How Effective Was the 2014 AUA Cryptorchidism Guideline? A Multi-institutional Evaluation.

INTRODUCTION: In 2014, the AUA published guidelines regarding the evaluation of cryptorchidism. This multi-institutional study aims to determine if these guidelines reduced the age of referral and the utilization of ultrasound in boys with cryptorchidism. We hypothesize that delayed referral continues, and utilization of ultrasound remains unchanged. METHODS: A retrospective review of boys referred for the evaluation of cryptorchidism was performed at 4 academic institutions, collecting data for 1 year prior (2013) and 2 nonconsecutive years following guideline creation (2015 and 2019). Across these time frames, we compared median ages at evaluation and surgery, and rates of patient comorbidities, orchiopexy, and preevaluation ultrasound. RESULTS: A total of 3,293 patients were included. The median age at initial pediatric urology evaluation in all cohorts was 39 months (IQR: 14-92 months). Following publication of the AUA Guidelines, there was no difference (P = .08) in the median age at first evaluation by a pediatric urologist between 2013 and 2015, and an increase (P = .03) between 2013 and 2019. Overall, 21.2% of patients received an ultrasound evaluation prior to referral, with no significant difference between 2013 and 2015 (P = .9) or 2019 (P = .5) cohorts. CONCLUSIONS: Our data suggest that, despite publication of the AUA Guidelines on evaluation and treatment of cryptorchidism, there has been no reduction in the age of urological evaluation or the utilization of imaging in boys with undescended testis. Finding alternative avenues to disseminate these evidence-based recommendations to referring providers and exploring barriers to guideline adherence is necessary to improve care for patients with cryptorchidism.

Role of the androgen, estrogen, and progesterone receptors in adherent perinephric fat in robotic partial nephrectomy.

To determine whether androgen, estrogen, and/or progesterone signaling play a role in the pathophysiology of adherent perinephric fat (APF). We prospectively recruited patients undergoing robotic assisted partial nephrectomy during 2015-2017. The operating surgeon documented the presence or absence of APF. For those with clear cell renal cell carcinoma (ccRCC), representative sections of tumor and perinephric fat were immunohistochemically stained with monoclonal antibody to estrogen α, progesterone, and androgen receptors. Patient characteristics, operative data, and hormone receptor presence were compared between those with and without APF. Of 51 patients total, 18 (35.3%) and 33 (64.7%) patients did and did not have APF, respectively. APF was associated with history of diabetes mellitus (61.1% vs 24.2%, p = 0.009) and larger tumors (4.0 cm vs 3.0 cm, p = 0.017) but not with age, gender, BMI, Charleston comorbidity index, smoking, or preoperative estimated glomerular filtration rate. APF was not significantly associated with length of operation, positive margins, or 30-day postoperative complications but incurred higher estimated blood loss (236.5 mL vs 209.2 mL, p = 0.049). Thirty-two had ccRCC and completed hormone receptor staining. The majority of tumors and perinephric fat were negative for estrogen and progesterone while positive for androgen receptor expression. There was no difference in hormone receptor expression in either tumor or perinephric fat when classified by presence or absence of APF (p > 0.05). APF is more commonly present in patients with diabetes or larger tumors but was not associated with differential sex hormone receptor expression in ccRCC.

Positive Surgical Margins After Robot-Assisted Partial Nephrectomy Predict Long-Term Oncologic Outcomes for Clinically Localized Renal Masses.

Introduction: For patients with clinically localized renal masses, positive surgical margins (PSMs) after robotic partial nephrectomy (RPN) have been associated with a higher risk of disease recurrence, although some studies have challenged this conclusion. Owing to inconsistent reports and a lack of long-term robotic data, the clinical impact of PSM after RPN remains uncertain. We evaluate long-term (>6 years) survival outcomes after RPN in patients with clinically localized disease with respect to surgical margin status. Methods: We conducted a retrospective review of patients who underwent RPN for clinically localized renal masses from June 2007 to December 2012 at Washington University School of Medicine. Disease recurrence and overall survival (OS) were stratified on the presence or absence of PSM. The cohort was analyzed to identify patient- and tumor-specific characteristics associated with PSM. Results: We identified 374 RPNs performed from 2007 to 2012 with a mean follow-up time of 77.7 months (SD 32.2 months). PSM was identified in 12 (3.2%) patients. Patients with PSM were at 14-fold increased risk for recurrence with no difference in OS (p < 0.001, p = 0.130, respectively). Patients with PSM had higher incidence of chronic obstructive pulmonary disease (COPD) (25% vs 6.4%) and greater blood loss (425 mL vs 203 mL). Conclusion: With an extended follow-up period of 77 months after RPN, we found that PSM substantially increased the risk of recurrence without impacting OS. Our finding that PSM may occur more frequently in older patients with COPD must be confirmed in larger studies.

