Outcomes and Risk Factors of Revision and Replacement Artificial Urinary Sphincter Implantation in Radiated and Nonradiated Cases.

PURPOSE: Risk factors for complications after artificial urinary sphincter surgery include a history of pelvic radiation and prior artificial urinary sphincter complication. The survival of a second artificial urinary sphincter in the setting of prior device complication and radiation is not well described. We report the survival of redo artificial urinary sphincter surgery and identify risk factors for repeat complications. MATERIALS AND METHODS: A multi-institutional database was queried for redo artificial urinary sphincter surgeries. The primary outcome was median survival of a second and third artificial urinary sphincter in radiated and nonradiated cases. A Cox proportional hazards survival analysis was performed to identify additional patient and surgery risk factors. RESULTS: Median time to explantation of the initial artificial urinary sphincter in radiated (150) and nonradiated (174) cases was 26.4 and 35.6 months, respectively (p=0.043). For a second device median time to explantation was 30.1 and 38.7 months (p=0.034) and for a third device it was 28.5 and 30.6 months (p=0.020), respectively. The 5-year revision-free survival for patients undergoing a second artificial urinary sphincter surgery with no risk factors, history of radiation, history of urethroplasty, and history of radiation and urethroplasty were 83.1%, 72.6%, 63.9% and 46%, respectively. CONCLUSIONS: Patients without additional risk factors undergoing second and third artificial urinary sphincter surgeries experience revision-free rates similar to those of their initial artificial urinary sphincter devices. Patients who have been treated with pelvic radiation have earlier artificial urinary sphincter complications. When multiple risk factors exist, revision-free rates decrease significantly.

Renal Trauma Classification and Management: Validating the Revised Renal Injury Grading Scale.

PURPOSE: To better characterize traumatic renal injury a revision to the 1989 American Association for the Surgery of Trauma renal injury scale was proposed in which grade IV includes all collecting system and segmental vascular injuries and grade V includes main renal hilar injury. We sought to validate the 2009 grading scale, emphasizing reclassifications between the 1989 and 2009 versions, and subsequent management. MATERIALS AND METHODS: Patient demographics and renal injury characteristics, computerized tomography imaging, radiology reports and subsequent management were recorded in a prospective trauma database. Multivariable logistic regression models for intervention were compared using 1989 and 2009 grades to evaluate which grading scale better predicted management. RESULTS: Of 256 renal injury cases 56 (21.9%) were reclassified using the revised 2009 scale, including 50 (19.5%) which were upgraded, 6 (2.3%) which were downgraded and 200 (78.1%) which were unchanged. Of grade III or higher cases management was nonoperative in 112 (78.9%), angioembolization in 9 (6.3%), nephrectomy in 9 (6.3%) and renorrhaphy in 12 (8.5%). Management was significantly associated with original and revised grades (chi-square p=0.02 and <0.001, respectively). Further, the multivariable model using the 2009 grades significantly outperformed the 1989 model. Radiology reports rarely included renal injury scales. CONCLUSIONS: Using the revised renal injury grading scale led to more definitive classification of renal injury and a stronger association with renal trauma management. Applying the revised criteria may facilitate and improve the multidisciplinary care of renal trauma.

Nutrition, physical activity, and lifestyle factors in prostate cancer prevention.

PURPOSE OF REVIEW: To review current evidence for prostate cancer prevention with nutrition, physical activity, and lifestyle interventions and identify future research directions. RECENT FINDINGS: Multiple preclinical and observational studies have observed that diet, exercise, and lifestyle interventions may play a role in mitigating disease progression, mortality, and overall disease burden for high-grade and fatal prostate cancer. Increased vegetable and fruit intakes, decreased red meat and saturated fat intakes, and increased exercise are potentially associated with decreased risk of incident disease and increased progression-free, prostate cancer-specific, and overall survival. Randomized controlled trials (RCTs) have demonstrated that selenium and vitamin C supplements are ineffective in preventing incident prostate cancer and that vitamin E supplements potentially increase incident prostate cancer risk. A large RCT of a high vegetable diet intervention among prostate cancer patients on active surveillance, the Men's Eating and Living study, will soon complete analysis. An RCT for an exercise intervention among men with metastatic castrate-resistant prostate cancer is currently accruing. SUMMARY: Although preclinical and observational studies have identified potential benefits for high vegetable, low fat, low meat diets, and increased exercise, Level I evidence is limited. To inform clinical care, future research should focus on RCTs evaluating clinical effectiveness.

