Case presentation and review of renal autotransplantation for nutcracker syndrome.

Nutcracker Syndrome (NCS) is characterized by entrapment of the left renal vein, leading hematuria, flank pain, and proteinuria. We evaluated the efficacy of renal autotransplantation as a curative treatment for NCS through a review and case report. 55 patients from 18 studies were analyzed, with a combined 91% success rate of symptom resolution or improvement post-autotransplantation. In our case report, a 25-year-old man with severe NCS received laparoscopic nephrectomy and autotransplant, resulting in symptom resolution at 3.1 years follow up. Further research should confirm these findings and refine patient selection criteria and surgical techniques.

Reimagining Ambulatory Care in Urology: Conversion of the Urology Clinic into a Procedure Center Improves Patient's Experience.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic made it necessary to practice social distancing and limited in-person encounters in health care. These restrictions created alternative opportunities to enhance patient access to care in the ambulatory setting. We hypothesized that by transforming clinics into centers that prioritize procedures and transitioning ambulatory appointments to telehealth, we could establish a secure, streamlined, and productive method for providing patient care. Methods: Clinic templates were restructured to allow the use of the physical space to perform procedure-based clinics exclusively, while switching to virtual telemedicine for all nonprocedural encounters. Staff members were given specific roles to support one of the patient care modalities for a given day (Procedures vs. Telehealth). Performance and patient satisfaction metrics were collected between two periods of time defined as P1 (February-June 2019) and P2 Post-COVID (February-June 2020) and compared. These served as proxies of periods when the clinic workflow and templates were structured in the traditional versus the emerging way. Statistical analysis was performed using bivariate analyses. Results: The percentage of procedures performed among all in-person visits were higher in P2 compared to P1 (45% vs. 29%, p < 0.001). Although total charges and relative value units were lower in P2, the overall revenue generated was higher compared to P1 ($4,597,846 vs. $4,517,427$, respectively). This increase in revenue was mainly driven by the higher relative income generated by procedures. Patient experience, reflected through patient-reported outcomes, was more favorable in P2 where patients seemed more likely to "Recommend this provider office" (90% vs. 85.7%, p = 0.01), report improved "Access overall" (56% vs. 49%, p = 0.02), and felt they were "Moving through your visit overall" (59% vs. 51%, p = 0.007). Conclusions: Our data suggest that reorganizing urology clinics into a space that is centered around outpatient procedures can represent a model that improves the patient's access to care and clinical experience, while simultaneously improving operational financial strength. This efficient care model could be considered for many practice settings and drive high-value outpatient care.

Effects of standardized language on remote ultrasound-guided percutaneous nephrolithotomy training: A mixed-methods explorative pilot study.

Background: Remote teaching of procedural skills has demonstrated equivalence in knowledge acquisition compared to in-person teaching. Variations in terminology for probe and needle movements may serve as a barrier in remote training of ultrasound (US)-guided renal access for percutaneous nephrolithotomy (PCNL). This pilot study investigated the utility of standardized terminology in remote training of US-guided renal access for PCNL. Hypothesis: Standardization of verbal terminology to describe US probe and needle movement instruction improves remote teaching of US-guided renal access. Methods: Fifteen urology residents (PGY1-6) were stratified by year and randomized into two groups. We provided participants with images illustrating US probe and needle movements labeled with predetermined standardized terminology for the intervention group and images without labels for the control group. Both groups were asked to perform US-guided renal access on a training mannequin with a remote faculty educator with (intervention) or without (control) use of standardized movement instructions. Quantitative outcomes included number of attempts and time to achieve access. All trainees completed pre- and post-session surveys and participated in focus groups; authors conducted thematic analysis of focus group transcripts. Results: Differences in primary outcomes between groups, including number of attempts and time to achieve access of the renal pole, were not statistically significant. Analysis of focus group interviews revealed that the use of standardized terminology in the setting of remote training can reduce trainee confusion by clarifying ambiguity in educator feedback. Discussion: Use of standardized terminology during remote surgical skills training allows for more effective feedback to trainees.

