A rare case of uterine torsion with juvenile granulosa cell tumor in the pediatric patient Juvenile granulosa cell tumors (JGCT) of the ovary are rare sex cord-stromal ovarian tumors that are typically diagnosed during the first two decades of life. Most patients present with precocious puberty in the early stages of disease. We present a rare case of asymptomatic uterine torsion from a 15-centimeter JGCT in a 5-year-old girl with elevated inhibin B, breast development, vaginal bleeding and a palpable right-sided abdominal mass.
Left Kidney Within a Large Left Inguinal Hernia The patient is an 86-year-old male who presented with hematuria and discoloration of his left hemiscrotum. He had a past medical history significant for atrial fibrillation on apixaban, coronary artery disease, hypertension, diabetes, and a repaired 8-cm abdominal aortic aneurysm. He had recently been successfully treated for a urinary tract infection. He also had history of inguinal hernia for over three years for which he had consulted a general surgeon who recommended observation in view of the patient's multiple comorbidities and absence of symptoms.
Reply to: Letter-to-the-editor: Understanding the popcorn effect during holmium laser lithotripsy for dusting We thank the authors for their interest in our study. Our fundamental finding was that increasing the pulse frequency and the overall power led to significantly more fragmentation during popcorning. This was similar to what was also reported by Emiliani and colleagues.1 Moreover, we found that increasing the distance between the fiber tip and the stone decreased fragmentation. As noted, figure 2 showed that the percentage of submillimeter fragments when utilizing 40Hz and 80Hz at 0.5J was 67% and 73%, respectively.
The relative efficacy and safety of mirabegron and onabotulinumtoxinA in patients with overactive bladder who have previously been managed with an antimuscarinic: A network meta-analysis This study compared the efficacy and safety of mirabegron and onabotulinumtoxinA in the management of treatment-experienced patients with overactive bladder. The network meta-analysis was based on evidence from a systematic literature review of randomized controlled trials and a post-hoc analysis of treatment-experienced subpopulations from mirabegron studies. Nineteen trials described in 21 publications were included. Overall, compared to mirabegron, there was some evidence that onabotulinumtoxinA was associated with improved outcomes, including reductions in the number of micturitions in a 24-hour period, and the number of incontinence episodes.
Examining Trends in Underrepresented Minorities in Urology Residency To examine trends in underrepresented minority (URM) representation in urology residency. Comparison is made between URM representation in urology residency and URM representation in other surgical fields as well as all medical fields. We hypothesized that percentage of URM in urology has been limited when compared to both surgical fields and all other fields.
Malignant renal solitary fibrous tumor with two local recurrences and distant pulmonary metastasis A 53-year-old man presented to our hospital with right upper quadrant (RUQ) pain alongside nausea and vomiting. Physical examination revealed RUQ tenderness, Murphy sign, and fever. He otherwise had no significant past medical or surgical history. Subsequent abdominal ultrasound showed signs of cholecystitis and an incidental lobulated hypoechoic mass of the left kidney with heterogeneous echotexture and hypervascularity on Doppler. The patient had a cholecystectomy without complications during the postoperative period.
Rare Abdominal Cutaneous Presentation of Clear Cell Renal Cell Carcinoma: A Case Report Cutaneous metastasis from renal cell carcinoma is rare, typically involves the head and neck, and occurs in late stage disease, usually in the context of previously diagnosed and treated primary tumour, and after lymphatic spread.This patients’ initial presentation of clear cell renal cell carcinoma was a cutaneous lesion to the ipsilateral abdominal wall. The primary renal tumour was subsequently demonstrated on CT; this also showed no apparent lymph node involvement despite cutaneous metastatic disease.