Quality of diagnostic staging in patients with bladder cancer: a process-outcomes link.

BACKGROUND: Muscle sampling is often used as a surrogate for staging quality in patients with bladder cancer. The association of staging quality at diagnosis and survival was examined among patients with bladder cancer. METHODS: The clinical records of all individuals within the Los Angeles Surveillance, Epidemiology, and End Results registry with an incident diagnosis of non-muscle-invasive bladder cancer in 2004-2005 were reviewed. Patient demographics, tumor characteristics, staging quality (presence of muscle in the specimen and mention of muscle in the pathology report), and vital status were recorded. With mixed-effects and competing-risks regression analyses, the association of patient and tumor characteristics with staging quality and cancer-specific survival was quantified. RESULTS: The sample included 1865 patients, 335 urologists, and 27 pathologists. Muscle was reported to be present in 972 (52.1%), was reported to be absent in 564 (30.2%), and was not mentioned in 329 (17.7%) of the initial pathology reports. The presence of muscle did not differ according to the grade or depth of invasion. Mortality was associated with staging quality (P < .05). Among patients with high-grade disease, the 5-year cancer-specific mortality rates were 7.6%, 12.1%, and 18.8% when muscle was present, absent, and not mentioned, respectively. CONCLUSIONS: The omission of muscle in the specimen or its mention in the pathology report in nearly half of all diagnostic resections was associated with increased mortality, particularly in patients with high-grade disease. Because urologists cannot reliably discern between high- and low-grade or Ta and T1 disease, it is contended that patients with bladder cancer should undergo adequate muscle sampling at the time of endoscopic resection.

EGFR activation suppresses respiratory virus-induced IRF1-dependent CXCL10 production.

Airway epithelial cells are the primary cell type involved in respiratory viral infection. Upon infection, airway epithelium plays a critical role in host defense against viral infection by contributing to innate and adaptive immune responses. Influenza A virus, rhinovirus, and respiratory syncytial virus (RSV) represent a broad range of human viral pathogens that cause viral pneumonia and induce exacerbations of asthma and chronic obstructive pulmonary disease. These respiratory viruses induce airway epithelial production of IL-8, which involves epidermal growth factor receptor (EGFR) activation. EGFR activation involves an integrated signaling pathway that includes NADPH oxidase activation of metalloproteinase, and EGFR proligand release that activates EGFR. Because respiratory viruses have been shown to activate EGFR via this signaling pathway in airway epithelium, we investigated the effect of virus-induced EGFR activation on airway epithelial antiviral responses. CXCL10, a chemokine produced by airway epithelial cells in response to respiratory viral infection, contributes to the recruitment of lymphocytes to target and kill virus-infected cells. While respiratory viruses activate EGFR, the interaction between CXCL10 and EGFR signaling pathways is unclear, and the potential for EGFR signaling to suppress CXCL10 has not been explored. Here, we report that respiratory virus-induced EGFR activation suppresses CXCL10 production. We found that influenza virus-, rhinovirus-, and RSV-induced EGFR activation suppressed IFN regulatory factor (IRF) 1-dependent CXCL10 production. In addition, inhibition of EGFR during viral infection augmented IRF1 and CXCL10. These findings describe a novel mechanism that viruses use to suppress endogenous antiviral defenses, and provide potential targets for future therapies.

Neoadjuvant chemotherapy prior to radical cystectomy for non-muscle invasive bladder cancer: national trends and pathologic outcomes.

