A laparoscopic approach to parastomal hernia repair with re-siting of urinary stoma Parastomal and ventral hernias are common complications in patients with continent catheterizable channels or incontinent urinary diversions. Patients with neurogenic bladder are at particularly high risk due to weak abdominal wall musculature, and hernia repair often requires re-siting of their stoma. While parastomal hernia repair with urinary stoma re-siting has acceptable long-term success rates, it often necessitates a laparotomy which is associated with significant morbidity.
Technique and outcomes of hand-assist laparoscopic continent cutaneous ileocecocystoplasty Continent cutaneous ileocecocystoplasty (CCIC) involves reconfiguring the ileocecal segment for use as a bladder augment and continent catheterizable channel. CCIC requires release of the hepatic flexure of the colon, which necessitates a longer midline laparotomy than would be required for a standard bladder augmentation. This is associated with high rates of ventral and parastomal hernias.
The impact of physician productivity models on access to subspecialty care: A white paper from the Society for the Study of Male Reproduction and the Society for Male Reproduction and Urology Male infertility is a common disease. Male infertility is also a core competency of urology training and clinical practice. In this white paper from the Society for the Study of Male Reproduction and Society for Male Reproduction and Urology, we identify and define different physician productivity plans. We then describe the advantages and disadvantages of various physician productivity measurement systems for male infertility practices. We close with recommendations for measuring productivity in male infertility practices that we hope urologists and administrators can use when creating productivity plans for male infertility practices.
Implementing Continuous Quality Improvement in an Integrated Community Urology Practice: Lessons Learned To determine the effectiveness of two different continuous quality improvement (CQI) interventions in an integrated community urology practice. We specifically assessed the impact of audited physician feedback on improving physicians’ adoption of active surveillance (AS) for low-risk prostate cancer (PCa) and adherence to a prostate biopsy time-out intervention.
Implications of Calcification in Peyronie's Disease, A Review of the Literature A common characteristic of Peyronie's Disease (PD) is plaque calcification, which is associated with decreased response to treatments and higher rates of surgical intervention. Despite its prevalence in the PD population, the literature on plaque calcification is limited. While the diagnosis of PD is mostly clinical, imaging modalities such as ultrasound can be used to identify plaque calcification. The proper identification of plaque calcification is crucial for guiding management and setting therapeutic expectations for patients with PD.
Single-Stage Reconstruction of Fossa Navicularis Strictures Using A “Sliding-T” Dorsal Inlay Urethroplasty With Buccal Mucosal Graft To describe a single-stage urethroplasty for fossa navicularis strictures using a “sliding-T” dorsal inlay technique with buccal mucosa. Strictures of the fossa navicularis are challenging. Endoscopic treatments typically offer only temporary relief and necessitate lifelong instrumentation. Reconstruction should provide an unobstructed urethra, slit-like meatus, preserve sexual function and create a cosmetically appealing glans. The ideal urethroplasty technique has not yet been elucidated despite various described single-stage and multi-staged approaches.
Author Reply to Letter-to-the-Editor regarding “Use of a Closed Diurnal Indwelling Catheter for Patients With Spinal Cord Disorders: A Pilot Study” We appreciate the thoughtful response to this initial study of closed diurnal catheterization in a select population of youth with neurogenic bladder. All patients were using a daytime CIC regimen q2 to q4 hours at time of enrollment; their baseline frequency of bladder drainage was continued during the CDIC trial. Inclusion of patients was limited to those with a history of compliance with prescribed therapies. Additionally, during weekly screening calls the study coordinator verified that bladder drainage frequency was maintained.
Congenital Bladder Prolapse Through a Patent Urachus: Two Institutions’ Experience We describe our experience in 2 institutions handling bladder prolapse through a patent urachus (PU), together with a brief review of published literature. Case 1: A term neonate with congenital prolapsed bladder via PU. Ultrasound at 21 weeks gestation revealed a male fetus with a large midline pelvic cyst communicating with the bladder which disappeared on subsequent 27 weeks ultrasound. Case 2: A term female neonate with congenital prolapsed bladder via PU with no prenatal diagnosis. In both cases the bladder closure was undertaken during the newborns’ first days of life.
An Update on Evaluation and Management in Cystinuria Cystinuria is the most common cause of inherited stone disease and is caused by the failure of absorption of filtered dibasic amino acids including cystine in the proximal tubules. It is associated with a very high recurrence rate in affected patients, with the potential for significant morbidity in such patients due to the need for repeated surgical interventions. A multimodal and multispecialty approach in a dedicated centre is the key to improving treatment outcomes and patient adherence to the treatment.
The Evolution of Colonic Mucosa Use in Urethral Reconstruction While oral mucosa remains the preferred graft tissue for urethral reconstruction, rectal mucosa is a viable alternative enteric mucosal graft with the advantage of a less limited supply. Though it has re-emerged in more recent medical literature, the documented use of rectal mucosal grafts for urethral reconstruction dates to the same era as that for oral mucosal grafts in the 1890s. The Russian surgeon Kirill Sapezhko first published his experience with urethroplasty using oral mucosal grafts in 1894, and it was his protégé, Igor Thyrmos, who first published the use of rectal mucosal grafts for urethral reconstruction in 1902.
Prostate Cancer Foundation Hormone-Sensitive Prostate Cancer Biomarker Working Group Meeting Summary Androgen deprivation therapy remains the backbone therapy for the treatment of metastatic hormone-sensitive prostate cancer (mHSPC). In recent years, several treatments, including docetaxel, abiraterone + prednisone, enzalutamide, and apalutamide, have each been shown to demonstrate survival benefit when used upfront along with androgen deprivation therapy. However, treatment selection for an individual patient remains a challenge. There is no high level clinical evidence for treatment selection among these choices based on biological drivers of clinical disease.
Antibiotic Stewardship and Postoperative Infections in Urethroplasties To determine surgical site infection and UTI rates in the setting of urethroplasty. Given significant variation in the utilization of antibiotics, there is an opportunity to improve antibiotic stewardship. This study aims to elucidate the rate of both UTI and surgical site infection after urethroplasty on a standardized peri-operative antibiotic regimen, and to obtain patient and operative characteristics that may predict infection.
Preserving Well-being in Patients With Advanced and Late Prostate Cancer Androgen deprivation therapy, alone or in combination with androgen signaling inhibitors, is a treatment option for patients with advanced prostate cancer (PC). When making treatment decisions, health care providers must consider the long-term effects of treatment on the patient's overall health and well-being. Herein, we review the effects of these treatments on the musculoskeletal and cardiovascular systems, cognition, and fall risk, and provide management approaches for each. We also include an algorithm to help health care providers implement best clinical practices and interdisciplinary care for preserving the overall well-being of PC patients.
Renal Urothelial Carcinoma Complicated by Inferior Vena Cava Tumor Thrombus and Acute Pyelonephritis Renal urothelial carcinoma (UC) with inferior vena cava tumor thrombus is rare, especially when it is concomitant with acute pyelonephritis. In this report, a 70-year-old diabetic man with right flank pain, intermittent painless gross hematuria, and recurrent high fever was described. On the basis of the symptoms, physical examination, cytology and imaging results, renal UC with extension into inferior vena cava, and acute pyelonephritis was established. The patient was unresponsive to antimicrobial chemotherapy.
Patient Satisfaction and Regret After Robot-assisted Radical Prostatectomy: A Decision Regret Analysis To assess treatment satisfaction and decision regret post robot-assisted radical prostatectomy (RARP) and correlate these with clinical, demographic and quality of life indicators. Our study took place at a high-volume United Kingdom center and patients were assessed at a minimum of 18 months postsurgery.
A New Combined Laparoscopic-Vaginal Lateral Suspension Procedure for the Treatment of Pelvic Organ Prolapse To show an original technique of a new combined vaginal-laparoscopic lateral suspension in Hysteropexy with cistocele and rectocele. In recent years, changes in attitudes toward sexuality, psychological value of reproductive organs and the desire to preserve fertility have led to a growing interest in uterine-preserving surgery for Pelvic Organ prolapse. Minimally invasive procedures derived from sacrocolpopexy are considered the gold standard in the treatment of apical Pelvic Organ prolapse. However, dissection at the level of the promontory may be challenging, particularly in obese women and when an anatomical variation exists.
Providing a Fossa Navicularis in Reconstruction of Hypospadias I read with great interest the article titled “Tubularized Reconstructed Plate Urethroplasty: An Alternative Technique for Distal Hypospadias Repair” by Taneli et al.1 The authors describe their technique as providing the “fossa navicularis” of the male urethra by increasing the surface area of the glanular urethra with removal of a segment of tissue from the base of the ventral glans surface. The presence of the “fossa navicularis” in the glans penis has been overlooked for decades, and almost all repair techniques for hypospadias involve uniform reconstruction of the urethra over a catheter or stent.