Voided volume may not impact stone outcomes: Review of a large institutional nephrolithiasis cohort.

Background: Urologic guidelines universally recommend increasing fluid intake for kidney stone prevention. Increased voided volume is thought to help reduce stone recurrence and severity, but supporting evidence is limited. Patients and Methods: Nephrolithiasis outcomes and 24-h urine data for patients from the Registry for Stones of the Kidney and Ureter (ReSKU), a registry of nephrolithiasis patients collected between 2015 and 2020, were retrospectively analysed. Outcome was stone events, either an office visit where a patient reports symptomatic passage of stones or surgery for stone removal. Results: We identified 450 stone patients with 24-h urine and kidney stone outcome data. There was no significant difference in 24-h voided volume between patients with one stone event and patients with two or more stone events. On multivariable logistic regression, after controlling for age, gender, BMI, and 24-h sodium and creatinine per kilogram, no significant associations were found between voided volume and stone events. There was a statistically significant negative correlation noted between voided volume and stone events in calcium oxalate dihydrate stone formers (Spearman R = -0.42, p = 0.04), but not others. Conclusions: Twenty-four-hour voided volume was not associated with stone events in a large institutional cohort, and subset analysis reveals that some stone formers may benefit more from increased voided volume than others; identifying such patients represents a novel precision medicine opportunity.

Clinical and postoperative characteristics of stentless ureteroscopy patients: a prospective analysis from ReSKU.

INTRODUCTION: To evaluate the clinical characteristics as well as the postoperative course of urolithiasis patients undergoing a ureteroscopy (URS) without stent placement. MATERIALS AND METHODS: This was a prospective case cohort study utilizing data collected in the Registry for Stones of the Kidney and Ureter (ReSKU) from a single institution between October 2015 and December 2020. We identified all consecutive patients undergoing URS for stone disease and analyzed data encompassing demographics, medical history, intra and postoperative characteristics, including complications and postoperative symptoms. Univariate and multivariate logistic regression analyses were performed based on the presence or absence of an indwelling ureteral stent. RESULTS: A total of 470 patients were included for analysis, 92 patients in the stentless group (19.5%). Factors associated with stentless ureteroscopy were a lower stone burden (p < 0.001), the pre-existence of a ureteral stent (37.4% vs. 27.9% p = 0.011), absence of an access sheath (14.6% vs. 69.5% p < 0.001), and a shorter operative time (31 vs. 58 min p < 0.001). Postoperative gross hematuria and lower urinary tract symptoms (LUTS) were reported less frequently in stentless patients (p = 0.02, p = 0.01, respectively). There was no difference in postoperative complications between both groups (15.2% vs. 12.0%, p = 0.385). On multivariate analysis, the risk of postoperative complications was associated with obesity, stone burden ≥ 1 cm, and positive preoperative urine culture. There was no patient who required emergent stent placement in the stentless group. CONCLUSION: Our data show that, in well selected patients, omitting ureteral stent placement after URS can decrease postoperative gross hematuria and LUTS without increasing postoperative complications.

A Novel Standardized Morbidity and Mortality Process to Promote Discourse, Improve Education, and Facilitate Practice Change: The M-PROVE Model.