BCG Renal Granuloma A 66-year-old gentlemen with a history of recurrent urothelial carcinoma in situ treated with endoscopic resection and induction BCG developed a new renal mass on surveillance computerized tomography (CT) and was referred to our institution for surgery. Biopsy was performed and pathology showed BCG granuloma. The patient was clinically asymptomatic. No surgical intervention was required. This is a rare entity in those undergoing intravesical BCG therapy. To avoid unnecessary surgery, a careful patient history and judicious use of renal mass biopsy is critical.
Medial Renal Ptosis: First Radiographic Documentation With Computed Tomography Medial renal ptosis is the abnormal mobility of the kidney towards or across the midline of the body. Historically, this phenomenon is evaluated by observing abnormal mobility in the lateral decubitus position during intravenous pyelography. Here, we present the first radiographic documentation of this anomaly on computed tomography on a 34-year-old female who experienced an intermittent abdominal bulge over her right upper quadrant. Nephropexy is the definitive treatment for symptomatic patients.
Botryoid Wilms Tumor: A Rare Diagnosis With an Atypical Presentation Wilms tumor commonly presents as an asymptomatic abdominal mass. In some cases, it can be accompanied with hypertension, constitutional symptoms, and hematuria when involving the collecting system. Below, we review the case of a child diagnosed with botryoid Wilms tumor involving the upper calyces and renal pelvis in which the presenting symptom was a concern for a foreign body in her left ear, and the only abnormality during initial history and physical examination was stage II hypertension.
What Would a Suprapubic Catheter Indwelling for 4 Years Be Like? A Case Report A 35-year-old male of 165 cm height and weight of 65 kg, had a suprapubic catheter indwelling for 4 years without replacement for urethral stricture. The catheter became gradually obstructed, and urine leaked out around the suprapubic catheter. A lumbar abdominal distension, an inferior abdominal mass and renal failure prompted him to seek medical attention in our hospital in September 2018. This clinical case is hereby presented from 3 aspects of imaging, lab examination, and operation.
Magnetic-assisted Robotic Surgery to Facilitate Reduced-port Radical Prostatectomy Tissue retraction during minimally-invasive urologic surgery currently is achieved by either gravity via patient positioning or placement of additional ports for robotic arms or bedside assistant instrumentation. A novel magnetic retractor system (Levita Magnetic Surgical System, San Mateo, CA) was recently approved by the Food and Drug Administration for use in minimally invasive surgery.
Crossing Into the Unknown. A Peculiar Cause of Ureteropelvic Junction Obstruction in a 14-Year-Old Boy Ureteropelvic junction obstruction (UPJO) is a common cause of upper urinary tract obstruction and consequent hydronephrosis. We present a case of right UPJO caused by a crossing vessel suspected to be the right second lumbar vein. While crossing vessels are a common cause of UPJO in older children and adults, they are usually attributed to lower pole vessels. We believe that this is the first case report of UPJO caused by a lumbar vein. Recognition of crossing vessels requires knowledge of variant vasculature anatomy around the kidneys.
Predictors of Recurrence and Complications in Pediatric Pyeloplasty To assess the predictors of recurrence and complications, we retrospectively analyzed our experience in primary pediatric pyeloplasty. Management of pyeloplasty failure is challenging both for patients and for surgeons, especially in pediatric cases. Early detection of recurrence and early manipulation may help preserving renal function.
Impact of Medicare Office Visit Payment Reform on Urologic Practices To evaluate the 2019 Medicare Physician Fee Schedule, which modifies reimbursement for office evaluation and management (E&M) visits. This policy moves payment to a single rate for levels 2 through 4 office E&M visits, regardless of complexity.
Ex-vivo Imaging of Upper Tract Urothelial Carcinoma Using Novel ICG-Var3 pHLIP Imaging Agent To improve visualization of upper tract urothelial carcinomas (UTUC). Previous studies using the novel pH low insertion peptide (pHLIP) variant 3 (Var3) conjugated to indocyanine green (ICG) have demonstrated high sensitivity and specificity for imaging of bladder urothelial carcinoma. Here, we describe a novel approach for the imaging of UTUC using ICG-Var3 pHLIP.
