Implementation of single-port robotic urologic surgery: experience at a large academic center.

The Single-Port (SP) robotic system is increasingly being implemented in the United States, allowing for several minimally invasive urologic procedures to be performed. The present study aims to describe our single-center experience since the adoption of the SP platform. We retrospectively collected and analyzed consecutive SP cases performed at a major teaching hospital in the Midwest (Rush University Medical Center) from December 2020 to December 2023. Demographic variables were collected. Surgical and pathological outcomes were analyzed in the overall cohort and for each type of procedure. The study timeframe was divided into two periods to assess the evolution of SP technical features over time. In total, 160 procedures were performed, with robot-assisted radical prostatectomy (RARP) being the most common (49.4%). Overall, 54.4% of the procedures were extraperitoneal, with a significantly higher adoption of this approach in the second half of the study period (30% vs 74.3%, p < 0.001). A "plus one" assistant port was adopted in 38.1% of cases, with a shift towards a "pure" single-port surgery in the most recent procedures (21.1% vs 76.7%, p < 0.001). The median LOS was 33.5 h (30-48), with a rate of any grade and CD ≥ 3 postoperative complications of 9.4% and 2.5%, respectively, and a 30-day readmission rate of 1.9%. SP robotic surgery can be safely and effectively implemented for various urologic procedures. With increasing experience, the SP platform allows shifting away from transperitoneal procedures, potentially minimizing postoperative pain, and shortening hospital stay and postoperative recovery.

A Case Series of Delayed Proximal Ureteral Strictures After Nephron-Sparing Treatment of Renal Masses.

Background: Delayed proximal ureteral stricture (DPUS) after nephron-sparing treatment (partial nephrectomy [PN] and image-guided percutaneous ablation) of renal masses is a rare complication that occurs because of an unrecognized injury to the proximal ureter and/or its associated vascular supply. We present a multi-institutional series of patients who developed DPUS after nephron-sparing treatment and review relevant tumor characteristics, timing of DPUS presentation, presenting symptoms, and outcome of stricture management. Case Presentation: Between 2000 and 2019, nine patients (five PN and four ablation) were found to have DPUS diagnosed at an average of 9 (6-119) months after PN and 5.5 (1-6) after ablation. Average tumor size was 4.5 (2.9-7.3) cm and 3.6 (3-4.1) cm for those treated with PN and ablation, respectively. Nephrometry score was 8.3 (6-11) and 6.5 (5-8), respectively. For resected tumors, all were located in the lower pole, but uniformity was not found as far as medial vs lateral (3 vs 2), anterior vs posterior (2 vs 2, 1 N/A), and right vs left (3 vs 2). For ablated tumors, all four tumors were right sided, anterior, medial, and lower pole. Initial signs and symptoms include sepsis (2), flank pain (5), and asymptomatic hydronephrosis (2). Concomitant urinoma (2) and retroperitoneal abscess (1) was found on imaging. Initial management included ureteral stenting (5) and percutaneous nephrostomy tube (4). Three underwent nephrectomy. Two had spontaneous resolution of DPUS after a course of ureteral stenting. Conclusion: Potential risk factors associated with DPUS after nephron-sparing treatment, including medial and lower pole tumors, and particularly right-sided anterior masses for ablation and higher complexity nephrometry score for PN. Recognition of delayed symptoms and imaging abnormalities in the surveillance period should cue clinical suspicion to DPUS.

Correction: Predictors of fluoroquinolone-resistant bacteria in the rectal vault of men undergoing prostate biopsy.

The original version of this article contained an error in the name of author Alfredo Mena Lora. This has now been corrected.

Predictors of fluoroquinolone-resistant bacteria in the rectal vault of men undergoing prostate biopsy.