INTRODUCTION: The morbidity and mortality conference is essential to medical education and quality improvement. Ideally, the conference is inclusive, judgment-free, and focused on practice improvement. In reality, it may not meet these goals. We reimagined the process by standardizing presentations and creating an oversight committee to improve the perceived value of the conference and identify opportunities for improvement. This study evaluates the subjective impact of the redesigned process at our institution and provides a blueprint for our reproducible model. METHODS: We created a faculty and resident committee to review all submitted cases, implemented a standardized presentation template and moderating structure, and tracked quality improvement measures from proposed improvement initiatives. Attitudes toward the conference, including perceived quality/relevance, identification of potential systems changes, inclusiveness, and educational value, were assessed among faculty and trainees using pre- and postintervention Likert-style surveys. RESULTS: Of 45 eligible department members, 41 (91%) completed the preintervention and 36 (80%) completed the postintervention survey. We found a statistically significant improvement in all questions between pre- and postintervention surveys except on the question about the conference environment being nonthreatening, which also improved but was not statistically significant. The overall average answer improved on the postintervention survey compared to the preintervention survey (3.36 vs 4.20, P < .001). These trends were similar regardless of attendee role and gender. CONCLUSIONS: Redesigning and standardizing the morbidity and mortality conference with greater attention to education, inclusion, systems change, and quality improvement improves the attitudes of conference attendees and increases the perceived value of the conference.

Ultrasound-Only Percutaneous Nephrolithotomy Is Safe and Effective Compared to Fluoroscopy-Directed Percutaneous Nephrolithotomy.

Introduction: Outcomes after ultrasound-only percutaneous nephrolithotomy (PCNL), in which no fluoroscopy is used, are not well known. The goal of this study was to compare outcomes of ultrasound-only and fluoroscopy-directed PCNL. Materials and Methods: Prospectively collected data from the Registry for Stones of the Kidney and Ureter database were reviewed for all patients who underwent PCNL at one academic center from 2015 to 2021. Primary outcomes were complications and stone-free rates (no residual fragments ≥3 mm). Results: Of the 141 patients who underwent ultrasound-only PCNL and 147 who underwent fluoroscopy-directed PCNL, there was no difference in complication rates (15% vs 16%, p = 0.87) or stone-free status (71% vs 65%, p = 0.72), respectively. After adjusting for body mass index, American Society of Anesthesiologists (ASA), stone size, and stone complexity by Guy score, ultrasound-only PCNL was not associated with any increased odds of complications (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.3-1.6, p = 0.41) or residual stone fragments ≥3 mm (OR 1.0, 95% CI 0.5-1.9, p = 0.972) compared with fluoroscopy-directed PCNL. Ultrasound-only PCNL was associated with shorter operative time (median 99.5 vs 126 minutes, p < 0.001), and the use of ultrasound remained a significant predictor of short operative time (<100 minutes) after controlling for supine positioning, stone size, and stone complexity by Guy score (OR 2.31, 95% CI 1.01-5.29, p = 0.048). Patients in the ultrasound-only group were spared a mean radiation exposure dose of 10 mGy per procedure. Conclusions: Ultrasound-only PCNL is safe and achieves similar stone-free rates compared with fluoroscopy-directed PCNL with the added benefit of avoidance of radiation.

Maternal family history of urolithiasis is associated with earlier age of onset of stone disease.

PURPOSE: To evaluate the impact of detailed family history on the severity of disease and age of onset in patients with urolithiasis. METHODS: Prospectively collected data from a single institution between October 2015 and December 2020 were analyzed. Our primary endpoint was the number of patients experiencing at least one recurrent stone during the follow-up period. RESULTS: Of 1566 patients analyzed, 603 (39%) reported at least one family member with a history of stones. The percentage of patients experiencing at least one recurrent stone event was higher in patients with a family history of stones (38%) compared to those without a family history of stones (28%) over a median follow-up period of 8 months (p = 0.001). On multivariate analysis, the presence of any family history of urolithiasis increased risk of recurrent stone events (odds ratio [OR] 1.62, p < 0.001). The presence of both a first- and a second-degree relative with urolithiasis was associated with higher odds for a recurrent stone event (OR 2.17; p = 0.003) and a younger age of onset for stones, (OR 3.32; < 0.001). A maternal-side relative with stones conferred a higher odds ratio for younger age of first onset of stones (OR 2.93; p < 0.001). CONCLUSION: Any family history of kidney stone disease imparts an increased risk of recurrent stone event and an earlier age of onset for urolithiasis. The presence of both first- and second-degree relatives or a maternal-side relative with kidney stones may be a predictor for an earlier age of onset for urolithiasis.

