Are there disparities in access to robot-assisted laparoscopic surgery among pediatric urology patients? US institutional experience.

OBJECTIVE: Literature suggests access to robotic surgery varies by race and payer status. We seek to investigate whether disparities exist in robot-assisted laparoscopic surgery among the pediatric urology population at our tertiary academic medical center and, if so, to find plausible reasons why. METHODS: Retrospective analysis identified patients who underwent open or robot-assisted laparoscopic surgery by a single surgeon at a tertiary care center between 2008 and 2019. Univariate and multivariate analyses determined the relationship of patient demographic and socioeconomic factors to procedure approach. RESULTS: Among 356 patients, race, age, American Society of Anesthesiologists status, and year of surgery were significant by univariate analysis. Insurance status was not significant (P = 0.066). Multivariate analysis indicated that age, American Society of Anesthesiologists status, and year of surgery were statistically significant (P < 0.001, P = 0.005, P < 0.001). By multivariate logistic regression, Black and Hispanic patient race were not significant with an odds ratio of 0.60 (0.35-1.02) (P = 0.061). In 60.2% of open cases, open approach selection was attributable to complex pathology, limitations of robotic approach, and surgeon's robot-assisted laparoscopic learning curve. CONCLUSIONS: Optimal procedure approach was determined by case complexity and surgeon's robot-assisted laparoscopic learning curve and was independent of patient race and payer status. This study did not find racial or socioeconomic disparities in robotic surgery within pediatric urology at our tertiary medical center, inconsistent with previous literature.

Systematic Review of the Impact of Varicocele Grade on Response to Surgical Management.

PURPOSE: We evaluated the impact of varicocele grade on the response to varicocelectomy or spermatic vein embolization. MATERIALS AND METHODS: We systematically reviewed the published English language literature to identify studies on changes in semen quality and pregnancy outcomes after varicocele treatment, stratified by varicocele grade. Descriptive statistics and continuous random effects models were used to study the impact of varicocele grade and the surgical approach on the response to treatment. Result heterogeneity among studies was analyzed using the I2 statistic. Quality assessment of nonrandomized studies was done with the Newcastle-Ottawa Scale. Publication bias was analyzed using funnel plots and the Egger test. RESULTS: We identified 20 studies describing the outcome of varicocele treatment stratified by varicocele grade in a total of 2,001 infertile men with varicocele. A microsurgical approach (inguinal, subinguinal and/or Palomo) was used in 11 of the 20 studies (55%). Varicocele treatment was associated with improvements in sperm concentration and overall motility in patients with all grades of varicocele. Semen quality improvements were directly related to varicocele grade. The mean sperm concentration improvement in men with grades 1, 2, 2-3 and 3 varicoceles were 5.5, 8.9, 12.7 and 16.0 million sperm per ml, respectively. The mean improvement in the percent of overall motility in men with grades 1, 2, 2-3 and 3 varicoceles was 9.6%, 10.6%, 10.8% and 17.7%, respectively. Pregnancy outcomes were assessed but could not be analyzed systematically due to the lack of adequate published data. CONCLUSIONS: Mean improvements in the sperm concentration and the percent of overall motility after treatment of grade 1 varicocele were statistically significant but small in magnitude. In contrast, mean improvements in the sperm concentration and the percent of overall motility after treatment of grade 2-3 varicoceles were greater and highly likely to be clinically significant. Incorporating varicocele grade into shared decision making discussions with affected couples may improve the ability to select patients who are the best candidates for treatment.

Ex-vivo microscopic oncotesticular sperm extraction: step-by-step surgical technique at time of radical orchiectomy.

OBJECTIVE: To demonstrate the intraoperative surgical techniques required for simultaneous radical orchiectomy and microscopic oncotesticular sperm extraction (m-OncoTESE) in a step-by-step fashion. DESIGN: Video presentation. SETTING: University Hospital (University of Chicago). PATIENTS: A 37-year-old man (status after right orchiectomy at another institution for stage II-C testicular seminoma with positive preoperative tumor markers) was referred for contralateral orchiectomy of multifocal left testis mass and fertility preservation. Semen analysis before, microscopic testicular sperm extraction during, and semen or testicular specimen analysis after the first orchiectomy were unable to identify any sperm. A postoperative analysis of the m-OncoTESE performed on the left testis resulted in the cryopreservation of 200,000 motile sperm for future assisted reproductive technology (i.e., in vitro fertilization or in vitro fertilization-intracytoplasmic sperm injection). INTERVENTIONS: Left radical orchiectomy and left m-OncoTESE. MAIN OUTCOME MEASURES: A comprehensive visual documentation of m-OncoTESE surgical techniques with concurrent commentary detailing the reasons behind each surgical step. A brief discussion on the background of m-OncoTESE and alternative fertility preservation methods accompanies the procedure. RESULTS: This video provides a step-by-step guide to performing an m-OncoTESE (proceeding a radical orchiectomy in a patient with testicular cancer) as a means of fertility preservation in an azoospermic patient. Successful extraction and cryopreservation of testicular spermatozoa were achieved after targeted ex-vivo testicular microdissection. CONCLUSIONS: Sperm extraction via m-OncoTESE is a viable option for azoospermic patients with testicular cancer undergoing radical orchiectomies. The use of preoperative imaging and microsurgical techniques facilitates and optimizes surgical dissection and sperm recovery.