IMPORTANCE: Fluoroquinolone (FQ)-resistant rectal vault flora is associated with infectious complications in men undergoing transrectal ultrasound-guided prostate needle biopsy (TRUS-PNB). OBJECTIVE: To determine the patient factors that predict FQ-resistant rectal cultures in men who are undergoing transrectal ultrasound-guided prostate needle biopsy. METHODS: An IRB approved retrospective review of 6183 consecutive men who had undergone a rectal swab culture in preparation for TRUS-PNB between January 2013 and December 2014 was performed. Multivariable logistic regression was used to determine the clinical and demographic factors associated with FQ-resistant Enterobacteriaceae in the rectal vault. RESULTS: Of the 6179 rectal swabs analyzed, 4842 (78%) were FQ-sensitive, and 1337 (22%) were FQ-resistant. On univariable analysis, increasing age, prior TRUS-PNB, higher number of biopsy cores obtained, diabetes mellitus, antimicrobial use within the past 6 months and non-Caucasian race were predictors of FQ-resistance (all p < 0.05). Men with FQ-resistant cultures were more likely to have benign pathology on TRUS-PNB (p = 0.004). On multivariable analysis, increasing patient age (OR = 1.01/year [1.00-1.02]), use of antimicrobials in the last 6 months (OR = 2.85[2.18-3.72]), African American (OR = 1.99 [1.66-2.37]), Asian (OR = 3.39 [2.63-4.37]), and Hispanic (OR = 2.10 [1.72-2.55]) races were independently associated with FQ-resistant rectal cultures. The overall infectious rate was 1.1% (56/5214) and the sepsis rate was 0.46% (24/5214). The infection rate in the FQ-resistant group was 3.9% (43/1107) compared to FQ-sensitive group 0.3% (13/4107), p < 0.001. CONCLUSION: In this cohort, increasing age, recent antimicrobial-use, and non-Caucasian race were independent predictors of FQ-resistance in the rectal vault. As FQ-resistance is associated with infectious complications from transrectal ultrasound-guided prostate needle biopsy, understanding risk factors may assist infection control efforts.

Should We Separate the Pulmonary Surveillance Protocol for Postsurgical T1a and T1b Renal Cell Carcinoma? A Multicenter Database Analysis.

OBJECTIVE: To investigate the incidence of pulmonary metastases (PM) and the utility of the surveillance chest radiography (CXR) in detecting PM after curative treatment to better define surveillance recommendations for T1a and T1b renal cell carcinoma. MATERIALS AND METHODS: A retrospective review of a multi-institutional database was performed to include patients with renal masses treated with partial nephrectomy or radical nephrectomy. Patients were excluded for ≥T2 disease, benign pathology, and metastases. The primary outcome was the incidence of asymptomatic pulmonary lesion concerning for PM detected by CXR within 3 years. RESULTS: Five hundred sixty-eight patients met criteria of which 384 had T1a and 184 had T1b at a mean follow-up of 45 and 43 months, respectively. Patients averaged 2.96 and 2.99 CXRs for T1a and T1b with 46.8% having surveillance beyond 3 years. Indeterminate lesions were found in 5.7% (22) of T1a and 5.4% (10) in T1b of which 0.01% (2) and 1.1% (2) were confirmed PM by chest computed tomography and biopsy. Three-year CXR surveillance period detected asymptomatic PM in zero and two patients for T1a and T1b, respectively. High risk pathological features were not present in patients with PM. There was no difference in the incidence PM for patients undergoing partial nephrectomy (3/290) or radical nephrectomy (1/278) (P = .62). CONCLUSION: Our review suggests that post-treatment pulmonary surveillance should be reserved for T1b and may not be required for T1a given the low yield and false positives of CXR leading to unnecessary radiation and potential biopsies.

Urology Residents' Experience and Attitude Toward Surgical Simulation: Presenting our 4-Year Experience With a Multi-institutional, Multi-modality Simulation Model.