Determinants of ureteral obstruction after percutaneous nephrolithotomy.

BACKGROUND: Ureteral obstruction after percutaneous nephrolithotomy (PCNL) may require prolonged drainage with a nephrostomy tube (NT) or ureteral stent, but it is not well understood how and why this occurs. The goal of this study was to identify risk factors associated with postoperative ureteral obstruction to help guide drainage tube selection. METHODS: Prospective data from adult patients enrolled in the Registry for Stones of the Kidney and Ureter (ReSKU) who underwent PCNL from 2016 to 2020 were used. Patients who had postoperative NTs with antegrade imaging-based flow assessment on postoperative day one (POD1) were included. Patients with transplanted kidneys or those without appropriate preoperative imaging were excluded. We assessed the association between patient demographics, stone characteristics, and intraoperative factors using POD1 antegrade flow, a proxy for ureteral patency, as the primary outcome. Stepwise selection was used to develop a multivariate logistic regression model controlling for BMI, stone location, stone burden, ipsilateral ureteroscopy (URS), access location, estimated blood loss, and operative time. RESULTS: We analyzed 241 cases for this study; 204 (84.6%) had a visual clearance of stone. Antegrade flow on POD1 was absent in 76 cases (31.5%). A multivariate logistic regression model found that stones located anywhere other than in the renal pelvis (OR 2.63, 95% CI 1.29-5.53; p = 0.01), non-lower pole access (OR 2.81, 95% CI 1.42-5.74; p < 0.01), and concurrent ipsilateral URS (OR 2.17, 95% CI 1.02-4.65; p = 0.05) increased the likelihood of obstruction. BMI, pre-operative stone burden, EBL, and operative time did not affect antegrade flow outcomes. CONCLUSION: Concurrent ipsilateral URS, absence of stones in the renal pelvis, and non-lower pole access are associated with increased likelihood of ureteral obstruction after PCNL. Access location appears to be the strongest predictor. Recognizing these risk factors can be helpful in guiding postoperative tube management.

The endoplasmic reticulum stress response in prostate cancer.

In order to proliferate in unfavourable conditions, cancer cells can take advantage of the naturally occurring endoplasmic reticulum-associated unfolded protein response (UPR) via three highly conserved signalling arms: IRE1α, PERK and ATF6. All three arms of the UPR have key roles in every step of tumour progression: from cancer initiation to tumour growth, invasion, metastasis and resistance to therapy. At present, no cure for metastatic prostate cancer exists, as targeting the androgen receptor eventually results in treatment resistance. New research has uncovered an important role for the UPR in prostate cancer tumorigenesis and crosstalk between the UPR and androgen receptor signalling pathways. With an improved understanding of the mechanisms by which cancer cells exploit the endoplasmic reticulum stress response, targetable points of vulnerability can be uncovered.

Plant-based diet index and erectile dysfunction in the Health Professionals Follow-Up Study.

OBJECTIVE: To evaluate the longitudinal association between plant-based diet index (PDI) score and incident erectile dysfunction (ED). MATERIALS AND METHODS: We conducted a prospective analysis of 21 942 men aged 40 to 75 years who were enrolled in the Health Professionals Follow-Up Study. ED was assessed with questionnaires every 4 years starting in 2000. Dietary data were collected via validated food frequency questionnaires completed every 4 years and were used to calculate total PDI scores, as well as healthy (hPDI) and unhealthy (uPDI) subscores. Multivariable Cox proportional hazards models were used to compute hazard ratios (HRs) for incident ED. All models were stratified by age (<60, 60 to <70, ≥70 years). RESULTS: Among men aged 60 to <70 years, hPDI was inversely associated with incident ED. Those in the highest quintile of hPDI in that age group had an 18% lower risk of ED (HR 0.82, 95% confidence interval (CI) 0.73-0.91; P-trend <0.001) compared to those in the lowest quintile. Conversely, uPDI was positively associated with ED in men aged <60 years (HR 1.27, 95% CI 1.01-1.60; P-trend = 0.02). CONCLUSIONS: Encouraging a healthy plant-based diet may be an environmentally sustainable intervention for men interested in maintaining erectile function.