Comparing Off-clamp and On-clamp Robot-assisted Partial Nephrectomy: A Prospective Randomized Trial.

OBJECTIVE: To determine whether performing robot-assisted partial nephrectomy without warm ischemia "off-clamp" results in favorable postoperative renal functional outcomes compared with the on-clamp method. METHODS: We conducted a prospective trial of 80 patients who underwent robot-assisted partial nephrectomy. They were randomized in a 1:1 ratio to undergo the procedure with renal artery clamping or without clamping. The groups were compared across demographics, operative information, perioperative outcomes, and postoperative renal function. We assessed renal function by estimated glomerular filtration rate and renal scintigraphy both preoperatively and at 3 months postoperatively. RESULTS: Patients in the on-clamp and off-clamp groups were similar in age, gender, body mass index, comorbidities, clinical tumor size, nephrometry score, and laterality. Off-clamp procedures were lengthier at an average 178.0 minutes vs 156.0 minutes for on-clamp (P = .011). Estimated blood loss, rates of pelvicalyceal repair, postoperative complications, and positive margins were not different. At a median 3-month follow-up, no significant differences were seen in change in postoperative estimated glomerular filtration rate or percent split renal function between both groups. CONCLUSION: In this prospective study, off-clamp robot-assisted partial nephrectomy resulted in similar perioperative outcomes compared with the on-clamp technique. No benefit was demonstrated in the preservation of renal function. Urologists may safely employ either an on-clamp or off-clamp strategy depending on surgeon preference and patient-specific factors including baseline renal insufficiency, multiple masses, or solitary kidney.

Unplanned 30-Day Encounters After Ureterorenoscopy for Urolithiasis.

OBJECTIVE: To identify avoidable predictors of postureteroscopy (URS) unplanned encounters and to minimize 30-day encounters. MATERIALS AND METHODS: We performed retrospective chart review and telephone surveys on patients who underwent URS for urolithiasis between January and June 2016. Univariate and multivariable analyses evaluated for potential predictors of unplanned encounters. RESULTS: Of 157 patients, there were 44 (28.0%) unplanned patient-initiated clinical phone calls, 23 (14.6%) emergency department (ED) visits, and 8 (5.1%) readmissions, with pain being the most common complaint during the encounters. Factors associated with a higher rate of phone calls include first-time stone procedure (36.6% vs 20.9%, p = 0.029), outpatient status (30.3% vs 0%, p = 0.021), intraoperative stent placement (31.2% vs 0%, p = 0.006), and stent removal at home (58.8% vs 28.8%, p = 0.014). Factors associated with increased rate of ED visits were first-time stone procedure (22.5% vs 8.1%, p = 0.011) and ureteral access sheath (UAS) usage (29.6% vs 11.8%, p = 0.018). Factors associated with a higher rate of readmissions were lower body mass index (23.9 vs 29.7, p = 0.013), bilateral procedure (20.0% vs 2.9%, p = 0.010), and UAS usage (14.8% vs 3.1%, p = 0.032). Stone burden, operative time, Charlson comorbidity index, and preoperative urinary tract infection were not significantly associated with postoperative encounters. CONCLUSIONS: Pain, first-time stone treatment, presence of a ureteral stent, outpatient status, bilateral procedures, and UAS usage were common reasons for postoperative encounters after URS. Appropriate perioperative patient education and counseling and adequate pain management may minimize these encounters and improve treatment quality and patient satisfaction.

Electronic nutritional intake assessment in patients with urolithiasis: A decision impact analysis.