A Novel Technique for Management of Simultaneous Fibro-Epithelial Polyp and Blind-Ending Branch in a Duplicated Ureter: A Case Report With 23-year Follow-Up Ureteral duplication with a blind-ending branch (BEB) is rare anomaly. The presence of fibro-epithelial polyps in duplicated ureters is also infrequent. Despite the noticeability of endoscopic polypectomy, further recurrence of polyps and persistence of pain increase the probability of further ureteral resection with surgical procedures. In such cases, BEB of duplicated ureter is an excellent reservoir to save the function of the kidney. This is the first case with concomitant presence of fibro-epithelial polyps and BEB in duplicated ureter managed with novel surgical technique of uretero-pelvic junction and BEB branch anastomosis.
Propeller Flap Perineal Urethrostomy Revision To describe a technique for perineal urethrostomy (PU) revision using a posterior thigh propeller flap for a complex repair at high risk for stenosis.
Minimally Invasive Approach for Wilms Tumor Treatment in a Small Child - A Case Report Wilms tumor is the most common malignant primary tumor in children. Open traditional approach is often aggressive and offers a burden on the patient's life, imposing longer hospital stays, scarring, and higher levels of complications. Here, we present a case of a small child with Wilms tumor on the right kidney that was successfully treated with minimally invasive surgery, with no tumor spillage or rupture, hospital discharge in the next day, and good oncological outcome, with 1-year recurrence-free follow-up.
Multicystic Dysplastic Kidney With Mass Effect in a Neonate Treated With Nephrectomy: Case Report Multicystic Dysplastic Kidney is a developmental disease that results in a lobulated kidney of noncommunicating cysts and abnormal parenchymal tissue. Dysplastic kidneys are usually benign and often involute over time with conservative management. The second most common cause of palpable abdominal mass in a neonate, Multicystic Dysplastic Kidney can cause respiratory distress secondary to extrinsic compression. However, such cases are sparse. Here we present the case of an otherwise healthy term newborn with an exceptionally large MCDK requiring CPAP support and intubation.
An Unusual Cause of Female Urinary Incontinence Following Obstetric Trauma Urethral coitus is a rarely reported cause of female urinary incontinence and has been most commonly described in women with vaginal and hymenal anomalies. Herein, we report a 41-year-old woman with a complex obstetric history, who presented with continuous urinary incontinence. On evaluation, she was found to have an abnormally dilated urethral orifice and vaginal stenosis suggestive of chronic urethral coitus. She underwent a reduction urethroplasty with autologous sling insertion and a vaginoplasty using vaginal flaps.
Extended Primary Anastomosis With Penile Plication (EPAPP): A Promising New Alternative to Perineal Urethrostomy for Reconstruction of Long Urethral Strictures At present, excision and primary anastomosis (EPA) urethroplasty is a highly reliable method of reconstruction for short bulbar urethral strictures. Longer strictures are often managed with grafting techniques to ensure a tension-free repair. Here we report our initial experience with a new, extended anastomotic technique for long bulbar strictures that incorporates plication of the ventral corporal bodies to reduce the distance between the urethral ends and obviates the need for grafting.
Variant of Bladder Exstrophy With an Intact Penis: Surgical Options and Approach Variants of bladder exstrophy are a rare but diverse spectrum of bladder exstrophy-epispadias complex. This case series describes a group of 4 unique exstrophy variant cases who had an intact phallus, but a completely open bladder plate. These patients underwent exstrophy repair and concomitant umbilicoplasty at the Civil Hospital, Ahmedabad as part of the US-India Multi-institutional Bladder Exstrophy Collaboration and were followed at the same institution. We believe that a detailed assessment of bladder neck prior to reconstructive repair and bladder closure would be beneficial in these cases as the extent of bladder neck involvement would affect reconstructive approach.
Pneumorenum—A Technique to Ease Laparoscopic Nephrectomy in Giant Hydronephrotic Nonfunctioning Kidney Laparoscopic nephrectomy in a giant hydronephrotic nonfunctioning kidney occupying the most of the abdomen is challenging task. To overcome the difficulty in laparoscopic dissection of such kidneys we described a technique “Pneumorenum,” wherein the kidney is decompressed by suction through a 5 mm trocar inserted directly into kidney under vision. Following suction decompression, the kidney is inflated later during dissection with carbon dioxide gas to moderate size to do the dissection in an easy manner.
Jean Wilson and His Legacy, 50 Years and Counting To evaluate the legacy of endocrinologist Jean Wilson, whose discovery in 1969 of 5 alpha-reductase (5AR) and description of dihydrotestosterone (DHT) as the primary hormone associated with prostatic growth ushered in a golden age of collaboration between endocrinologists, oncologists, and urologists that led to some of the critical discoveries in the understanding and treatment of prostatic pathology.
A Rare Neoplasm: Primary Adrenal Leiomyosarcoma Adrenal incidentalomas are common neoplasms and while they are often benign, they have the potential to be malignant. The American Urological Association guidelines state that adrenal incidentalomas should be surgically resected if they are large, metabolically active, or display malignant characteristics. Other groups have suggested that growth kinetics be factored in as well. We present a case of an adult woman with adrenal incidentaloma which was subsequently discovered to be a primary adrenal leiomyosarcoma, a rare subtype of soft tissue tumors.
Prostate Cancer Undetected by mpMRI: Tumour Conspicuity is Reliant Upon Optimal Scan Timing and Quality We thank the authors of this intriguing letter for their significant interest in our work. They raise essential points that we would like to respond to in detail. The authors' first concern was that, contradictory to "guidelines", the magnetic resonance imaging (MRI) studies included in our analysis were done after prostate cancer was diagnosed with a biopsy, causing bleeding and making it harder to visualize the tumor inside the prostate. The patients included in our study were prostate cancer patients receiving MRI for surgical planning.
Prostate Cancer Undetected by mpMRI: Tumor Conspicuity is Reliant Upon Optimal Scan Timing and Quality We commend Alanee et al for their detailed description of prostate cancers not detected by multiparametric magnetic resonance imaging (mpMRI).1 They analyzed radical prostatectomy findings for 33 men lacking mpMRI-conspicuous prostate cancer (defined as Prostate Imaging Reporting and Data System [PI-RADS] scores 1-2) on preoperative mpMRI. They found 27% (9/33) of men with negative mpMRI had Gleason Grade Group (GGG) 3-5 cancer at prostatectomy, including 9 with extraprostatic extension, and 1 with Gleason grade 5 + 5 disease.
Neonatal Serum Electrolyte and Proteinuria Screening on 46,XY Ambiguous Genitalia Patients May Allow Early Diagnosis of Denys-Drash Syndrome: A Case Report A term infant with prenatally noted ambiguous genitalia and nonpalpable gonads presented with life-threatening hyponatremia, hypertension, acidosis, and anuric renal failure requiring peritoneal dialysis at age 3 months.Sequencing confirmed 46, XY Denys-Drash syndrome (DDS) due to heterozygous Wilms tumor-1 exon 8 mutation encoding p.His445Arg. Renal US identified bilateral multifocal renal masses at age 8 months. Bilateral retroperitoneal nephrectomies found bilateral nephroblastomatosis without Wilms’ tumor avoiding chemotherapy, followed by bilateral laparoscopic orchiopexies.
In Vivo Evaluation of a Novel Pigtail Suture Stent To compare pressure, dilation, and histology in a porcine model after stenting with a pigtail suture stent (PSS)–where the ureteral and bladder component consists of a suture and a double J (DJ) stent.
More Than Dysuria: Corynebacterial Encrusted Cystitis Corynebacterium species, typically considered contaminants in urine culture, can cause encrusted cystitis (EC), a form of chronic urinary tract infection causing pain, bladder necrosis, renal failure, and death. Delayed diagnosis is common due to its rarity and the fastidious nature of Corynebacterium urealyticum. Reported mostly in elderly and immunocompromised patients, EC is rare in pediatric patients. A female adolescent on high dose steroids developed persistent dysuria after urinary catheterization.
Dr. Andre De Vries: The Father of Israeli Urolithiasis Research The Middle East has become known as the “Stone Belt” region due to its high prevalence of urinary stones.1 This phenomenon is well documented in even the early civilizations of Medieval Persia,2 Egypt, and Mesopotamia.1 In 1917, during World War I, Palestine came under British legal rule until the founding of the Israeli state in 1948. Researchers described urolithiasis in Jerusalem in 19303 and again in 1936.4 However, this subject was hardly investigated until the end of the 1950s, until internal physician Dr.