OBJECTIVE: To evaluate the Urological resident's attitude and experience with surgical simulation in residency education using a multi-institutional, multi-modality model. MATERIALS AND METHODS: Residents from 6 area urology training programs rotated through simulation stations in 4 consecutive sessions from 2014 to 2017. Workshops included GreenLight photovaporization of the prostate, ureteroscopic stone extraction, laparoscopic peg transfer, 3-dimensional laparoscopy rope pass, transobturator sling placement, intravesical injection, high definition video system trainer, vasectomy, and Urolift. Faculty members provided teaching assistance, objective scoring, and verbal feedback. Participants completed a nonvalidated questionnaire evaluating utility of the workshop and soliciting suggestions for improvement. RESULTS: Sixty-three of 75 participants (84%) (postgraduate years 1-6) completed the exit questionnaire. Median rating of exercise usefulness on a scale of 1-10 ranged from 7.5 to 9. On a scale of 0-10, cumulative median scores of the course remained high over 4 years: time limit per station (9; interquartile range [IQR] 2), faculty instruction (9, IQR 2), ease of use (9, IQR 2), face validity (8, IQR 3), and overall course (9, IQR 2). On multivariate analysis, there was no difference in rating of domains between postgraduate years. Sixty-seven percent (42/63) believe that simulation training should be a requirement of Urology residency. Ninety-seven percent (63/65) viewed the laboratory as beneficial to their education. CONCLUSION: This workshop model is a valuable training experience for residents. Most participants believe that surgical simulation is beneficial and should be a requirement for Urology residency. High ratings of usefulness for each exercise demonstrated excellent face validity provided by the course.

En Bloc Stapling of the Renal Hilum During Laparoscopic Nephrectomy: A Double-institutional Analysis of Safety and Efficacy.

OBJECTIVE: To explore the safety and efficacy of en bloc stapling of the renal hilum (EBSH) during laparoscopic nephrectomy (LNx) in a large double-institution cohort with an extended follow-up period. METHODS: We performed a retrospective review of patients undergoing LNx with EBSH between 2008 and 2014 at 2 academic medical centers. Data analyzed included tumor size, tumor pathology, operative time, estimated blood loss, and perioperative or postoperative complications. Evaluation of arteriovenous fistula (AVF) formation was assessed by postoperative imaging studies, physical examination, or new-onset diastolic hypertension. RESULTS: A total of 428 patients (mean age: 63 years) underwent LNx, of which there were a total of 433 renal units with EBSH (226 left renal units, 207 right renal units). Mean operative time was 169 minutes (range: 51-489 minutes). Mean estimated blood loss was 155 mL (range: 5 mL-2000 mL). Mean tumor size was 5.6 cm (range: 0.9-14.5 cm). EBSH was performed on 69 patients with chronic infectious and inflammatory benign conditions. Three hundred (70%) patients received post-procedural imaging. No patients developed clinical or radiographic evidence of AVF at a mean follow-up of 51 months. CONCLUSION: EBSH during LNx is efficient, effective, and safe. This large series lends further support that EBSH during LNx may not be associated with any significant risk of AVF formation at extended follow-up. We advocate that this technique is a safe alternative to ligating the renal artery and vein during LNx.

Physician Perceptions of Patient Health: A Comparative Analysis between Urologist and Hospitalist Perceptions of Need for Inpatient Hospitalist Comanagement Following Radical Cystectomy.

BACKGROUND/AIMS: The morbidity of radical cystectomy remains high. A multidisciplinary approach utilizing hospitalist comanagement may improve outcomes. It is unclear what factors should be considered to determine which patients might benefit from this approach. We sought to determine if there are differences between the perceived need for co-management between urologists and hospitalists. Preoperative variables were analyzed to determine which factors might be associated with need for comanagement. METHODS: A case-based survey was emailed to urologists and hospitalists at 3 academic institutions to investigate perceptions regarding need for inpatient medical comanagement of fictitious patients following cystectomy. Decisions were rated based on patient comorbidities, age, race, sex, cancer stage, neoadjuvant therapy, alcohol intake, performance status, and English literacy. A Wilcoxon rank sum test assessed each question for differences. A Mantel-Haenszel chi-square test was used to assess whether the proportion of respondents who advocated for comanagement increased as Charlson comorbidity score increased. RESULTS: The most significant determinant of need for postoperative comanagement was patients' comorbidities. Urologists and hospitalists did not differ significantly in beliefs regarding need for comanagement. CONCLUSION: The most important determining factor for comanagement was presence of comorbidities. Further studies are needed to evaluate the impact of this multidisciplinary approach.