Metachronous Isolated Splenic Metastasis in a Young Patient With Renal Cell Carcinoma: Case Report and Literature Review Splenic metastasis is uncommon and is usually associated with widespread disease.1,2 Isolated splenic metastases from renal cancer are also rarer and are often an incidental finding. This eventuality may turn into a dangerous scenario due to a spontaneous splenic rupture leading to sudden death.2,3 At the best of our knowledge, only few cases of metastasis from renal cell carcinoma (RCC) have been documented in the literature.4-11 We hereby present a literature review of these cases and report a case of isolated splenic metastasis in a young man on active follow-up for a clear cell RCC clear cell Renal Cell Carcinoma (ccRCC).
Uncovering a Novel Stone in 27 Patients: Calcium Tartrate Tetrahydrate To further analyze calcium tartrate tetrahydrate stones after a recent case report described this novel stone. Prior to this, there was only one previously reported occurrence of this stone in a human. This unusual stone composition is not tested for routinely. True prevalence and possible causes of this stone are unknown.
Minimally-Invasive Ureteral Reconstruction for Ureteral Complications of Kidney Transplants To present the technique, feasibility and results of minimally-invasive reconstruction of the transplanted ureter using the native ipsilateral ureter in post-transplant ureteral strictures and vesicoureteral reflux (VUR) causing graft pyelonephritis. Ureteral complications after kidney transplantation represent a significant cause of morbidity potentially leading to graft dysfunction or loss.
Medical Treatments of Peyronie's Disease: Past, Present, and Future Peyronie's disease (PD) is a benign fibroproliferative disorder, which causes the formation of plaque in the tunica albuginea of the corpora cavernosa in the penis. The disease is named after François Gigot de la Peyronie (1678-1747), although Fallopius and Vesalius had already described the disorder in 1561.1
The Urinary Microbiome: Implications in Bladder Cancer Pathogenesis and Therapeutics Recent investigation has proven that the bladder is not sterile. However, the implications of this finding in the pathophysiology and management of urothelial cell carcinoma have not been fully described. In this review, we summarize the literature relating to the urinary and gastrointestinal microbiomes in the context of urothelial cell carcinoma. The bladder microbiome may relate to urothelial cell carcinoma pathogenesis/progression, act as a noninvasive and modifiable urinary biomarker and have implications in treatment using immunotherapy agents such as intravesical bacillus Calmette-Guerin.
Testicular Torsion Postorchiopexy: A Case of Twisted Hammock We herein report an unusual case of testicular torsion a decade after orchiopexy. An occurrence of postorchiopexy testicular torsion is an exceedingly rare event, infrequently reported in literature. Previously placed anchoring sutures in the inferior pole resulted in a “hammock” testicular torsion, resulting in twisting of cord with involvement of the sutures themselves.
A Case of Primary Paratesticular Wilms Tumor in an Undescended Testis Extrarenal Wilms tumor is rare. We describe the first reported case of primary paratesticular extrarenal Wilms tumor with regional metastasis in 8-month old male with left undescended testis. Patient underwent left radical orchiectomy with regional lymph node excision. The inguinal node and paratesticular mass demonstrated the classic Wilms triphasic pattern, stained positively for WT-1 and demonstrated no loss of heterozygosity of chromosomes 1p and 16q. Work-up was negative for primary renal Wilms tumor or distant metastasis.
Reply by Author: “New Evidence for the Benefits of Prostate-Specific Antigen Screening” Before detailing my responses, I want to say that in the commentator's reading of my data tables there seem to be some misinterpretations, and in his estimate of the potential impact of the noted problems, the likely effect is greatly exaggerated. In addition, he fails to look at the concordance between this study and others using similar parameters and testing intervals – the cumulative across study analysis that is as important in a scientific approach as the hunt for potentially problematic imperfections.