The 10-item LURN Symptom Index (LURN SI-10) Detects Additional Symptoms and Shows Convergent Validity With the IPSS in Men Presenting With Lower Urinary Tract Symptoms.

OBJECTIVE: To determine how the LURN-SI-10, a novel questionnaire developed by the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN), compares with the International Prostate Symptom Score (IPSS) in men with lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH). Specifically, to assess convergent validity and determine how frequently the LURN-SI-10 identifies symptoms not captured by the IPSS. MATERIALS AND METHODS: Men presenting with BPH/LUTS were prospectively administered LURN-SI-10 and IPSS questionnaires. Urinary incontinence (UI) including post-void dribbling (PVD), urgency urinary incontinence (UUI), stress urinary incontinence (SUI), as well as bladder pain were considered present if the patient reported "about half the time or more" on LURN-SI-10. Correlations between LURN-SI-10 and IPSS were assessed as continuous and categorical variables. Multivariable linear regression analysis was performed to determine associations with symptom scores. RESULTS: LURN-SI-10 and IPSS were highly correlated in men with BPH/LUTS (r = 0.82, n = 429), as were respective bother and quality of life scores (ρ = 0.74). The LURN-SI-10 identified additional symptoms including PVD (24%), UUI (13%), SUI (2%), and pain (8%). Men with any UUI, SUI, or PVD had on average a 7.6-point higher LURN-SI-10 score than those without UI (P<.001) and 8.0-point higher IPSS score than those without UI (P<.001). CONCLUSION: The LURN-SI-10 correlates strongly with the IPSS, but the LURN-SI-10 identifies additional important symptomatology in men with LUTS. This additional information may improve the evaluation and treatment of men with BPH/LUTS. Further prospective studies of the LURN-SI-10 is warranted.

Pilot study of machine learning in the task of distinguishing high and low-grade pediatric hydronephrosis on ultrasound.

PURPOSE: Hydronephrosis is a common pediatric urological condition, characterized by dilation of the renal collecting system. Accurate identification of the severity of hydronephrosis is crucial in clinical management, as high-grade hydronephrosis can cause significant damage to the kidney. In this pilot study, we demonstrate the feasibility of machine learning in differentiating between high and low-grade hydronephrosis in pediatric patients. MATERIALS AND METHODS: We retrospectively reviewed 592 images from 90 unique patients ages 0-8 years diagnosed with hydronephrosis at the University of Chicago's Pediatric Urology Clinic. The study included 74 high-grade hydronephrosis (145 images) and 227 low-grade hydronephrosis (447 images). Patients were excluded if they had less than 2 studies prior to surgical intervention or had structural abnormalities. We developed a radiomic-based artificial intelligence algorithm incorporating computerized texture analysis and machine learning (support-vector machine) to yield a predictor of hydronephrosis grade. RESULTS: Receiver operating characteristic analysis of the classifier output yielded an area under the curve value of 0.86 (95% CI 0.81-0.92) in the task of distinguishing between low and high-grade hydronephrosis using a five-fold cross-validation by kidney. In addition, a Mann-Kendall trend test between computer output and clinical hydronephrosis grade yielded a statistically significant upward trend (p<0.001). CONCLUSIONS: Our findings demonstrate the potential of machine learning in the differentiation between low and high-grade hydronephrosis. Further studies are warranted to validate our findings and their generalizability for use in clinical practice as a means to predict clinical outcomes and the resolution of hydronephrosis.

Clinical and pathological features of renal epithelioid angiomyolipoma (PEComa): A single institution series.

Renal angiomyolipomas are benign tumors of the kidney that belong to the 'PEComa: perivascular epithelioid cell' family. Epithelioid AMLs (eAML) are a rare monotypic subtype with malignant potential, that can occur sporadically or be associated with tuberous sclerosis (TSC). Due to their epithelioid nature, eAMLs can closely resemble high-grade renal cell carcinoma (RCC), which may result in misdiagnosis. Multiple clinicopathologic parameters are predictive of worse outcomes for patients with eAML. Those can be used to stratify patients into groups with low, intermediate and high risk for disease progression. A high index of suspicion and a thorough immunohistochemical study are required to correctly diagnose eAML. Radiographically, eAMLs are also a diagnostic challenge as they share features with RCC on CT and MR imaging. Due to this close mimicry, the true incidence of eAML is thought to be much higher than 200 cases as reported in the literature. We report a series of four patients diagnosed with eAML and compare their clinical courses. We also report on the successful treatment of a patient with pulmonary metastasis from eAML using the mTOR inhibitor, everolimus. By identifying eAML and recognizing its high-risk features, it is possible mTOR inhibitors may have a meaningful role in the adjuvant treatment of these patients.