Background: There is a sparsity of literature on treatment outcomes for patients with non-muscle invasive bladder cancer (NMIBC) who received neoadjuvant chemotherapy (NAC). We aim to analyze the outcomes associated with the use of NAC prior to radical cystectomy for NMIBC utilizing the National Cancer Database. Materials/Methods: The National Cancer Database bladder dataset was evaluated for patients with NMIBC and known pT staging undergoing RC from 2006-2016. The primary outcome was the utilization of NAC. The secondary outcomes were pathologic down staging to pT0, positive surgical margins, 30-day readmission, and overall survival. Results: The proportion of patients receiving NAC prior to radical cystectomy for NMIBC increased from 8.6% in 2006 to 14.8% in 2016. Those who received NAC had significantly higher tumor stages (cT1 vs cTa/is) with 85.7% of patients receiving NAC presenting with cT1 as opposed to only 82% in those not receiving NAC (p < 0.001). Similarly, there were significantly more patients who were cN+ in the NAC group as compared to those who did not receive NAC (5.5% vs. 1.1%, p < 0.001). For patients who received NAC, the rate of downstaging to pT0 was 12.7% as compared to only 3.3% in patients who did not receive NAC (p < 0.001). There was no significant difference comparing the rates of positive margins or 30-day readmissions between groups. On multivariable logistic regression for pathologic downstaging, NAC was significant (OR 4.1, p < 0.05). There was no significant difference in overall survival between patients treated with or without NAC. Conclusion: NAC prior to RC in patients with NMIBC has increased in recent years and correlates with tumor downstaging. Further research is requisite to identify patients who obtain the greatest benefit of NAC in the NMIBC setting.

Gel Rolls Increase Percutaneous Nephrolithotomy Radiation Exposure.

Introduction: Despite increasing interest in reducing radiation doses during endoscopic stone surgery, there is conflicting evidence as to whether percutaneous nephrolithotomy (PCNL) positioning (prone or supine) impacts radiation. We observed clinically that a patient placed prone on gel rolls had higher than expected radiation with intraoperative CT imaging and that gel rolls were visible on the coaxial imaging. We hypothesized that gel rolls directly increase radiation doses. Methods: Anthropomorphic experiments to simulate PCNL positions were performed using a robotic multiplanar fluoroscopy system (Artis Zeego Care+Clear, Siemens) and a 5-second coaxial imaging protocol (5s BODY). A fluoroscopy phantom was placed in various positions, including prone on a gel roll; prone on blankets of equal thickness; prone and supine directly on the table; and modified supine (MS) positions using a thin gel roll or rolled blanket. Impacts of C-arm direction and use of a 1 L saline bag were also evaluated. Measured dose area product (DAP) was compared for the groups. Results: Measured DAP was found to increase by 146 µGy*m2 (287%) when prone on gel rolls compared with only 62.29 (23%) when placed on blankets of equal thickness, although the model likely both overstates the relative impact and understates the absolute impact that would be seen clinically. Measured DAP between experimental groups also varied considerably despite fluoroscopy time being held constant. Conclusions: Our experiments support our hypothesis that gel rolls directly increase radiation dose, which has not been previously reported, using an anthropomorphic model. Surgeons should consider radiolucent materials for positioning to limit radiation exposure to patients and the surgical team.

Quality and Readability of Online Health Information on Common Urologic Cancers: Assessing Barriers to Health Literacy in Urologic Oncology.

INTRODUCTION: A growing number of Americans search online for health information related to urologic oncologic care each year. The American Medical Association recommends that medical information be written at a maximum sixth-grade level in order to be comprehensible by the majority of patients. As such, it is important to assess the quality and readability of online patient education material that patients are being exposed to. METHODS: A Google search was performed using the terms "testicular cancer," "prostate cancer," "kidney cancer," and "bladder cancer," and the top 30 results for each were reviewed. Websites were categorized based on their source. Readability was assessed using the Flesch-Kincaid Grade Level, the Gunning Frequency of Gobbledygook, and the Simple Measure of Gobbledygook indices. Quality was assessed using the DISCERN Quality Index (1-5 scale). RESULTS: A total of 91 websites were included in our analysis. On average, online health information pertaining to urologic cancers is written at a 10th- to 11th-grade reading level, which is significantly higher than that of an average American adult and that recommended by the American Medical Association (P < .01). The overall quality of websites was 3.4 ± 0.7, representing moderate to high quality. There was no significant difference in readability based on cancer type or information source. CONCLUSIONS: Despite being of moderate to high quality, online patient education materials related to common urologic cancers are often written at a grade level that exceeds the reading level of an average American adult. This presents as a barrier to online health literacy and calls into question the utility of these resources.

Association of Frailty and Complications Following Prostate Biopsy: Results From a Population-Based, Privately Insured Cohort.