Bilateral Calculi in a Child With Bilateral Single System Ureteroceles Ureteroceles in children are detected with prenatal sonography and less commonly during the evaluation following a urinary tract infection. Rarely do ureteroceles in the pediatric population present with stones, particularly in a bilateral fashion. We present a case of a 5-year-old boy found to have bilateral intravesical single system ureteroceles harboring multiple large calculi treated successfully with a staged endoscopic approach.
Overlapping Urological Surgeries at a Tertiary Academic Center To evaluate whether the practice of procedure-time overlapping surgery (OS) is associated with inferior outcomes compared to nonoverlapping surgery (NOS) in urology, to address the paucity of data surrounding urologic surgeries to support or refute this practice.
PTEN Hamartoma Tumor Syndrome: A Case of Renal Cell Carcinoma in a Young Female PTEN Hamartoma-Tumor-Syndrome (PHTS) describes a series of conditions characterized by germline-mutation of the PTEN tumor-suppressor gene. PHTS patients have an increased lifetime risk of multiple malignancies, including thyroid, breast, and endometrial cancers. PHTS patients also have 20-30 fold increased risk of renal cell carcinoma (RCC) compared to age-matched controls. As with many hereditary RCC syndromes, tumors present early and multifocally. We present a case of one of the youngest patients diagnosed with RCC in PHTS and review the urologic implications of this syndrome.
Trends for Stage and Grade Group of Prostate Cancer in the US (2010-2016) To quantify the yearly prostate cancer incidence per 100,000 men, comparing consecutive years from 2010 through 2016. In the years immediately following the 2011/2012 U.S. Preventive Services Task Force update to prostate specific antigen (PSA) screening guidelines, PSA screening, biopsy, and subsequent prostate cancer diagnosis and definitive local treatment have declined. We performed an analysis of stage and grade at diagnosis for prostate cancer in the US, in the years following the 2011/2012 update.
Cost Effectiveness of Sacral Neuromodulation and OnabotulinumtoxinA in Managing Refractory Idiopathic Overactive Bladder Little information from clinical and modelled studies are available on cost effectiveness of OnabotulinumtoxinA and SNM for the treatment of idiopathic overactive bladder. We aimed to summarize the evidence in this regard from different healthcare systems. Seven studies from 5 countries were reviewed. Some modelled studies with a 10-year time frame showed that sacral neuromodulation became dominant long-term; others suggested OnabotulinumtoxinA was more cost effective at <5 years. There was considerable heterogeneity in the base case/sensitivity analysis and statistical modelling among the studies.
Generalizability of Prostate-Specific Antigen (PSA) Screening Trials in a “Real World” Setting: A Nationwide Survey Analysis The Prostate, Lung, Colorectal and Ovarian cancer (PLCO) and the European Randomized Study of Screening for Prostate Cancer (ERSPC) trials 1,2 have been widely used to inform policy decisions regarding prostate-specific antigen (PSA) screening in the US. However, the generalizability of any trial to its intended population is directly contingent on the study subjects being "representative" of the "universe" (ie, US men without symptoms or known diagnosis of prostate cancer [PCa]). In the context of PSA screening, its efficacy and effectiveness is predicated upon age, ethnicity, and family history of PCa (amongst other factors).
Inflammatory Myofibroblastic Tumor After Treatment of Wilms Tumor in a 6-Year-Old Boy: A Case Report and Literature Review Inflammatory myofibroblastic tumor (IMT) is a rare tumor with an indolent course. It is less often reported as a second tumor that occurs after treatment of malignant tumors in pediatric patients. Here, we report a case of IMT following Wilms tumor (WT), and conduct a literature review concerning IMTs and WT to evaluate the diagnostic possibility of IMT as a second tumor. The coexistence of the 2 tumors may cause confusion as to whether they share genetic links or that IMTs may appear as late effects of the treatment of WT.
Fertility Preservation: A Tale of Two Testicles The transgender population has long been marginalized by society. Societal stigmata, fear to seek care, and dearth of provider knowledge regarding transgender health issues has caused disparities to widen. The purpose of this case study is to call to attention the often-overlooked aspect of transgender care: the importance of fertility preservation prior to undergoing therapy.
Author Reply to Letter-to-the-Editor on: Validating the Martini Staging System for Rectourethral Fistula We appreciate the commentary by Martini et al.1,2 on our article on the validation of their rectourethral fistula (RUF) staging system. The commentary brings to light many core concepts that we raised in our manuscript. The first of which is the limitation of the staging system. We fully agree with the commentary that RUF is a complex pathology that cannot be fully captured by a single staging system which is comprehensive enough to account for the multitude of etiologies that lead to RUF. In fact, the authors elucidate that their staging system is primarily meant for postprostate cancer treatment.
Flank Pain as a Symptom of COVID-19 The COVID-19 disease is spreading rapidly worldwide, and no vaccine or very effective drug has been found yet. However, the transmission rate of the disease can be reduced by taking precautions. Therefore, it is essential to detect the patients early to prevent the spread of the disease.1,2 We report a case of 26-year-old male patient who was admitted to our urology outpatient clinic with the complaint of flank pain and had incidental findings of COVID-19 in the lung bases on abdominal CT.
Response to “Trends in Female Representation in Urology Residency: Impact on Workforce Projections” We thank the author for their interest in our manuscript and acknowledge the mostly linear growth of female urology residents over the past 12 years based on Accreditation Council for Graduate Medical Education data.1 We acknowledge that our assumption of continued 25% of residents being female could be an underestimate; however, that estimate is derived from the best available data.
Trends in Female Representation in Urology Residency: Impact on Workforce Projections Accurate, reliable projections of the health care workforce can inform employment trends, policy decisions, and insights about the training pipeline. In urology, worrisome forecasts about inadequate postgraduate training positions to replace retiring surgeons and meet increasing demand from an aging population have spurred continued legislative advocacy to increase physician supply.1 These efforts have focused primarily on quantity—how many new urologists are entering the workforce, or how many U.S.
Prenatally Diagnosed Solid Renal Mass Congenital mesoblastic nephroma is the most common renal neoplasm diagnosed in the first month of life of which 15% occur prenatally. We present a prenatal diagnosis of a 5.8 cm solid renal mass identified on the 36-week ultrasound. Labor was induced at 38 weeks and a female infant was delivered vaginally without complications. The postnatal ultrasound demonstrated a 6.3 cm heterogeneous mass nearly replacing the kidney. The infant underwent a radical nephrectomy on the first day of life and pathology confirmed stage II classic CMN with negative margins and nodes.
Resection of Inferior Vena Cava Without Reconstruction for Intravascular Intrusion of Wilms Tumor Persistent inferior vena cava (IVC) tumor thrombus in Wilms tumor patients represents a management challenge. We describe three pediatric cases with preoperative evaluation documenting complete IVC occlusion and well-developed collaterals. They underwent nephrectomy and tumor thrombus removal accomplished with circumferential resection of the retrohepatic IVC without vascular reconstruction. All patients are asymptomatic and disease-free at 9, 2.5, and 2 years after stopping therapy. Cavectomy without reconstruction is safe and well tolerated in Wilms tumor patients with completely occlusive IVC tumor thrombus.
Bladder Duplication - A Case Series To describe 5 cases with complete urinary bladder duplication, their associated conditions, and their respective treatment. Urinary bladder duplication is an extremely rare congenital anomaly of the urinary system. So far about 70 cases have been published in the English literature, most of them as case reports and a few case series.
Do Hispanic Men Have Worse Outcomes After Radical Prostatectomy? Results From SEARCH To examine the associations between ethnicity and outcomes after radical prostatectomy (RP) among Hispanics. While non-Hispanic Black men have worse prostate cancer (PC) outcomes, there are limited data on outcomes of Hispanic men, especially after RP.
Removal of a Steel Ring Causing Penile Strangulation Without the Use of Powered Tools or Sharp Blades Penile strangulation is an uncommon urologic emergency that requires prompt evaluation and treatment to avoid disastrous consequences. Strangulation has been reported with objects ranging from hair tourniquets, to plastic rings, to iron rings. Strangulation with these devices can result in vascular congestion of the penis, swelling and eventual gangrene of the penis distal to the constricting device. We present a case report of a 43-year-old male who had a 2-day history of penile pain and swelling secondary to a metal ring constricting the proximal phallus.