Single-cell analysis of human primary prostate cancer reveals the heterogeneity of tumor-associated epithelial cell states.

Prostate cancer is the second most common malignancy in men worldwide and consists of a mixture of tumor and non-tumor cell types. To characterize the prostate cancer tumor microenvironment, we perform single-cell RNA-sequencing on prostate biopsies, prostatectomy specimens, and patient-derived organoids from localized prostate cancer patients. We uncover heterogeneous cellular states in prostate epithelial cells marked by high androgen signaling states that are enriched in prostate cancer and identify a population of tumor-associated club cells that may be associated with prostate carcinogenesis. ERG-negative tumor cells, compared to ERG-positive cells, demonstrate shared heterogeneity with surrounding luminal epithelial cells and appear to give rise to common tumor microenvironment responses. Finally, we show that prostate epithelial organoids harbor tumor-associated epithelial cell states and are enriched with distinct cell types and states from their parent tissues. Our results provide diagnostically relevant insights and advance our understanding of the cellular states associated with prostate carcinogenesis.

Utility of Blue Light Cystoscopy for Post-bacillus Calmette-Guérin Bladder Cancer Recurrence Detection: Implications for Clinical Trial Recruitment and Study Comparisons.

PURPOSE: The utility of blue light cystoscopy (BLC) in patients receiving bacillus Calmette-Guérin (BCG) during post-treatment cystoscopy is not well understood. Our objective was to determine if BLC improves recurrence detection in patients with non-muscle invasive bladder cancer (NMIBC) undergoing BCG. MATERIALS AND METHODS: Using the prospective multi-institutional Cysview® Registry (2014-2019), patients with NMIBC who received BCG within 1 year prior to BLC were identified. Primary outcomes were recurrences and whether lesions were detected on white light cystoscopy (WLC), BLC or both. We calculated the percentage of cystoscopies with recurrences that were missed with WLC alone. The cystoscopy-level BLC false-positive rate was the proportion of cystoscopies with biopsies only due to BLC suspicious lesions without recurrence. RESULTS: Of 1,703 BLCs, 282 cystoscopies were in the analytic cohort. The overall recurrence rate was 45.0% (127). With only WLC, 13% (16/127) of recurrences would have been missed as 5.7% (16/282) of cystoscopies performed had recurrence only identified with BLC. Among 16 patients with recurrence missed with WLC, 88% (14) had carcinoma in situ. The cystoscopy-level BLC false-positive rate was 5% (15). CONCLUSIONS: BLC helped detect recurrences after recent BCG that would have been missed with WLC alone. Providers should consider BLC for high-risk patients undergoing BCG and should discuss the risk of false-positives with these patients. As clinical trials of novel therapies for BCG-unresponsive disease increase and there are no clear guidelines on BLC use for post-treatment cystoscopies, it is important to consider how variable BLC use could affect enrollment in and comparisons of these studies.

Ex vivo human testes as a practical model to simulate ultrasound-guided testicular cell transplantation for human fertility restoration.