INTRODUCTION: Prostate needle biopsy (PNBx) is essential for prostate cancer diagnosis, yet it is not without risks. We sought to assess patients who underwent PNBx using a claims-based frailty index to study the association between frailty and postbiopsy complications from a large population-based cohort. We hypothesized that increased frailty would be associated with adverse outcomes. METHODS: Using Market Scan, we identified all men who underwent PNBx from 2010 to 2015. Individuals were stratified by claims-based frailty index into 2 prespecified categories: not frail, frail. Complications occurring within 30 days from prostate biopsy requiring emergency department, clinic, or hospital evaluations constituted the primary outcome. Unadjusted and adjusted analyses identified patient covariates associated with complications. RESULTS: We identified 193,490 patients who underwent PNBx. The mean age was 57.6 years (SD: 5.0). In all, 5% were prefrail, mildly frail, or moderately to severely frail. The rate of overall complications increased from 11.1% for not frail to 15.5% for frail men. After adjusting for covariates, individuals with any degree of frailty experienced a higher risk of overall complication (odds ratio [OR]: 1.29; P < .001), clinic (OR: 1.26; P < .001) and emergency department visits (OR: 1.32; P = .02), and hospital readmissions (OR: 1.41; P < .001). CONCLUSIONS: Frailty was associated with a higher risk of complications for patients undergoing PNBx. Frailty assessment should be integrated into shared decision-making to limit the provision of potentially harmful care associated with prostate cancer screening.

Cost of upper tract imaging obtained during hematuria evaluation: Analysis of a national claims database.

INTRODUCTION: To investigate the actual cost of hematuria evaluation using nationally representative claims data, given that the workup for hematuria burdens the healthcare system with significant associated costs. We hypothesized that evaluation with contrast-enhanced computed tomography (CT) confers more cost to hematuria evaluation than renal ultrasound (US). METHODS: Using a national, privately insured database (MarketScan), we identified all individuals with an incident diagnosis of hematuria. We included patients who underwent cystoscopy and upper tract imaging within 3 months of diagnosis. We tabulated the costs of the imaging study as well as the total healthcare cost per patient. A multivariable model was developed to evaluate patient factors associated with total healthcare costs. RESULTS: We identified 318,680 patients with hematuria who underwent evaluation. Median costs associated with upper tract imaging were $362 overall, $504 for CT with contrast, $163 for US, $680 for magnetic resonance imaging (MRI), $283 for CT without contrast, and $294 for retrograde pyelogram. Median cystoscopy cost was $283. Total healthcare costs per patient were highest when utilizing MRI and CT imaging. When adjusted for comorbidities, the use of any imaging other than ultrasound was associated with higher costs. CONCLUSIONS: In this nationally representative analysis, hematuria evaluation confers a significant cost burden, while the primary factor associated with higher costs of screening was imaging type. Based upon reduced cost of US-based strategies, further investigation should delineate its cost-effectiveness in the diagnosis of urological disease.

Ultralow-Dose Intraoperative Computed Tomography During Endoscopic Stone Surgery: A Quality Improvement Project.

Objectives: To improve care in patients with large kidney stones using advanced intraoperative imaging techniques to reduce perioperative radiation exposure, improve stone-free rates (SFRs), and reduce the number of surgical interventions in a quality improvement project. Patients and Methods: Patients with kidney stones appropriate for percutaneous nephrolithotomy (PCNL) treatment were scheduled into a hybrid operating room for endoscopic surgery (PCNL and/or ureteroscopy) with intent to perform intraoperative CT (ICT). Imaging was performed using an Artis Zeego Care+Clear™ (Siemens) robotic-armed multiplanar fluoroscopy system with collimation to the level of the affected kidney(s). After the initial case, the proprietary CARE™ (combined applications to reduce exposure) protocol was used. When the hybrid room was unavailable, a mobile CT scanner (O-Arm; Medtronics) was used in the traditional room (n = 2). Results: Thirty-one ICTs were performed in 23 consecutive patients during endoscopic stone procedures with a median effective radiation dose of 1.39 mSv per scan, significantly less than the preoperative noncontrast CT (12.02 mSv) in the same patients (p < 0.001). Longitudinal radiation exposure associated with stone treatment significantly decreased by 83% (15.80 to 2.68 mSv, p < 0.001) compared with a similar historical PCNL cohort. Clinically significant residual stones (≥3 mm) were identified at initial ICT in eight patients (35%) and further treated in six patients. One patient had missed residual stone diagnosed 34 days after surgery, which was apparent on re-review of the ICT. Thus, final verified SFR was 87% for all stages. Mean number of procedures improved from 1.77 to 1.30 (p = 0.05) and rate of postoperative CT scans improved from 82% to 26% (p < 0.001). Conclusion: Ultralow-dose ICT was demonstrated to simultaneously improve SFR and number of staged treatments, and greatly reduce the perioperative radiation dose for our patients. The findings support the continued use of this modality to benefit all patients with large stones.