Side Effects of Intravesical BCG and Chemotherapy for Bladder Cancer: What They Are and How to Manage Them Intravesical therapy for nonmuscle invasive bladder cancer decreases recurrence and progression but carries a high risk of side effects, which limit patient adherence. Appropriate management of the toxicities from intravesical therapy requires consideration of the agent used, the side effects experienced, and the timing of those side effects. Management strategies for intravesical toxicities ideally improve patient tolerance without sacrificing oncologic outcomes. This review aims to provide a comprehensive overview of the available evidence regarding the side effects of intravesical therapies for nonmuscle invasive bladder cancer and to propose practical strategies for toxicity management.
Prospective Observational Study of a Racially Diverse Group of Men on Active Surveillance for Prostate Cancer To evaluate the risk upgrading of active surveillance (AS), we reviewed the outcomes of African American men (AA) after electing AS. AS is the standard of care for men with low-grade prostate cancer (PCa). AA are known to have more advanced PCa features and are more likely to die from PCa, thus subsequent disease progression for AA on AS is unclear.
A 26-Year-old Woman With Dysuria and Hematuria In this case, we present imaging findings characteristic of chronic genitourinary schistosomiasis. Schistosoma haematobium, a blood fluke endemic to Africa and the Middle East, is a prominent cause of hematuria and bladder cancer in regions lacking adequate water sanitation. Luminal calcifications of the genitourinary tract, that is, of the bladder and/or ureters, from deposition of fluke eggs are a classic sign of chronic S. haematobium infection and should raise suspicion for the disease even when urine or serological tests are negative.
Persistent Dysuria in a Young Male A Cowper's Duct syringocele is a rare diagnosis and currently there exists no clinical guidelines for evaluation and management. This clinical challenge illustrates the case presentation, evaluation, diagnosis, and treatment options for of a newly diagnosed Cowper's Duct syringocele.
Clinical and Penile Dermoscopy Evaluation of a Reticulated Pattern on the Penile Glans A 32-year-old man visited our clinic for evaluation of a mildly pruritic lesion on the glans. He complained of a recurrent red patch, which had been slowly enlarging over the previous three months. Clinical examination revealed a slightly raised plaque with a reticulated lacy net pattern and white threads on the glans. There was no evidence of skin, nail or other mucosal involvement on physical examination. Laboratory tests, including hepatitis and syphilis serologies, were normal or negative. Penile dermoscopy revealed white reticular and circular lines [Wickham striae] on a red background.
Hot or Not: Tumor Mutational Burden (TMB) as a Biomarker of Immunotherapy Response in Genitourinary Cancers Pembrolizumab was recently approved for treatment of cancers with high tumor mutational burden (TMB). We conduct a focused literature review of TMB as a predictive biomarker. TMB quantifies the sum of nonsynonymous coding mutations (typically single nucleotide substitutions and short insertion-deletions) per megabase of sequenced DNA. As a proxy for expression of immunogenic neoantigens, TMB may be an effective predictive biomarker for response to immune checkpoint inhibitors. However, like other biomarkers in this setting, TMB has many limitations; the effect of this FDA approval in the current management of genitourinary cancers is likely limited to select situations.
Testis-sparing Surgery: A Single Institution Experience To demonstrate the safety and efficacy of testis-sparing surgery (TSS) in 2 specific circumstances: small, nonpalpable masses suspected to be benign and masses suspicious for germ cell tumor in a solitary or functionally solitary testicle or bilateral disease.
Response to Letter to Editor: “Development and Validation of a Male Anterior Urethral Stricture Classification System” We thank Dr Brandes and colleagues for taking such an interest in the LSE classification system and hope that others will take the time to understand its utility as much as they have. We also acknowledge the effort that he and others have taken into development of their U-score and will again recognize the similarities between the 2 systems here, as we did in the original manuscript. However, describing a urethral stricture based on its location, length, and etiology is hardly novel. There is nothing proprietary about saying “this patient has a 1 cm, proximal bulbar urethral stricture caused by a straddle injury”; or “this patient has a 2 cm, meatal stricture secondary to prolonged catheterization.” But the difference in how each respective classification/scoring system would categorize these strictures speaks to how they can and should be used in clinical practice.
Letter re: Erickson BA et al: Development and validation of a Male Anterior Urethral Stricture Classification System We read Erickson et al1 with interest. We agree with the authors that a validated anterior urethral stricture classification system is most helpful when it can “predict clinical outcomes, aid in clinical communication, and facilitate (comparative) research.” The U Score, which we published in 2015, is such a stricture classification system. The detailed TURNS LSE classification system is based on the 3 pillars of stricture length, location, and etiology (LSE). We published in 2012 the first descriptive anterior urethral stricture classification system, called UREThRAL score,2 which we refined later into a categorical grading scale called the U score.
“Bilateral Single System Ectopic Ureters With Vaginal Insertion in a Female Child, A Rare Variant” In most cases an ectopic ureter is associated with a duplicated renal collecting system while in only a few single systems is found. Bilateral single system ureteral ectopia is even rarer. A 9-year-old girl presented with urinary incontinence. Investigations pointed towards bilateral single system ectopic ureters with ectopic openings into vagina with a hypoplastic bladder. The left ureteric system was tortuous with malrotated and hypoplastic left kidney. A 4 × 2 cm hard calculus was found in the vagina.
Cannabinoids in Urology. Which Benign Conditions Might They Be Appropriate to Treat: A Systematic Review There is growing evidence suggesting cannabinoids may provide suitable alternatives to conventional treatments in an increasing number of clinical settings. This review evaluates how cannabinoids are used to treat certain benign urological pathologies and to clarify the clinical value of this data. This review includes 62 papers and was undertaken per PRISMA's guidelines, it evidences the therapeutic potential of cannabinoids in the management of specific benign urological diseases, most notably neurogenic bladder dysfunction (clinical studies), renal disease (animal studies), and interstitial cystitis (animal studies).
A Modified Neobladder Technique: The “I-Pouch” – Illustration of Surgical Approach and Tricks Various techniques for orthotopic neobladder (ONB) are currently used and have shown satisfactory oncological and functional outcomes.3 Among the relevant oncological and functional aspects for long-term follow up is the easy accessibility of the upper urinary tract in urinary diversion for endoscopic monitoring. In addition, variety exists in the amount of ileum needed to create a urinary reservoir. Depending on the ONB technique, up to 60 cm of ileum are required, and bowel dysfunction may be a consequence especially when the ileocecal valve is used for the urinary diversion.
Recurrent Genital Ulcers Papulonecrotic tuberculid represents a hypersensitivity reaction to Mycobacterium tuberculosis or its products that disseminate through hematogenous route to the skin from an internal tuberculous focus. It is characterized by recurrent eruptions of asymptomatic, dusky red papules, which undergo ulceration and crusting, and eventually heal after a few weeks with varioliform scarring. Although it most commonly involves extragenital sites, isolated glans penis involvement has been reported very rarely.
Unusual Presentation, Relapse, and Metastasis of a Pediatric Testicular Yolk Sac Tumor: Case Report Testicular tumors are not uncommon in children and represent 1%-2% of all pediatric malignancies. Prepubertal testicular yolk sac tumor is the most common childhood testicular cancer, accounting for 70%-80% of all cases. The clinical presentation varies from one patient to another; most common presentation is painless scrotal mass. Herein, we present a case of pediatric patient with a testicular yolk sac tumor who had unusual presentation followed by a local relapse and metastasis and continued to have high markers while he was on chemotherapy, then underwent retroperitoneal lymph node dissection and local recurrence excision.
Women Leaders in Academic Urology: The Views of Department Chairs Women now comprise the majority of matriculants to medical school (51.6% in 2018),1 yet continue to be underrepresented in academic leadership. Across specialties, women comprise 14% of department chairs, 22% of vice chairs, 22% of division directors, and 17% of decanal positions.2 The lack of women who hold these leadership positions in the field of urology is more pronounced. In a 2017 study, women comprised 3.3% (4 of 122) of department chairs, 4.5% (2 of 44) vice chairs, and 7.9% (20 of 253) division directors.
Chief Year: Finding a New Normal During Uncertain Times On Saturday March 14, 2020, my off-site rotation director informed me that the rotation would be suspended, but should resume at the end of April. These early days of the pandemic were filled with equal parts confidence and denial. I, like so many others, was being reassigned. In the months that followed, I saw the drastic changes in normalcy through a very personal lens. Redeployed to the VA Hospital to help manage the overwhelming burden of rescheduling veteran's clinic appointments and taking call for emergencies, I spent much of the remainder of my fourth year of residency at home.