OBJECTIVE: To develop an ex vivo model to practice ultrasound-guided injection of cellular material into human seminiferous tubules to simulate testicular cell transplantation (TCT). DESIGN: Simulated TCT injections were performed in human testes removed during orchiectomy. The rete testis was the target site of injection. Successful retrograde infiltration of injected material into the lumen of the seminiferous tubules was detected using ultrasound and confirmed with histology. SETTING: Single academic surgical center. PATIENT(S): Adult patients undergoing orchiectomy for nononcologic indications. INTERVENTION(S): The testes were injected with sonographic contrast (Optison), methylene blue, and fluorescent-labeled cells. MAIN OUTCOME MEASURE(S): A characteristic streaming pattern of sonographic contrast in the testis was used to define sonographic success, and the presence of methylene blue and fluorescent-labeled cells within the seminiferous tubules confirmed histologic success. RESULT(S): We performed simulated TCT injections in 30 testes obtained from 16 patients undergoing orchiectomy. We were able to achieve sonographic success in 57% of injections and confirmed that sonographic success is correlated with histologic success. CONCLUSION(S): Testicular cell transplantation injections can be practiced using human testes. As there appears to be a learning curve associated with this procedure, developing this infrastructure to practice these skills is critical before implementation in patients.

Live Renal Ultrasonography Facilitates Double-J Ureteral Stent Insertion at the Bedside: A Pilot Study for the COVID-19 Era.

Objectives: To investigate the feasibility and efficacy of live renal ultrasonography to guide Double-J ureteral stent placement at the bedside. Patients and Methods: Between April 12 and June 5, 2020, patients presenting with acute ureteral obstruction requiring decompression were prospectively selected for ultrasound-guided bedside ureteral stent placement. During stent placement, upper tract access confirmed using ultrasound with or without retrograde injection of ultrasound contrast before Double-J stent insertion. A postprocedural abdominal X-ray was obtained for stent position confirmation. Results: Eight patients (four men and four women) were offered bedside ultrasound-guided ureteral stent placement, and all eight consented to proceed. Stents were placed in seven of eight patients. One patient had an impacted ureterovesical junction stone and stricture requiring ureteroscopy and laser lithotripsy in the operating room. All patients tolerated procedures without immediate complications. Conclusion: Live renal ultrasonography can facilitate a high success rate for bedside ureteral stent placement outside the operating room. This approach is an attractive alternative to fluoroscopy-guided stent placement in the operating room and is of particular value in the COVID-19 era when judicious use of these resources is salient.

Urethral Defect in Setting of Recurrent Urethral Foreign Body Insertion.

We present a case of recurrent episodes of foreign body insertion into the urethra, ultimately resulting in urethral defect at the penoscrotal junction. We have decided against treating the urethral defect as it facilitates nonoperative retrieval of the urethral foreign bodies. We present our experience and rationale for the clinical management of this complex patient.

Non-oncologic Indications for Male Fertility Preservation.

PURPOSE OF REVIEW: To explore non-oncologic indications for male fertility preservation. RECENT FINDINGS: Common scenarios in which male fertility could be irreversibly compromised include autoimmune conditions requiring treatment with cyclophosphamide, gender dysphoria prior to starting hormone therapy, military deployment, and critical illness. Fertility preservation should be considered with particular attention to the timing and logistics specific to each scenario. Recognition and familiarity with such situations will help physicians provide better counseling to patients and their families, improve the quality of decision-making, and ultimately reduce missed opportunities and regret.

spict, a cyst cell-specific gene, regulates starvation-induced spermatogonial cell death in the Drosophila testis.

Tissues are maintained in a homeostatic state by balancing the constant loss of old cells with the continued production of new cells. Tissue homeostasis can shift between high and low turnover states to cope with environmental changes such as nutrient availability. Recently, we discovered that the elimination of transit-amplifying cells plays a critical role in maintaining the stem cell population during protein starvation in the Drosophila testis. Here, we identify spict, a gene expressed specifically in differentiating cyst cells, as a regulator of spermatogonial death. Spict is upregulated in cyst cells that phagocytose dying spermatogonia. We propose that phagocytosis and subsequent clearance of dead spermatogonia, which is partly promoted by Spict, contribute to stem cell maintenance during prolonged protein starvation.