PURPOSE: To evaluate a physician's impression of a urinary stone patient's dietary intake and whether it was dependent on the medium through which the nutritional data were obtained. Furthermore, we sought to determine if using an electronic food frequency questionnaire (FFQ) impacted dietary recommendations for these patients. MATERIALS AND METHODS: Seventy-six patients attended the Stone Clinic over a period of 6 weeks. Seventy-five gave consent for enrollment in our study. Patients completed an office-based interview with a fellowship-trained endourologist, and a FFQ administered on an iPad. The FFQ assessed intake of various dietary components related to stone development, such as oxalate and calcium. The urologists were blinded to the identity of patients' FFQ results. Based on the office-based interview and the FFQ results, the urologists provided separate assessments of the impact of nutrition and hydration on the patient's stone disease (nutrition impact score and hydration impact score, respectively) and treatment recommendations. Multivariate logistic regressions were used to compare pre-FFQ data to post-FFQ data. RESULTS: Higher FFQ scores for sodium (odds ratio [OR], 1.02; p=0.02) and fluids (OR, 1.03, p=0.04) were associated with a higher nutritional impact score. None of the FFQ parameters impacted hydration impact score. A higher FFQ score for oxalate (OR, 1.07; p=0.02) was associated with the addition of at least one treatment recommendation. CONCLUSIONS: Information derived from a FFQ can yield a significant impact on a physician's assessment of stone risks and decision for management of stone disease.

2D versus 3D visualization: impact on laparoscopic proficiency using the fundamentals of laparoscopic surgery skill set.

INTRODUCTION: We compared the impact of two-dimensional (2D) versus three-dimensional (3D) visualization on both objective and subjective measures of laparoscopic performance using the validated Fundamentals of Laparoscopic Surgery (FLS) skill set. SUBJECTS AND METHODS: Thirty-three individuals with varying laparoscopic experience completed three essential drills from the FLS skill set (peg transfer, pattern cutting, and suturing/knot tying) in both 2D and 3D. Participants were randomized to begin all tasks in either 2D or 3D. Time to completion and number of attempts required to achieve proficiency were measured for each task. Errors were also noted. Participants completed questionnaires evaluating their experiences with both visual modalities. RESULTS: Across all tasks, greater speed was achieved in 3D versus 2D: peg transfer, 183.4 versus 245.6 seconds (P<.0001); pattern cutting, 167.7 versus 209.3 seconds (P=.004); and suturing/knot tying, 255.2 versus 329.5 seconds (P=.031). Fewer errors were committed in the peg transfer task in 3D versus 2D (P=.008). Fourteen participants required multiple attempts to achieve proficiency in one or more tasks in 2D, compared with 7 in 3D. Subjective measures of efficiency and accuracy also favored 3D visualization. The advantage of 3D vision persisted independent of participants' level of technical expertise (novice versus intermediate/expert). There were no differences in reported side effects between the two visual modalities. Overall, 87.9% of participants preferred 3D visualization. CONCLUSIONS: Three-dimensional vision appears to greatly enhance laparoscopic proficiency based on objective and subjective measures. In our experience, 3D visualization produced no more eye strain, headaches, or other side effects than 2D visualization. Participants overwhelmingly preferred 3D visualization.

Source of drugs for prescription opioid analgesic abusers: a role for the Internet?

OBJECTIVE: There has been a sharp increase in the abuse of prescription opioid analgesics in the United States in the past decade. It has been asserted, particularly by several governmental and regulatory agencies, that the Internet has become a significant source of these drugs which may account to a great extent for the surge in abuse. We have studied whether this is correct. DESIGN: We asked 1,116 prescription drug abusers admitted for treatment, through standardized questionnaires, where they obtained their drugs. We also attempted to purchase scheduled II and III drugs from a random sample of Internet sites offering such sales. RESULTS: Dealers, friends or relatives, and doctors' prescriptions were listed as a source of drugs with equal frequency ( approximately 50-65%), with theft and forgery far behind at 20%. The Internet was mentioned by fewer than 6% of the total responders. Because these data suggest either lack of availability or that our sample has not yet realized that the Internet is a potential source, we attempted to purchase scheduled II and III opioids and the unscheduled opioid, tramadol, from a random sample of 10% of the sites listing such sales. We were unsuccessful in purchasing a single scheduled opioid analgesic, but found that tramadol, as an unscheduled drug, was freely available. CONCLUSIONS: The assertion that the Internet has become a dangerous new avenue for the diversion of scheduled prescription opioid analgesics appears to be based on no empirical evidence and is largely incorrect.