New Insights on the Basic Science of Bladder Exstrophy-epispadias Complex The exstrophy-epispadias complex is a rare congenital anomaly presenting as a wide spectrum of disorders. The complex nature of this malformation leads to continuous investigations of the basic science concepts behind it. Elucidating these concepts allows one to fully understand the mechanisms behind the disease in order to improve diagnosis, management, and treatment ultimately leading to improvement in patient quality of life. Multiple technological advancements within the last 10 years have been made allowing for new studies to be conducted.
Pentosan Polysulfate Maculopathy: What Urologists Should Know in 2020 To conduct a review of current literature to assess whether an association exists between Pentosan Polysulfate Sodium and the development of macular disease, as it is the only oral medication approved by the Food and Drug Administration for the management of interstitial cystitis.
Gender-Based Differences in Urology Residency Applicant Personal Statements To gain insight into the perceptions of urology held by medical students as they enter the field, we analyzed the linguistic characteristics and gender differences in personal statements written by urology residency program applicants.
Current Status and Role of Patient-reported Outcome Measures (PROMs) in Endourology Kidney stone disease can have a number of adverse effects on patients including quality of life. Studies assessing outcome measures in this area have largely been focused on objective assessments such as stone free rate. However, as part of the evolution to shift healthcare to a more patient centered position, patient-reported outcome measures have emerged as an improved tool to address this deficit. Key patient-reported outcome measures in Urology now include Ureteral Stent Symptom Questionnaire, Wisconsin Stone QoL Questionnaire, Cambridge Ureteric Stone PROM, Cambridge Renal Stone PROM, and Urinary Stones and Intervention Quality of Life.
Seminal Vesicle Cysts With Upper Urinary Tract Abnormalities: A Single-center Case Series of Pediatric Zinner Syndrome Seminal vesicle cysts are usually congenital and frequently accompanied by upper urinary tract abnormalities due to mesonephric duct maldevelopment. Zinner syndrome, first described in 1914, refers to a triad of features consisting of seminal vesicle cysts, ejaculatory duct obstruction, and unilateral (mostly ipsilateral) renal agenesis. We herein present four pediatric patients with Zinner syndrome diagnosed at a children's medical center. A remnant ureteral structure was observed in three (75%) patients.
Metoidioplasty With Urethral Lengthening: A Stepwise Approach Metoidioplasty is a gender-affirming surgical option for individuals who desire masculine genitalia while preserving erogenous sensation and avoiding the morbidity of phalloplasty. Concurrent urethral lengthening offers patients the potential to stand to urinate.
Gender Differences in Authorship in Urology: a Five-year Review of Publications in Five High-impact Journals To describe the proportions of peer-reviewed manuscripts authored by women in 5 high-impact, widely available urology journals, and to compare these to the proportion of women in urology. About 9% of attending urologists and 25% of urology residents are women. We hypothesized that women comprised fewer than 25% of first authors and fewer than 10% of last/senior authors.
Statewide Price Variation for Generic Benign Prostatic Hyperplasia Medications To examine the geographic and pharmacy-type variation in costs for generic benign prostatic hyperplasia (BPH) medications in order to improve drug price transparency and reduce health disparities. Medical therapy for BPH can be expensive, having significant implications for uninsured and underinsured patients.
Women in Leadership in Urology: The Case for Increasing Diversity and Equity There is a persistent male gender predominance in urology, especially with respect to female representation in leadership. We review the current status of women in urology leadership, discuss challenges women face in leadership positions, present the case for adopting inclusive practices that increase diversity and gender equity in urology leadership, and review the potential benefits of such an expansion. We discuss practical strategies to grow the role of women in urologic leadership, including increasing mentorship, modifying academic promotion criteria, and addressing implicit bias, while presenting a roadmap toward achieving equity and diversity at the highest ranks of urologic leadership.
Hyperbaric Oxygen as Salvage Therapy for Neonates Suffering From Critical Ischemia of the Glans Penis After Circumcision Ischemic complications of glans penis following circumcision are rare, and if occurs can culminate in irreversible necrosis with severe long-term consequences. Here we present 2 challenging cases of neonates suffering from acute severe glans penis ischemia after circumcision that were treated by hyperbaric oxygen treatment (HBOT). In addition to case presentations, the literature related to complications of circumcision and the physiological effects of HBOT are being reviewed. Based on the review and the case presented, we conclude that HBOT can be used as salvage treatment for circumcision induced glans ischemia as early as possible before full necrosis develops.
Cystoscopic Management of Prostatic Utricles In this case series (n = 7) on prostatic utricles (PU), retention of urine was seen in 5 of 7, urinary tract infection (4 of 7), recurrent epidydymo-orchitis (3 of 7), and scrotal sinus (1 of 7). Voiding cystourethrogram established diagnosis in 3 of 7 patients while CT/MRI in 4 of 7 patients. Four patients were primarily managed by cystoscopic widening of mouth of PU. Three with large PU underwent initial open (2) or laparoscopic (1) excision but later warranted cystoscopic widening for residual PU.
Mature Ovarian Cystic Teratoma Mimicking a Bladder Diverticulum in a 16-year-old Female A 16-year-old female was incidentally found to have an abnormal pelvic ultrasound while undergoing evaluation for mild scoliosis. A large, thick-walled, lobular, fluid-filled structure was found at midline in the pelvis that initially resembled bladder diverticula due to its anatomical position and sonographic appearance. Voiding cystourethrogram and computed tomography later revealed a large cystic mass originating from the right ovary. This report outlines a case of a mature cystic teratoma convincingly mimicking bladder anomaly on sonography.
Management of Testicular Torsion and a Contralateral Testicular Mass Presenting Synchronously Testicular masses found in prepubertal males are often benign in nature. This has led to an increase in the use of testis-sparing surgery. Testicular torsion is considered a urologic emergency that requires immediate surgical intervention. Based off literature review, it is rare for these unique entities to present synchronously in a single patient. This report demonstrates that in the pediatric population it is possible to safely treat a suspected benign testicular mass with testis sparing mass enucleation if it presents synchronously with testicular torsion in the contralateral testis.
“Beyond the Bump” – Insight Into the Postpartum Women's Experience of Pelvic Organ Prolapse as Expressed on Reddit To qualitatively analyze the biopsychological experiences of postpartum women regarding pelvic organ prolapse (POP) as expressed on Reddit, a widely used internet platform for anonymous discussion and information sharing. POP is a prevalent condition in postpartum women, yet personal experiences are often not discussed due to social stigma.
Suboptimal Prediction of Clinically Significant Prostate Cancer in Radical Prostatectomy Specimens by mpMRI-Targeted Biopsy To investigate the correlation of multiparametric magnetic resonance imaging targeted (TBx) and/or systematic prostate biopsy (SBx) in predicting the presence of clinically significant (cs) prostate cancer (PCa) in radical prostatectomy (RP) specimens. Concordance of mpMRI and RP specimen lesions was also investigated in terms of tumor localization and histopathological features.
Nephrolithiasis in Pregnancy: Treating for Two To review the literature regarding the epidemiology of stone disease and develop a management algorithm based on current evidence and societal guidelines.
Surgical Treatment of Primary Penile Scrotal Lymphedema: A Case Report Lymphedema is the result of altered lymphatic drainage. Primary lymphedema is a rare condition with a reported incidence of only 0.6%. Most cases in children are caused by congenital factors. We report a 4-year-old child with primary penile scrotal lymphedema combined with bilateral hydrocele, and satisfactory therapeutic and aesthetic results were obtained through surgical resection and genital reconstruction.
Optimizing Women's Sexual Function and Sexual Experience After Radical Cystectomy Survivorship in bladder cancer has improved in terms of lower morbidity, mortality, and improved oncological outcomes. However, there is a dearth of research on women's quality of life, specifically, on the effect of radical cystectomy on women's sexual function and sexual experience. This narrative literature review focuses on the current state of knowledge about women's sexual function after cystectomy, identifies patient and provider-related factors that have contributed to the lack of research and sexual health support in clinical practice, and proposes a model for sexual rehabilitation as well as future areas for research.
Baseline Renal Volumes in Children Born With Cloacal Anomalies To better understand why children born with cloacal anomalies are at a high risk of renal insufficiency, this study aims to determine baseline renal volume in children with cloacal anomalies compared to controls. We hypothesized children with cloacal anomalies would be born with less renal volume.
Assessing Contemporary Trends in Female Speakership within Urologic Oncology To evaluate multidisciplinary female representation at urologic oncology conferences, we reviewed speakership trends at contemporary Society of Urologic Oncology (SUO) and American Society of Clinical Oncology Genitourinary Symposium (GU-ASCO) annual meetings.