Primary Urethral Melanoma: A Case Report and Literature Review Patients with localized urethral melanoma have a high risk of recurrence and poor disease-specific survival. Multi-disciplinary approach including surgery, radiation therapy, and chemotherapy/immunotherapy is needed to maximize survival. Current research efforts include investigation of novel tyrosine kinases as well as the combination of targeted therapies with immunotherapies in this population. Combinations may provide a synergistic effect to overcome various obstacles to disease response.
Germ Cell Testicular Tumors—Contemporary Diagnosis, Staging and Management of Localized and Advanced disease Germ cell testicular tumors are the most commonly diagnosed cancer in young men, with cure rates exceeding 95%. Clinical stage 1 disease is the most common manifestation, with radical orchiectomy curing the majority of Clinical stage 1 patients, making active surveillance the treatment of choice, with a cancer specific survival nearing 100% and low relapse rates. However, in metastatic disease, chemotherapy, radiotherapy, and surgery are curative options. Chemotherapy remains the mainstay of therapy for advanced disease with surgical management of residual disease.
Adult Wilms Tumor During Pregnancy: Case Report and Literature Review Adult Wilms tumor (WT) is a well-known, albeit rare entity and has historically been associated with worse overall clinical outcomes when compared to younger patients. Because WT is uncommon in adult patients, it is often misdiagnosed and treated off standardized pediatric protocols. WT associated with pregnancy is even more rare, and there is not a standardized approach to this small subset of patients. We present a case of an adult WT discovered and managed during the perinatal period and review prior published cases.
Herlyn-Werner-Wunderlich Syndrome: Report of a Prenatally Recognised Case and Review of the Literature Herlyn-Werner-Wunderlich syndrome, defined by the triad of uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis, is a rare Mullerian malformation, usually diagnosed after menarche, when symptoms related to hematocolpos arise. Rarely, this malformation is diagnosed in the neonatal period, normally following prenatal diagnosis of renal agenesis. Herein, a case recognized on prenatal imagiology that underwent surgery on the fourth day of life is reported. The records of prepubertal cases were also collected, addressing the clinical and imagiological features.
New Perspectives Into Peyronie's Disease: Etiology, Management, and Prevention Although it was first reported by Fallopius in 1561, Peyronie's disease (PD) bears the name of Francois de la Peyronie who reported a case in 1743.1 PD is characterized by penile induration, nodule, or plaque resulting in erectile deformity. Although PD is frequently linked to erectile dysfunction (ED), it is not clear how often it is or which comes first. Mulhall states “Elucidating the role preexisting ED plays in the development of PD remains a difficult task, as ED is also a known sequel of PD.
WITHDRAWN: EDITORIAL COMMENT This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause.
WITHDRAWN: PSMA-PET: a maturing tool This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause.
Variant Presentations of the Exstrophy-Epispadias Complex: A 40-Year Experience To investigate the diagnosis, surgical management, and outcomes in patients with variant EEC. Variant presentations of the exstrophy-epispadias complex (EEC) span a wide range of abnormalities. The rarity and diversity of EEC variants can lead to challenges in the diagnosis and subsequent management of this population.
Acute Testicular Segmental Infarct Following Endovascular Repair of a Juxta-renal Abdominal Aortic Aneurysm: Case Report and Literature Review A 61-year-old male presented to our Accident & Emergency department with a 3-day history of nausea and vomiting. On examination, he had a soft non-tender abdomen but pronounced pulsation of his abdominal aorta. A computed tomography angiogram revealed a 6 cm juxta-renal abdominal aortic aneurysm with thrombus within the aneurysm sac and juxta-renal neck segment. There was also moderate atherosclerotic change of the common, internal, and external iliac arteries bilaterally. Given the lack of a suitable infrarenal sealing zone for the stent graft, he underwent a complex endovascular aortic aneurysm repair using a stent graft (Cook Medical, Limerick, Ireland) with suprarenal coverage with 4-vessel fenestrations (coeliac axis, superior mesenteric, and left and right renal arteries).