Carbon Dioxide Pyelography: A Convenient and Safe Alternative to Both Room Air and Iodinated Contrast Pyelography During Endourologic Procedures.

Introduction/Background: There are increasing reports of serious complications related to the air pyelography technique, which raise concerns about the safety of room air (RA) injection into the renal collecting system. Carbon dioxide (CO2) is much more soluble in blood than nitrogen and oxygen and thus considerably less likely to cause gas emboli. Iodinated contrast medium (ICM) is expensive, and supplies may not be as reliable as previously assumed. CO2 pyelography (CO2-P) techniques using standard fluoroscopy and digital subtraction fluoroscopy (CO2 digital subtraction pyelography [CO2-DSP]) are described. Materials and Methods: During the endourologic stone cases, 15 to 20 mL of CO2 gas was typically injected into the renal pelvis through a catheter or sheath. Imaging was usually obtained with endovascular CO2 digital subtraction angiography settings using either a traditional fluoroscopy system (TFS) or robotic arm multiplanar fluoroscopy system (RMPFS) (Artis Zeego Care+Clear®; Siemens). Results: CO2-P was performed in 22 endoscopic stone treatment cases between March 2021 and August 2022, primarily using digital subtraction settings in 20 cases. CO2-DSP overall provided higher quality images of the renal pelvis and collecting system than CO2-P, but with a relatively higher radiation dose. Following a quality intervention, fluoroscopy doses for CO2-DSP cases were decreased by 81% overall. The use of CO2-P avoided fluoroscopic or intraoperative CT (ICT) artifacts seen with intraluminal ICM. Conclusions: CO2-P allows the urologist to obtain imaging of the renal collecting system without ICM and with much lower risk of air embolism compared with RA pyelography. CO2 is a nearly cost-free alternative to ICM. Because CO2 is widely available and the technique is easy to perform, we propose that CO2-P should be favored over traditional air pyelography to improve patient safety.

Geographic Variation of Infectious Complications Following Prostate Biopsy in The United States: Results From a Population-Based Cohort of Privately Insured Patients.

OBJECTIVE: To elucidate regional trends of infectious complications following transrectal ultrasound prostate biopsy (TRUS-PB) from a national, privately-insured database. MATEREIAL AND METHODS: Using Market Scan, we identified all men who underwent TRUS-PB from 2010 to 2015. Infectious complications (UTI, prostatitis, sepsis) occurring 30 days after the prostate biopsy from emergency room (ER) visits or hospital admissions constituted the primary outcomes. We analyzed unadjusted and adjusted rates of infectious complications from ER visits and hospital admissions per 100 prostate biopsies by state. Multivariable logistic regression analyses were used to identify patient covariates associated with infectious complications. RESULTS: During the study interval, we identified 193,490 patients who underwent TRUS-PB. The mean age was 57.6 years (SD: 5.0). Over time the unadjusted national rates of infectious complications remained similar from 0.4 ER visits per 100 prostate biopsies in 2010 -0.2 in 2015 (P = 0.83), and 1.2 hospital admissions per 100 prostate biopsies in 2010 to 1.1 in 2015 (P= 0.58). Connecticut had the lowest unadjusted infectious complication rate per 100 biopsies at 0.64, whereas West Virginia had the highest at 2.34. Multivariable analysis revealed higher Elixhauser status and patient age were associated with higher odds of infectious complications (P<0.05). CONCLUSIONS: While rates of infectious complications attributable to prostate biopsies remain relatively stable, significant variation exists at the state level regarding this adverse outcome.