Segmental Testicular Infarction Associated to Torsion: First Case Report in Childhood Testicular torsion in children is not uncommon emergency problem which occur due to twist in the spermatic cord leading to ischemia or infarction to testicle. Hemorrhagic infarction can occur following testicular torsion is globally; however, in extremely rare situation, such infarction can be segmental.Segmental testicular infarction (STI) was reported in an infant due to epididymitis and a newborn with STI in 1 testicle with complete infarction in the contralateral testicle due to birth trauma.
Supernumerary Kidney Associated With Horseshoe Malformation and Ureteric Stricture With Hydroureteronephrosis – A Rare Case Supernumerary kidney is an accessory kidney with its own vasculature, collecting-system and encapsulated parenchyma with about 100 cases reported in the literature. However, there is no report of supernumerary kidney associated with horseshoe malformation with ureteric stricture. We report a rare case of 20 months old female admitted with left-sided abdomen lump and mild abdominal pain. During surgery, supernumerary kidney with horseshoe component with grossly-dilated left-sided pelvicalyceal system and proximal 1-cm of left-ureter, distal to which whole of left-ureter was noncanalized, was seen.
Urinary Pubic Symphysis Fistula Leads to Histopathologic Osteomyelitis in Prostate Cancer Survivors To assess the histologic findings in the pubic bone resected during extirpative surgery for urinary pubic symphysis fistula (UPF). The concurrent presence of osteomyelitis and the need for bone resection at time of extirpative surgery for UPF has been debated. We hypothesized that UPF results in histopathologically confirmed osteomyelitis, underscoring the importance of bone resection at the time of surgery.
Native Ureter Ventriculo-Ureteral Shunt Placement for Management of Refractory Hydrocephalus in a Child With a History of Renal Transplant: Case Report and Technical Note This report describes the case of a 5-year-old male with intractable hydrocephalus secondary to neonatal intraventricular hemorrhage who was ultimately managed with the placement of a ventriculo-ureteral (VU) shunt. He had previously failed numerous attempts at cerebrospinal fluid shunting, choroid plexus cauterization, and endoscopic third ventriculostomy. The patient had a history of end stage renal disease, and had previously undergone renal transplant. In an operation that involved Neurosurgeons, Pediatric Urologists, and Transplant surgeons, a Gibson incision was used to avoid the patient's multiple intra-abdominal adhesions, and his nonfunctioning renal unit was used to implant a VU shunt without early or late complications.
Gynecologic Considerations for the Urologic Surgeon While gynecologic malignancy is uncommon in women with conditions such as pelvic organ prolapse and bladder cancer, urologists should be acquainted with the relevant gynecologic literature as it pertains to their surgical care of female patients. While taking the patient history, urologists should be aware of prior cervical cancer screening and ask about vaginal bleeding, which can be a sign of uterine cancer. Urologic surgeons should also discuss the role of concomitant prophylactic oophorectomy and/or salpingectomy for ovarian cancer risk reduction at the time of pelvic surgery.
A Rare Case of Prolapsed Ureterocele With Large Redundant Flap After Unroofing in Adult Female We present a case of 26-year female who presented with acute urinary retention and vulvar mass. She denies any urinary complaints in the past except for occasional straining for voiding. Imaging revealed a prolapsed ureterocele, it was successfully managed with incision and excising a flap of ureterocele due to the risk of postoperative protrusion of the redundant ureterocele. On follow-up at 6 months she was voiding well without any complaints.
Rising Tides: Challenges and Opportunities for Women in the Urologic Workforce The number of practicing female urologists has increased from < 2% in 1980 to 9.2% in 2018. Despite this increase, urology trails far behind medical fields overall and surgical subspecialties, in achieving gender parity. Barriers, such as pervasive biases and institutional policies, exist at the medical student, resident, and practicing urologist levels. Once recognized as detrimental, action can be taken to combat these forces to allow for advancement of women in the field of urology. This will result in a richer workforce better able to serve its patient population and advance the field.
Management of Vesicoureteral Reflux in a Patient With Recurrent Febrile Urinary Tract Infections, Neurogenic Bladder, and Ureteral Triplication Ureteral triplication is a rare anomaly with about 100 total cases reported in the literature. In this case presentation, we present a case of ureteral triplication in a young female with a history of neurogenic bladder secondary to L5 lipomeningocele who presented with recurrent febrile urinary tract infections (UTIs) and vesicoureteral reflux despite antibiotic prophylaxis. Given her high grade reflux, she underwent ureteral reimplantation which ultimately led to resolution of her UTIs and reflux.
Let's Talk About Sex: Special Considerations in Reproductive Care and Sexual Education in Young Women With Spina Bifida Medical advances in the last several decades have allowed an increasing number of children with spina bifida to reach adolescence and adulthood. As they reach puberty, girls with spina bifida face unique social and health challenges to their sexuality, such as orthopedic restrictions, continence, and pelvic floor disorders. Recent research efforts have focused on better understanding female sexual desires, dysfunctions, and activity and the role of the physician in educating this vulnerable population.
Congenital Lymphedema of the Foreskin in a 3-Year-Old Boy: A Case Report and Literature Review Congenital lymphedema of the external genitalia is a rare, disfiguring disorder. We describe here a case of a 3-year-old male with primary foreskin lymphedema persisting since birth. A compact, heterogenous swelling of the foreskin's distal third was observed, inhibiting preputial retraction (phimosis). Right lower extremity lymphedema was also observed in this case, while no further abnormalities were found. Surgery was performed, maintaining the foreskin, producing an excellent result with no recurrence at 10-month follow up.
Gastric Adenocarcinoma Arising in Gastrocystoplasty Gastric cancer is a rare long-term complication in gastrocystoplasty. We report 2 cases of gastric adenocarcinoma and review the literature for similar cases. A total of 14 cases are identified. The majority of patients are males, presented with hematuria, and developed cancer at a younger age, more than 10 years after gastrocystoplasty. Long-term follow up information was limited, but 5 patients (36%) died within 5 years of diagnosis. Annual surveillance for malignancy may not be effective due to its rarity.
Associations Between Female Sex and Treatment Patterns and Outcomes for Muscle-invasive Bladder Cancer To investigate the association of female sex with the selected treatment for patients with nonmetastatic muscle-invasive bladder cancer. Sex is a known independent predictor of death from bladder cancer. A potential explanation for this survival disparity is difference in treatment pattern and stage presentation among males and females.
Predictive Risk Factors for Continued Smoking after the Diagnosis of a Genitourinary Malignancy To determine risk factors for continued smoking following a diagnosis of a genitourinary (GU) malignancy. Smoking is a well established risk factor in the development of cancers involving the GU tract. Unfortunately, a large percentage of patients continue to smoke or relapse after cancer diagnosis; by doing so, there is an increased risk of recurrence, poor survival rates, treatment complications, secondary primary cancers, and other chronic smoking related illnesses.
Incidence of Significant Findings of Microhematuria Workup in Women—What Guidelines Work Best? To apply the American Urogynecological Society (AUGS)/American College of Obstetricians and Gynecologists (ACOG) recommendations of foregoing workup in patients under 50 years of age with less than 25 red cells per high-powered field, to a cohort of asymptomatic microscopic hematuria (AMH) patients, and assess diagnostic accuracy, sensitivity, specificity, positive, and negative predictive value compared to the American Urologic Association (AUA) guidelines.
Testicular Torsion From Bell-clapper Deformity A 12-year-old otherwise healthy boy presents to a local emergency room with sudden onset, sharp, continuous left testicular pain for 9 hours, associated with nausea and vomiting. Exam and ultrasound is consistent with testicular torsion. During scrotal exploration, a bell-clapper deformity of the left testicle is appreciated, with a normal gubernacular attachment of the right testicle. Bell-clapper deformity is a congenital failure of the posterior attachment of the gubernaculum to the testis, which increases testicular mobility within the tunica vaginalis and predisposes individuals to testicular torsion.
Presentation and Diagnosis of Ureteral Quadruplication: Case Report and Analysis of the Literature Ureteral quadruplication is exceedingly rare. All except for 2 cases were symptomatic and nearly all underwent intervention. We present the first case of asymptomatic ureteral quadruplication in the presence of ureteral cyst. The report is first to prove ureteral quadruplication, even with ureteral cyst, can have normal renal function and parenchyma without obstruction or reflux. The report analyzes differences between the 14 cases of ureteral quadruplication in the English literature. It is first to describe bilateral ureteral cysts with ureteral quadruplication and triplication, and is first to accurately characterize the appearance of quadruplicated ureters inside the kidney.