Sarcomatoid Cancer of Penis in a 45 Year Old Male A 42-year-old male patient presented to the outpatient department of our hospital with purulent discharge per urethra when voiding and a mass at the tip of the penis for the past 3 months. The patient had visited multiple practitioners of alternative medicine at his hometown before visiting our centre, but had no relief in his symptoms along with a progression in the size of the mass. There was no history of any surgical intervention or intervention on the penis in the past. The patient was sexually active and monogamous.
Urologic Management of Priapism Secondary to Chronic Myeloid Leukemia A 27-year-old Caucasian male with a history of chronic myeloid leukemia (CML), diagnosed at age 19, presented to his local emergency department with a painful persistent erection of 9 hours duration. He reported a history of 2 prior episodes of painful erections unrelated to sexual activity over the last 2 months, with each episode lasting less than 4 hours. Although his CML had been managed long-term with Imatinib (Gleevec), on presentation he admitted to medication noncompliance with Imatinib over the past year.
Traumatic Penile Pseudoaneurysm After Straddle Injury Presenting With Life Threatening Anemia: A Unique Case and a Diagnostic Challenge Partial urethral disruption after blunt perineal trauma can be initially managed with urethral catheterization. Lower urinary tract symptoms after catheter removal should raise suspicion for urethral stricture and requires further investigation. Lesser known complications require high index of suspicion to prevent life threatening sequelae. In this report, we describe a case of blunt perineal trauma and partial urethral disruption in a pediatric patient presenting with refractory anemia due to a penile artery pseudoaneurysm.
Robotic-assisted Proximal Perineal Urethroplasty: Improving Visualization and Ergonomics To describe the use of the robotic platform for proximal suture placement during perineal urethroplasty in the posterior and proximal anterior urethra. Repair of posterior urethral and proximal bulbar strictures requires deep perineal dissection, making visualization and accurate placement of sutures challenging. The robotic platform has demonstrated benefits in these characteristics in deep pelvic surgery.
Dermatofibrosarcoma Protuberans in a Male Infant Dermtofibrosarcoma protuberans is a rare cutaneous malignancy known to be locally aggressive. It is uncommonly seen in the pediatric population and can be difficult to distinguish from other benign skin lesions. We present a case of dermatofibrosarcoma protuberans of the penis in a 6-month-old child managed with surgical resection. This case highlights the challenges of diagnosis of genital lesions in children and the complexities of genitourinary reconstruction following surgical resection.
Real-World Impact of Minimally Invasive Versus Open Radical Cystectomy on Perioperative Outcomes and Spending To evaluate the effect of the minimally invasive approach on spending and perioperative outcomes for patients undergoing radical cystectomy for bladder cancer. In a randomized control trial conducted at high-volume centers, robotic, and open cystectomy were shown to have similar outcomes. However, because the majority of cystectomies are performed in low-volume centers, it is unknown whether these findings are broadly generalizable.
Testosterone Therapy for High-risk Prostate Cancer Survivors: A Systematic Review and Meta-analysis A systematic review and meta-analysis were performed to determine the relationship between testosterone therapy and the risk of recurrence in testosterone-deficient survivors of curatively treated high-risk prostate cancer. Primary outcome was the risk of biochemical recurrence (BCR) in 109 high-risk patients in 13 included studies (1997-2017). Biochemical and symptomatic effects of therapy were also reviewed. The BCR rate was 0.00 (0.00-0.05), lower than the expected rate for high-risk prostate cancer survivors, suggesting that testosterone therapy may not increase their BCR risk.
The Prognostic Value of PIK3CA Copy Number Gain in Penile Cancer To determine whether phosphatidylinositol-4,5-bisphosphate 3- kinase, catalytic subunit alpha (PIK3CA) copy number gain in penile cancer has prognostic value and association with histopathological parameters, human papillomavirus (HPV), and clinical outcome.