Urological Malpractice: Claim Trend Analysis and Severity of Injury.

INTRODUCTION: In the current malpractice environment all urologists are at risk. Claim trend data on costs, types of urological errors and severity of injury in urological surgery malpractice claims are lacking. METHODS: We analyzed physician level claim data from a large professional liability insurer with a nationwide client base. Available data included records on closed malpractice claims from 1985 to 2013. We evaluated insured demographics, total number of closed claims, costs of indemnity payments, costs of defense, types of errors resulting in closed claims and severity of injury in urological claims. RESULTS: Compared to other medical specialties urology ranks 13th in total claims and 15th in average cost of indemnity payments in the last decade. Most urological claims are dropped, dismissed or withdrawn without indemnity payment. Of closed urological claims 27.2% result in an indemnity payment to the plaintiff. Adjusting for inflation, urological indemnity payments have increased by 60% since the 1980s and average payouts are now greater than $350,000. Improper performance of a procedure is the most prevalent urological error resulting in closed claims (875 closed claims in the last decade). Procedures involving the kidney (245 closed claims) and prostate (244 closed claims) are most frequently implicated. The majority of urological errors result in temporary or minor permanent injury. Errors resulting in grave injury are the most costly, with average indemnity payments of $514,844. CONCLUSIONS: Awareness of claim trends and errors implicated can help urologists better understand the current malpractice environment.

The Current State of Medical Malpractice in Urology.

Medical malpractice can present an unwelcome professional, emotional, and economic burden to the practicing urologist. To date, there is a paucity of data specific to urologic malpractice in the literature. We performed a comprehensive literature search to identify and evaluate recent studies related to urologic malpractice. We also analyzed 6249 closed urologic claims from the largest available specialty-specific data set gathered by Physician Insurers Association of America from 1985 to 2012. The resulting comprehensive review seeks to raise awareness of current trends in the malpractice environment specific to urologic surgery while also helping urologists identify opportunities for risk management and improved patient care.

Characteristics of patients diagnosed with both melanoma and renal cell cancer.

BACKGROUND: Patients with renal cell carcinoma (RCC) and malignant melanoma (MM) have an increased risk of additional malignancies. We identified characteristics of MM and RCC associated with a patient developing both cancers. METHODS: A total of 147,656 cases of RCC and 225,548 of MM submitted to the Surveillance, Epidemiology, and End Results database between 1973 and 2008 were analyzed. Standardized incidence ratios (SIR) with 95 % confidence intervals (CI) were calculated for MM after RCC and vice versa. Clinical and pathological characteristics were compared between patients with RCC or MM only and with both cancers using multivariable proportional hazards and competing risks regression models. RESULTS: Overall 1,241 patients developed both cancers. The crude incidence rates of RCC in patients with a prior MM diagnosis and vice versa were 5.2 and 9.4 per 10,000 person-years, respectively. There was an excess of MM in RCC patients (SIR 1.45, CI 1.34-1.57) and of RCC in MM patients (SIR 1.34, CI 1.25-1.43). Median years from RCC to MM diagnosis was 4.3 (2.0-7.8) and from MM to RCC 4.7(2.3-9.9). Patients with a history of MM had more papillary RCC (10.2 vs. 4.8 %, p = 0.01) and were more likely to be female (25.9 vs. 20.5 %, p < 0.001). On multivariable analyses, ocular MM was independently associated with subsequent RCC (HR 1.76 CI 1.24-2.49), as were increasing age, and male sex. CONCLUSIONS: We confirmed a bidirectional association between RCC and MM. A history of MM was found to be associated with papillary RCC and advanced RCC. Ocular MM predicted an increased risk of RCC diagnosis. Further research is warranted into the mechanisms responsible for the association between RCC and MM.

The characteristics of bladder cancer after radiotherapy for prostate cancer.