Retroureteral Small Bowel Herniation Resulting in Bowel Obstruction Following Robotic Cystectomy With Extracorporeal Ileal Conduit An 80-year-old male with a history of atrial fibrillation on apixaban, hypertension, hyperlipidemia, and bladder cancer underwent robotic cystectomy with extracorporeal ileal conduit 8 years prior. His final pathology showed multifocal carcinoma in situ (pTisN0Mx). Although he had no recurrence of disease, his course was complicated by recurrent urinary tract infections, some resulting in urosepsis, for which he followed with Infectious Diseases and was managed with chronic antibiotic prophylaxis.
Characteristics of Genitourinary Fistula in Kigali, Rwanda; 5-Year Trends To assess the characteristics of women presenting with genitourinary fistula over a 5-year period in Kigali, Rwanda. Genitourinary (GU) fistula is a devastating condition that can result from difficult vaginal deliveries or as a surgical complication. Rwanda has seen notable increases in cesarean section rates as a result of a successful universal health care system. It is unclear how the increase in cesarean section rates may influence the types of fistula diagnosed.
Gender Disparities in Industry Payments to Urologists To analyze and compare industry payments to urologists in the Open Payments Database by gender. We hypothesized that industry payments might be greater to male vs women urologists.
Female Sexual Dysfunction – Awareness and Education Among Resident Physicians To develop a better understanding of the strengths and deficiencies of female sexual health education and the attitudes toward female sexual health amongst urology, obstetrics and gynecology, psychiatry, and family medicine trainees. Female sexual dysfunction (FSD) is characterized as distress related to sexual pain, interest/arousal, or orgasm. Despite the high prevalence of FSD there are few clinical resources available for patients and providers in Canada.
Post-cystectomy Enterocele: A Case Series and Review of the Literature To present a case series and literature review on post radical cystectomy (RC) pelvic organ prolapse (POP) to heighten awareness of the symptoms, imaging findings, and risk factors associated with this complication and discuss opportunities for prevention. Women with muscle invasive bladder cancer undergo RC with anterior exenteration, significantly disrupting the pelvic floor. These women are at risk for POP.
Vaginal Estrogen—What a Urologist Should Know The implications of estrogen depletion on the lower urinary tract and vagina are relevant to the urologist treating women with genitourinary symptoms. The main symptoms of vaginal estrogen depletion that affect women are dyspareunia and vaginal dryness, recurrent urinary tract infection, and lower urinary tract symptoms. Vaginal estrogen can be used to effectively treat these conditions. Vaginal estrogen is available in a variety of formulations. Each formulation has different considerations regarding its use and patients should be actively involved in choosing the right product for them.
High-Risk Nonmuscle Invasive Bladder Cancer: Selecting the Appropriate Patient for Timely Cystectomy The heterogenous nature of high-risk nonmuscle invasive bladder cancer encompasses a wide range of tumor biologies with varying recurrence and progression risks. Radical cystectomy provides excellent oncologic outcomes but is often underutilized. Timing for these patients is critical, however, to its effectiveness. Certain unfavorable tumor characteristics predict worse outcomes and may help select the most appropriate patients for more aggressive initial therapy. This manuscript aims to outline factors that predict worse outcomes in high-risk nonmuscle invasive bladder cancer and proposes which patients may benefit most from a timely radical cystectomy.
Nonobstetrical Robotic-Assisted Laparoscopic Surgery in Pregnancy: A Systematic Literature Review Urologic and gynecologic surgeons are the top utilizers of robotic surgery; however, nonobstetrical robotic-assisted laparoscopic surgery (RALS) in pregnant patients is infrequent. A systematic literature review was performed to ascertain the frequency, indication and complications of RALS in pregnancy. Results showed 38 pregnancies from eleven publications between 2008 and 2020. Five cases were for urologic indication and 33 for gynecologic indication. Minimal surgical alterations were required.
Gender Bias in Medicine: Does It Exist at AUA Plenary Sessions? To determine if gender bias exists at the plenary sessions of the American Urological Association (AUA) annual conference by evaluating variations in the use of a professional title (PT) during speaker introductions at these sessions.
Identifying Opportunities to Improve Patient Experience With Sacral Neuromodulation: A Human Factors Approach To use a human factors approach to conduct a needs assessment of patient preparedness, education, device usability, and satisfaction regarding all stages of sacral neuromodulation therapy and identify opportunities for improvement. Sacral neuromodulation, though minimally invasive, involves an initial testing phase that requires active patient participation. This process is relatively complex and, if a patient does not receive adequate preprocedure education, can be difficult to conceptualize.
Recurrent UTIs in Girls: What Is the Role of the Microbiome? Urinary tract infections (UTIs) are one of the most common childhood bacterial infections. Recurrent UTIs can lead to renal scarring. Compared to boys, girls are more likely to develop scars as a result of recurrent UTIs. Therefore, there is a need to identify girls at high risk for recurrent UTIs and develop interventions to decrease the risk of recurrent UTIs. In this commentary, we will review the hypothesized pathophysiology of recurrent UTIs, explore the literature on the role of the microbiome in recurrent UTIs, focusing on female pediatric patients when able, and highlight the need for future research in this area.
A Review of Mullerian Anomalies and Their Urologic Associations Structural anomalies of the female reproductive tract, known as Mullerian anomalies, can occur in isolation or in association with anomalies of other organ systems. Due to shared embryology, the most common association in up to 40% of patients is with renal, ureteral, and bladder anomalies. Affected girls can have a wide range of genitourinary symptoms with urologists playing an integral role in their diagnosis and treatment. To facilitate the recognition and management of these conditions, we provide a review of Mullerian anomalies including the embryology, classifications, syndromes, evaluation, and treatments with attention to their urologic applicability.
The Impact of Sex and Gender on Clinical Care and Research Design in Nephrolithiasis Although classically a disease of male preponderance, scrutiny of the available data on nephrolithiasis reveals substantial epidemiological discrepancies between males and females, suggesting sex-based pathophysiology underlying this disease.1 Furthermore, sex-based differences may exist in underlying urinary risk factors, presentation, and treatment response. Recognizing these differences will be essential to further understand the multitude of etiologies of kidney stone disease and aid in developing appropriately designed comparative effectiveness trials.
Robotic Adrenalectomy for Functional Adenoma in Second Trimester Treats Worsening Hypertension A 33-year-old G6P3023 was found to have a 4.2 cm right adrenal incidentaloma during an admission for right pyelonephritis. Computed tomography (CT) was performed to rule out perinephric abscess in the setting of worsening leukocytosis while on antibiotics (Fig. 1). Initial differential diagnosis from endocrinology included pheochromocytoma and primary aldosteronism. Due to the lack of typical physical exam stigmata, Cushing syndrome was initially of low concern. Of note, her past medical history included hypertension treated with amlodipine 10 mg and hydrochlorothiazide 12.5 mg.
Lower Urinary Tract Symptoms: Advances in Women's Urologic Health From MAPP and LURN Urinary tract conditions causing urinary symptoms, including pain and discomfort, are common in women of all ages. Lower urinary tract symptoms (LUTS) are highly prevalent with 59.2% of women exhibiting storage symptoms; 19.5% exhibiting voiding symptoms; and 14.2% exhibiting postmicturition symptoms and the prevalence of symptoms increases with age.1 Lower urinary tract pain, in particular, appears to be a problem more common in women than men.1 Unfortunately, many patients who seek care for LUTS experience neither total nor permanent resolution of their symptoms with current management approaches.
Laying the Foundation for Bladder Health Promotion in Women and Girls Prevention strategies have been effective in many areas of human health, yet have not been utilized for lower urinary tract symptoms (LUTS) or bladder health (BH). This commentary outlines LUTS prevention research initiatives underway within the NIH-sponsored Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS). Prevention science involves the systematic study of factors associated with health and health problems, termed protective and risk factors, respectively. PLUS is enhancing traditional prevention science approaches through use of: (1) a transdisciplinary team science approach, (2) both qualitative and quantitative research methodology (mixed methodology), and (3) community engagement.
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.
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 We thank the authors for their comments on our publication1 and acknowledge their urge for preventing potential unnecessary harm in patients with prostate cancer due to overstaging. The authors suggest a remaining role for DRE in local staging of prostate cancer, as it represents a low cost, noninvasive test that is highly specific for the identification of extraprostatic disease.
EDITORIAL COMMENT Multiparametric magnetic resonance imaging (mp-MRI) is an important tool in the evaluation of men with prostate cancer given the high-resolution anatomic visualization. It has been well established that mp-MRI improves the accuracy of biopsies and grading when screening men at risk for prostate cancer.1 Here, the authors have taken the next step by assessing mp-MRI as a clinical staging tool in the identification of nonorgan confined disease, which can be challenging. Using a multi-institutional registry, they report that mp-MRI is superior to digital rectal examination (DRE), with a 9% absolute improvement in the accurate identification of ≥pT3a disease.
