPSTF era, men diagnosed in the post-USPSTF era were found to have more adverse clinical features. In the pre-USPSTF era, White men were less likely to die of PCa than Black men. This survival disparity between White and Black men was no longer observed in the post-USPSTF era. CONCLUSIONS: In men diagnosed with PCa between 2014 and 2016, a survival disparity between White and Black men was not observed due to a decrease in survival among White men while the survival of Black men remained steady.