OBJECTIVES: Prostate radiotherapy (RT) has been associated with an increased risk of bladder cancer (CaB). However it is unknown how prior RT affects the stage, grade, and histology of secondary CaB. While irradiated patients have adverse surgical outcomes, how RT affects survival is also unknown. We sought to determine how RT for prostate cancer (CaP) affects the characteristics and outcomes of secondary CaB. MATERIALS AND METHODS: A retrospective review of 275,200 cases of clinically localized CaP submitted to the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2007 was performed. CaP treatment was stratified by radical prostatectomy (RP) alone, RT, or RP + RT. Diagnosis of CaB at least 1 year after CaP, and CaB death were the primary outcomes. The stage, grade, and histology of CaB of patients exposed to RT or RP were compared. A competing risks multivariable survival analysis was performed to determine the effect of RT on CaB-specific mortality. RESULTS: CaP patients treated with any RT were 1.70 times as likely to develop CaB (95% CI 1.57-1.86, P < 0.001) compared with RP alone. CaB in men who had RT were more likely non-urothelial (6.4% vs. 3.8%, P = 0.004), trigonal (6.9% vs. 5.4%, P = 0.012), and carcinoma in-situ (CIS) (9.2% vs. 7.0%, P < 0.001) compared with RP. RT increased CaB-specific mortality (HR = 1.30, P = 0.02), which remained significant when adjusted for CaB features (HR = 1.28, P = 0.05). CONCLUSIONS: Patients with localized CaP treated with RT have a higher risk of CaB. CaB after RT is more likely to be located at the trigone and contain CIS. Patients with CaB after RT have decreased cancer-specific survival compared with those undergoing RP alone.

Characteristics and outcomes of tumors arising from the distal nephron.

OBJECTIVE: To compare the characteristics and predictors of cancer-specific survival (CSS) of 2 rare distal nephron tumors--medullary renal cell carcinoma (MRCC) and collecting duct carcinoma (CDC). METHODS: All cases of histologically verified MRCC and CDC reported to The Surveillance, Epidemiology and End Results (SEER) database between 1995 and 2007 were considered. A number of characteristics were compared by tumor histology. Subset analyses were performed for metastatic patients and those managed surgically. CSS was analyzed using Cox proportional hazard models. RESULTS: Overall, 21 cases of MRCC and 227 cases of CDC met the criteria for analysis. Patients with MRCC were younger (median 24 vs 63 years, P < .001), more often black (71.4% vs 22.7%, P < .001), metastatic at presentation (71.4% vs 27.8%, P < .001), and less likely to undergo surgery (61.9% vs 85.6%, P = .015) compared with patients with CDC. Tumor size was similar between MRCC and CDC (median 6 vs 5 cm, P = .70). Median survival was 5 months for MRCC and 30 months for CDC (P < .001). In metastatic MRCC and CDC patients, surgery predicted CSS (HR 4.61 and 2.24, both P ≤.05) despite having larger primary tumors than those managed nonsurgically (median 7.5 vs 5.0 cm, P < .01). CONCLUSION: Patients with MRCC present younger, at a later stage, and are more often black than patients with CDC. The stage migration toward localized kidney cancer is not apparent for these tumors. Although both cancers have a poor prognosis, the clinical and survival characteristics are distinct. Patients selected for cytoreductive surgery have improved survival.

Marital status independently predicts testis cancer survival--an analysis of the SEER database.