Dual Pathology Causing Congenital Bladder Outlet Obstruction Anterior urethral syringocele is an uncommon congenital deformity characterised by cystic dilatation of bulbo-urethral gland ducts and is usually asymptomatic. We present a case on 4-day-old male neonate who presented with bilateral antenatal hydroureteronephrosis and renal impairment and found to have urethral syringocele and posterior urethral valves (PUV).
Author Reply The comments of the editor truly reflect the findings of our study on the surgical treatment of giant penoscrotal lymphedema. All the 19 patients described in the study were to be treated by surgery. Eight patients, however, defaulted, possibly because of their belief in alternative traditional herbal medicine and or financial constraint, because health insurance schemes are yet to be fully established in our environment.
WITHDRAWN: Stented or Unstented Distal Hypospadias Repair The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2017.04.057. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
WITHDRAWN: Editorial Comment on “Abnormal Expression of Sg I is Closely Related to Seminal Vesiculitis” The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2015.08.052. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
WITHDRAWN: Reply The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2015.08.053. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
WITHDRAWN: Editorial Comment The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2013.02.086.The duplicate article has therefore been withdrawn.
AUTHOR REPLY Holmium laser enucleation of the prostate (HoLEP) is the most complete and sophisticated surgical treatment for benign prostatic obstruction. No other technique is capable of removing so much tissue in such a minimally invasive manner. The great challenge of prostate surgeons is to develop methods to shorten and facilitate its learning curve. Simulators are attractive and safe tools that could serve this purpose.
EDITORIAL COMMENT Holmium laser enucleation of the prostate (HoLEP) has become an established surgical modality for the treatment of benign prostatic obstruction, particularly for larger glands or patients who require anticoagulation.1 Despite the advantages of HoLEP, the steeper learning curve, and access to appropriate equipment has hindered widespread adoption.2
Author Reply Bladder exstrophy is a rare condition yet these patients can be challenging to manage in adulthood especially when presenting with painful abdominal fluid collections which we believe are from remnants of prostatic tissue. As urologists may encounter these patients, even if only rarely, our goal was to provide recommendations for management based on our experience. Even if not universally applicable to every patient with a repaired bladder exstrophy, we believe our algorithm may be a good starting point.
Editorial Comment The authors present an unusual series of patients with complaints of persistent suprapubic pain. The report details their presumptive explanation for the etiology of the discomfort and a successful treatment regimen. This observation gives urologists a reasonable plan for management of symptomatic suprapubic fluid collections in males with a history of bladder exstrophy and/or epispadias repair.
AUTHOR REPLY We greatly appreciate the thoughtful comments in regards to our manuscript, which highlight a number of important issues about the use of PSMA-PET. It should be noted at the outset that PSMA-PET should not be considered a standard imaging modality. In the United States, PSMA-PET is investigational and is not FDA approved. Although PSMA-PET may be considered standard of care in a few countries, its use in the United States is limited to clinical trials. Nonetheless, the prevalence of PSMA-PET is likely to increase in the next few years, as we should be close to approval of this agent in the coming year.
Editorial Comment Hope et al.1 report on the impact of pretreatment 68Ga-PSMA-PET/CT or PET/MRI in the management of 45 patients with high-risk prostate cancer (PCA). Results of PSMA-PET/CTs were compared to the findings of CT scans and skeletal scintigraphy. Based on their data, PSMA-PET imaging resulted in changes of radiation therapy (RT) dose and volumes in 47% of the patients due to newly diagnosed N1/M1a disease. RT changes resulted in the extension of clinical target volume (CTV) covering the small pelvis and even the retroperitoneum or a RT boost to avid lymph nodes.
AUTHOR REPLY Indeed, in both bladder exstrophy and epispadias variants, the pubic separation is an important consideration in the reconstructive process. Some centers are performing pelvic osteotomies in the epispadias population.1 As addressing the bony pelvic abnormalities is a critical step in exstrophy management, this principle certainly applies in even rare exstrophy variants.