EDITORIAL COMMENT Given the high risk of postoperative incontinence, reconstruction in bulbo-membranous stenosis (BMS) after benign prostatic hyperplasia surgery is challenging. Because of this, initial conservative management with dilation or internal urethrotomy is usually recommended. Unfortunately, the cure rate is low, and the stenosis may remain unsolved, with many patients ending up with a suprapubic tube. While not particularly frequent, this is a devastating complication for patients undergoing supposedly routine BPH surgery.
AUTHOR REPLY Thank you very much for your insightful comments on our manuscript. Indeed, we recognize the limitations of the NSQIP database. Clearly, we cannot differentiate those patients with an overnight observation compared to those that were discharged on the same day of Artificial Urinary Sphincter (AUS) implantation. On a population level, utilizing claims-based data may enable this analysis, and better characterize these practice patterns as well as the safety and potential cost savings of same day AUS surgery. Dropkin et al, from Vanderbilt University, recently published their experience with pain requirements and perioperative complications among 163 patients undergoing AUS insertion, with 162 patients discharged home on the first postoperative day.
EDITORIAL COMMENT I read with interest the article entitled “Changing trends in management following artificial urinary sphincter surgery for male stress incontinence: an analysis of the National Surgery Quality Improvement Program database”. In this study, the authors evaluate the National Surgical Quality Improvement Program (NSQIP) for trends in artificial urinary sphincter in relation to early discharge defined as < 24 hours, and late discharge defined as > 24 hours. The authors are to be commended for emphasizing the importance of expedited return to home and normal function.
EDITORIAL COMMENT Black, Latinx, and female physicians represent 2.0%, 3.9%, and 9.9% of practicing urologists in the United States, respectively.1 For comparison, 13.4%, 18.5%, and 50.1% of the 2019 US population identified as Black, Latinx, and female.2 Modest improvements have occurred in the representative diversity of our workforce with increasing numbers of Black (3.1%), Latinx (5.7%), and female (29.4%) urology residents in the 2019 AUA census.3 Recognizing the importance of workforce diversity—and its role in improving clinical care and research—the time has come for our field to better understand what barriers exist in our recruitment of URM students.
EDITORIAL COMMENTARY Pentosan polysulfate sodium (PPS) is the only North American oral medication approved for the treatment of interstitial cystitis (IC). I had believed, that based on our large longitudinal experience,1 PPS actually helped some patients, a benefit that was not dose-related but seemed to increase with longer duration of use. I continued to prescribe PPS to a very few selected IC/bladder pain syndrome (IC/BPS) patients, even after our later randomized placebo controlled trial could not prove any significant efficacy compared to placebo.
AUTHOR REPLY We read with interest the Editorial from (Carol J. Bennett, and Scott Ian Zeitlin).1 related to our recent publication and we are happy to address the concerns that were raised. Previous evidence has demonstrated that male infertility may be a harbinger for later male health. There have been associations found between male infertility and medical conditions ranging from oncologic, cardiovascular, autoimmune, and other chronic diseases to quantifiable outcomes such as hospitalization rates.2-4 Furthermore, the cohort studies from Europe discussed in our article, have linked male infertility and/or low semen quality with higher mortality.
EDITORIAL COMMENT Until now when a patient would ask if having a varicocele affected their health in and of itself, we would respond no. Our faith in this answer has now been somewhat diminished. The concept that male infertility alone can increase one's mortality is provocative but certainly not definitive. In 2020, we face a more superficial reality where people read only headlines and the deeper dive is lost. Therefore, it is vital to remember that with big data comes big responsibility. Our fear regarding this data is that it lacks depth and context.
EDITORIAL COMMENT The authors compared the costs associated with a radical versus a partial cystectomy for patients with localized muscle-invasive bladder cancer and found no significant difference. They did, however, note worse cancer-specific survival for patients who had a partial cystectomy.1
EDITORIAL COMMENT The authors describe a large state-wide retrospective cohort of men diagnosed with favorable risk prostate cancer (FRPC) on active surveillance (AS) with or without follow up confirmatory testing within 6 months of diagnosis. Confirmatory testing included repeat prostate biopsy, MRI, MRI with biopsy or a tissue-based genomic classifier within 6 months of diagnosis. This study further evaluates the MUSIC initiative, a “Roadmap for FRPC,” during AS and the role of additional testing for the “Consideration Phase” of AS to help determine appropriate candidates for the “Surveillance Phase.”1
AUTHOR REPLY We thank the Gold Journal editorial office for the opportunity to comment on our manuscript. The volume-outcome relationship is well established across surgical disciplines. For rare diseases, this may be especially important not only given how seldom these clinical scenarios are encountered but then how infrequently these operations are performed there. Ideally, these patients would be taken care of by high-volume centers that have not only experienced providers to perform the extirpative operations but also the infrastructure in place for multidisciplinary care postoperatively.
EDITORIAL COMMENT Sui et al provide evidence that patients undergoing radical nephroureterectomy at higher volume centers have better outcomes than those treated at lower volume centers. This finding is consistent with a well-established body of literature that has shown the association between higher hospital and surgeon volume and better outcomes in the management of complex surgical and medical conditions. The causal factors that might explain these associations have not been definitively proven, but could include more technical expertise, earlier identification and rescue of complications, improved case selection, improved perioperative supportive care, more motivated, better informed, or higher resourced patients, among others.
EDITORIAL COMMENT In this issue of Urology, the authors discussed the impact of incorporating the Nutrition, Exercise, Patient Education, and Wellness (NEEW) pathway compared to the enhanced recovery after surgery (ERAS) pathway alone on perioperative outcomes after robotic-assisted radical cystectomy (RARC). Several outcomes after integrating the NEEW pathway were evaluated, one of which was psychosocial outcomes. As part of the NEEW pathway, social workers conducted a preoperative evaluation 4 weeks prior to RARC where they provided resources to patients who had concerns of anxiety, depression, substance use, financial concerns, and caregiver issues.
AUTHOR REPLY Many factors have previously been examined to reveal the elements related to the long-term complications and revisions for artificial urinary sphincter (AUS) surgery. In this study, we tried to highlight the role of a different aspect that affects patients’ outcomes following AUS implantation. As mentioned in the editorial comment, it is a nightmare for urologists to find a patient coming to emergency room with a urethral catheter placed through a closed cuff, or for an otherwise healthy man to, before undergoing an elective procedure, forget to inform his healthcare provider(s) that he has an AUS in place.
EDITORIAL COMMENT Anecdotally, many have seen the case where an elderly gentleman with dementia presents in retention, confused, and possibly with a urinary tract infection or acute kidney injury – all because he stopped cycling his artificial urinary sphincter (AUS).1 Many urologists have also seen the case where a urethral catheter was placed through the closed cuff in this patient, or in an otherwise healthy man who before undergoing an elective procedure forgot to inform his healthcare provider(s) he has an AUS in place.
AUTHOR REPLY We greatly appreciate the editorial comment on article. We used an adjusted 15-items nonvalidated questionnaire because, although there are many validated questionnaires that investigate male and female sexual function, none of these have ever had the specific purpose of examining couples sexual life at the time of a pandemic.
EDITORIAL COMMENT As of August 13, 2020, the World Health Organization has reported 20,439,814 global cases of and 744,385 deaths attributed to COVID-19.1 Italy is the epicenter in the European Union, with an estimated 251,713 cases and 35,225 deaths, leading to unprecedented healthcare challenges and widespread crises. To date, no effective treatment for COVID-19 has been established. Moreover, high viral transmissibility and considerable mortality rates have forced many national governments to implement quarantine measures to mitigate its progressive risk of spread in communities, as described succinctly herein by the authors.
AUTHOR REPLY We welcome and thank you for your comments, and strongly agree with your sentiments. Previously, Tao et al. reported continued smoking following a diagnosis in cancer results in a 59% increase in risk of death compared to those who stop smoking following diagnosis.1 We know that smokers who receive smoking cessation intervention from their urologist are 2.3 times more likely to quit.2 In a previous study by the authors, our institution reported that over half of urologists never discuss smoking cessation with patients following a diagnosis of bladder malignancy.
EDITORIAL COMMENT Urothelial bladder cancer is the urogenital cancer most strongly associated with tobacco use and it is interesting to note that whilst many guidelines recommend that clinicians encourage smoking cessation, it is argued that this is insufficient. Instead, we should be ensuring that patients are informed and empowered to stop smoking. Yet, many patients continue to smoke and half of surgeons fail to discuss smoking cessation.1
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