Poor Compliance With Postvasectomy Semen Testing: Analysis of Factors and Barriers.

OBJECTIVE: To ensure procedure success, American Urological Association Guidelines recommend postvasectomy semen analysis (PVSA); however, current literature suggests poor compliance. We sought to measure PVSA compliance and assess barriers to completion. METHODS: A retrospective review was performed of vasectomies at San Diego Veterans Administration Hospital and UC San Diego Health between 2006 and 2018. Patients received preprocedural counseling regarding semen analysis necessity. Postprocedural management included follow-up visit within 2-4 weeks and semen analysis after 15-20 ejaculations. Demographics and periprocedural variables were collected. Telephone interviews assessed patient reported reasons for noncompliance. Multivariable analysis was performed for factors associated with semen analysis. RESULTS: 503 men, mean age 38.8 years, underwent vasectomy at San Diego Veterans Administration Hospital (n = 331) and UC San Diego (n = 172). Overall, 80% completed clinical follow-up (n = 401) and 53% completed semen analysis (n = 268). The cohorts exhibited significantly different rates of semen analysis completion (46% vs 67%, P <.001) and clinical follow-up (64% vs 85%, P = .038). No difference was observed in age, fatherhood, or marital status. On multivariable analysis, fatherhood was the only factor associated with noncompliance of semen analysis (odds ratio 0.52, 95% confidence interval 0.33-0.83). Among men interviewed, the primary barriers to semen analysis completion were distance (38%), time constraints (34%), and forgetfulness (23%). Ninety-two% reported increased likelihood of completion with home-based semen testing. CONCLUSION: Patients demonstrated poor PVSA compliance despite preprocedural counseling. Given that distance and time constraints limited compliance, incorporating home-based semen testing may improve the quality of care for men undergoing vasectomy.

Management of bone complications in patients with genitourinary malignancies.

Skeletal metastases are common in genitourinary malignancies-including prostate cancer, renal cell carcinoma, and urothelial cancer-and portend significant morbidity and poor prognosis. The presence of skeletal metastases can result in decreased quality of life and increased morbidity. Strategies can be employed to prevent bone-related complications including lifestyle modifications and dietary supplementation. Additionally, pharmacologic agents exist to prevent bone loss and may be appropriate for patients at high risk of fragility-related or skeletal complications, such as pathologic fracture related to bone metastases. Finally, advancement in effective systemic treatments, particularly novel hormone-targeted agents and immunotherapies, may limit the morbidity of advanced disease and delay the onset of skeletal-related complications.

A Novel Video-Based Patient Education Program to Reduce Penile Prosthetic Surgery Cancellations.

Penile prosthetic surgery is an effective treatment for men with erectile dysfunction. Cancellation of surgery is disruptive and costly to patients, physicians, and the healthcare system. This pilot study sought to analyze surgery cancellations and implement a video-based patient education program to decrease surgery noncompletion. Baseline penile prosthetic surgery completion, rescheduling, and cancellation rates among consecutively scheduled surgeries were determined using a national cohort. Selected prosthetic surgeons then implemented Vidscrip, a video-based patient education program. Prerecorded videos were delivered via text message 14 days, 7 days, and 1 day preoperatively, as well as 1 day postoperatively. Subsequent analysis determined noncompletion rates, reasons for noncompletion, surgeon volume, and video utilization. Two-hundred twenty-six surgeries were scheduled in the baseline cohort; 141 were completed, and 85 were rescheduled or canceled. Among the intervention cohort, 290 patients completed, 7 rescheduled, and 37 canceled surgery. After program implementation, the surgery noncompletion rate was reduced compared to baseline (13.2% vs. 37.6%, p < .05), corresponding to a number needed to treat of 4.1. When stratified by surgeon volume, there was no difference in noncompletion rate (>20 cases vs. ≤20 cases: 8.20% vs. 32.0%, p = .35). Video utilization was widely variable among practices (median viewing time 58.6 min, IQR 5.09-113). Penile prosthetic surgery is frequently rescheduled or canceled. Implementing a video-based patient education program reduces surgery noncompletion, improving efficiency and quality of care. Wider implementation is needed to validate these findings, while cost-effectiveness analyses may further support their broad adoption.