EDITORIAL COMMENT This manuscript is extremely valuable as it brings this unique cohort to the rest of the pediatric urology community. It is unlikely this type of experience will be replicated.
AUTHOR REPLY We would like to thank Scott M. Gilbert for [his] thoughtful examination of this manuscript. As outlined, a major finding of this work is that patients with high-risk nonmuscle invasive bladder cancer (NMIBC) as defined by the European Urological Association and American Urological Association [ref] had significantly worse patient reported outcomes compared to those with nonhigh-risk disease. The survey tools utilized for the Medicare Health Outcomes Survey (MHOS) are not cancer specific instruments, yet still demonstrated statistically and clinically significant decreases in physical and mental health-related quality of life.
EDITORIAL COMMENT In the study “Nonmuscle Invasive Bladder Cancer Influences Physical Health Related Quality of Life and Urinary Incontinence, Wayne G. Brisbane and colleagues examine patient-reported quality of life (QOL) and urinary incontinence outcomes associated with the diagnosis and management of nonmuscle invasive bladder cancer. The study is based on SEER cancer registry data linked to patient-reported outcomes (PROs) data collected as part of the Medical Health Outcomes Survey (SEER-MHOS), which allowed the authors to not only evaluate patient-reported outcomes in a representative sample of bladder cancer patients managed with endoscopic and intravesical treatments, but also benchmark those outcomes to surveys taken from noncancer controls who participated in MHOS as part of their Medicare Advantage plan.
AUTHOR REPLY We appreciate the editor's commentary in placing our study within the larger context of management of this disease process. In particular, we agree that issues when comparing endopyelotomy with pyeloplasty warrant further discussion.
EDITORIAL COMMENT Proper patient selection and meticulous suturing were the keys to success in my experience with pyeloplasty. The attraction of the present publication is the presentation of both aspects. Are there good reasons to treat uretero pelvic obstruction different from what is proposed by the authors?
AUTHOR REPLY We agree with the authors that our study data on surgeon volume underscore the challenges in ensuring timely, high-quality care in any health system. At Kaiser Permanente, changes have been made to increase the number of patients receiving surgeries by higher-volume surgeons and specialists during the past 5 years which are not fully reflected in our study data of surgeries performed during 2010-2015. These changes have included referring more cystectomies to high-volume surgeons, offering multidisciplinary genitourinary oncology clinics, or having a high-volume surgeon assist during cystectomies that are performed by a lower-volume surgeon.
EDITORIAL COMMENT In the manuscript “Factors that Influence Selection of Urinary Diversion among Bladder Cancer Patients in 3 Community-Based Integrated Health Care Systems,” the authors present patient vs surgeon specific factors affecting the type of urinary diversion selection for patients undergoing radical cystectomy for bladder cancer. It is a well-designed examination of a large patient cohort in an integrated health system. In this study of 991 patients, 794 (80%) patients received an ileal conduit (IC) urinary diversion.
EDITORIAL COMMENT Once again it appears that some members of the medical community, this time retail pharmacies, are taking advantage of patients through opaque pricing. The authors uncovered and documented dramatic differences in 30- and 90-tablet prices in St. Louis for four generic medications commonly prescribed for lower urinary tract symptoms. It is a damning indictment that the cost at the register without insurance for these medications varies anywhere from three-threefold to as much as 30-fold.
EDITORIAL COMMENT Obliterative stricture disease of the pendulous urethra presents a unique technical challenge given the potential for iatrogenicpenile curvature if the scarred segment is completely excised. The authors of the manuscript “Excision and primary anastomosis reconstruction for traumatic stricture of the pendulous urethra,” should be commended for challenging the dictum that anastomotic repairs are contraindicated for penile urethra strictures.1 The authors hypothesized that for short strictures in the penile urethra, anastomotic repair would be a safe, feasible alternative to 1- or 2-stage substitution urethroplasty.
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