OBJECTIVES: Previous reports have shown that married men with malignancies have improved 10-year survival over unmarried men. We sought to investigate the effect of marital status on 10-year survival in a U.S. population-based cohort of men with testis cancer. MATERIALS AND METHODS: We examined 30,789 cases of testis cancer reported to the Surveillance, Epidemiology, and End Results (SEER 17) database between 1973 and 2005. All staging were converted to the 1997 AJCC TNM system. Patients less than 18 years of age at time of diagnosis were excluded. A subgroup analysis of patients with stages I or II non-seminomatous germ cell tumors (NSGCT) was performed. Univariate analysis using t-tests and χ(2) tests compared characteristics of patients separated by marital status. Multivariate analysis was performed using a Cox proportional hazard model to generate Kaplan-Meier survival curves, with all-cause and cancer-specific mortality as the primary endpoints. RESULTS: 20,245 cases met the inclusion criteria. Married men were more likely to be older (38.9 vs. 31.4 years), Caucasian (94.4% vs. 92.1%), stage I (73.1% vs. 61.4%), and have seminoma as the tumor histology (57.3% vs. 43.4%). On multivariate analysis, married status (HR 0.58, P < 0.001) and Caucasian race (HR 0.66, P < 0.001) independently predicted improved overall survival, while increased age (HR 1.05, P < 0.001), increased stage (HR 1.53-6.59, P < 0.001), and lymphoid (HR 4.05, P < 0.001), or NSGCT (HR 1.89, P < 0.001) histology independently predicted death. Similarly, on multivariate analysis, married status (HR 0.60, P < 0.001) and Caucasian race (HR 0.57, P < 0.001) independently predicted improved testis cancer-specific survival, while increased age (HR 1.03, P < 0.001), increased stage (HR 2.51-15.67, P < 0.001), and NSGCT (HR 2.54, P < 0.001) histology independently predicted testis cancer-specific death. A subgroup analysis of men with stages I or II NSGCT revealed similar predictors of all-cause survival as the overall cohort, with retroperitoneal lymph node dissection (RPLND) as an additional independent predictor of overall survival (HR 0.59, P = 0.001), despite equal rates of the treatment between married and unmarried men (44.8% vs. 43.4%, P = 0.33). CONCLUSIONS: Marital status is an independent predictor of improved overall and cancer-specific survival in men with testis cancer. In men with stages I or II NSGCT, RPLND is an additional predictor of improved overall survival. Marital status does not appear to influence whether men undergo RPLND.

Urological manifestations of sarcoidosis.

PURPOSE: We describe the urological manifestations of sarcoidosis and how the disease may affect the management of multiple urological conditions. MATERIALS AND METHODS: We performed a PubMed® search using the query sarcoidosis and multiple urological terms. RESULTS: Sarcoidosis is a disease that has variable manifestations. There is often genitourinary involvement that is clinically silent. However, sarcoidosis may cause symptoms, such as nephrolithiasis, which are sometimes the first manifestation of the disease. Renal function may be affected, and appropriate recognition and treatment may avert progressive functional decline. The presence of sarcoidosis may also confound the diagnosis and staging of various urological malignancies, particularly renal and testicular carcinoma. CONCLUSIONS: Urologists should be aware of the urological manifestations of sarcoidosis to avoid misdiagnoses and the over staging of urological cancers, and to identify when it is an underlying cause of nephrolithiasis or obstructive uropathy.

Urological malpractice: analysis of indemnity and claim data from 1985 to 2007.

PURPOSE: The possibility of a medical malpractice lawsuit is present in the practice of modern day medicine. A basic knowledge of trends, monetary values and types of claims involved in urological litigation is beneficial to the practicing surgeon. MATERIALS AND METHODS: Cumulative analysis of claims data from 1985 to 2007 from more than 20 member companies of the Physician Insurers Association of America was performed. A total of 28 medical specialties are represented in 230,000 claims. An analysis of urological claims with regard to other specialties, trends, and most prevalent and types of procedures was performed. RESULTS: Urology ranks 12th of 28 in the number of claims reported (5,577) and monies paid, totaling $285 million during 22 years. The average urology paid claim from 1985 to 2007 was $174,245, which is less than the average of all groups ($204,268). In 2007 the average indemnity paid was $227,838, which is an increase from $176,213 in 1997. The 2 most prevalent medical misadventures were improper performance and diagnostic errors, which accounted for 51% of all of the claims. CONCLUSIONS: Urology tends to be at or below average compared to other medical specialties in regard to total claims, total monies paid and average monies paid during the last 23 years. From 1997 to 2007 the average indemnity paid increased by 23%. Improper performance, diagnostic errors and failure to monitor cases resulted in the most lawsuits. In those groups malignancy of the prostate, testis and kidney appeared consistently. Continued analysis and education on medical litigation in urology can aid in increased awareness and possibly improved care for patients in the future.