Christopher E. Bayne

Use of social media in urology: data from the American Urological Association (AUA)

To characterise the use of social media among members of the American Urological Association (AUA), as the use of social media in medicine has greatly expanded in recent years.

Treatment of the Primary Tumor in Metastatic Prostate Cancer: Current Concepts and Future Perspectives

CONTEXT Multimodal treatment for men with locally advanced prostate cancer (PCa) using neoadjuvant/adjuvant systemic therapy, surgery, and radiation therapy is being increasingly explored. There is also interest in the oncologic benefit of treating the primary tumor in the setting of metastatic PCa (mPCa). OBJECTIVE To perform a review of the literature regarding the treatment of the primary tumor in the setting of mPCa. EVIDENCE ACQUISITION Medline, PubMed, and Scopus electronic databases were queried for English language articles from January 1990 to September 2014. Prospective and retrospective studies were included. EVIDENCE SYNTHESIS There is no published randomized controlled trial (RCT) comparing local therapy and systemic therapy to systemic therapy alone in the treatment of mPCa. Prospective studies of men with locally advanced PCa and retrospective studies of occult node-positive PCa have consistently shown the addition of local therapy to a multimodal treatment regimen improves outcomes. Molecular and genomic evidence further suggests the primary tumor may have an active role in mPCa. CONCLUSIONS Treatment of the primary tumor in mPCa is being increasingly explored. While preclinical, translational, and retrospective evidence supports local therapy in advanced disease, further prospective studies are under way to evaluate this multimodal approach and identify the patients most likely to benefit from the inclusion of local therapy in the setting of metastatic disease. PATIENT SUMMARY In this review we explored preclinical and clinical evidence for treatment of the primary tumor in metastatic prostate cancer (mPCa). We found evidence to support clinical trials investigating mPCa therapy that includes local treatment of the primary tumor. Currently, treating the primary tumor in mPCa is controversial and lacks high-level evidence sufficient for routine recommendation.

Testicular Torsion Presentation Trends before and after Pediatric Urology Subspecialty Certification

Purpose: We examined testicular torsion presentation and referral trends at our institution before and after pediatric urology subspecialty certification. Materials and Methods: We reviewed patients with testicular torsion presenting directly to our pediatric hospital emergency department (“direct”) or transferred urgently from an outside institution (“referred”) who underwent detorsion and orchiopexy or orchiectomy between 2005 and 2015. Presentations were considered acute (less than 24 hours) or delayed (24 hours or greater) based on time from symptom onset. Primary outcomes were case volume and presentation trends through time. Secondary outcomes were effect of presenting location and transport variables on orchiectomy rate. Results: Incidence of testicular torsion increased from 15 cases in 2005 to 32 in 2015. Annual incidence of direct cases increased slightly during the study period from 12 to 17, whereas incidence of referred cases increased from 3 in 2005 to 15 in 2015. Proportion of referred acute cases markedly increased from precertification (4 of 63, 6.3%) to postcertification period (42 of 155, 27.1%; p <0.01). The majority of referred cases (59 of 83, 71.1%) presented during weekday nights or weekends compared to a minority of direct cases (59 of 135, 43.7%; p <0.01). Orchiectomy rates were similar between direct and referred cases across all study periods and were not significantly impacted by presentation location, transport distance or transport modality (all p >0.05). Conclusions: Patients with testicular torsion have been increasingly referred to our institution, with the majority presenting on weekday nights and weekends. Our data do not support routinely transferring these patients to dedicated pediatric hospitals.

Factors Associated with Delayed Presentation and Misdiagnosis of Testicular Torsion: A Case-Control Study

&NA; We identified factors associated with delay in presentation and misdiagnosis of testicular torsion. Compared with acute cases, delayed presentations were more likely to report isolated abdominal pain, developmental disorders, and history of recent genital trauma. Failure to perform a genitourinary examination or scrotal imaging was associated with misdiagnosis.

Introducing the Pediatric Urology Journal Club on Twitter

The Journal of Pediatric Urology is excited to announce the Pediatric Urology Journal Club (PUJC). Beginning February 2017, JPU will sponsor monthly discussions on Twitter pertaining to peer-reviewed research articles on topics in pediatric urology. The journal club is the first of its kind in pediatric urology and one of the first in academic medicine. With PUJC, we aim to fuse the ubiquitous nature of social media, portability of open access literature, and diversity of international perspectives to drive a perpetually up-to-date educational platform to discuss literature and issues in our field. The overall concept is similar to those journal clubs at individual institutions across the world but with global participation and an online setting. PUJC will also provide a forum for international research collaboration. Twitter (twitter.com) is a free microblogging application in which users (designated with an @ symbol) communicate in140-charactermessages (tweets). Messages are publicly viewable on the internet. Twitter catalogues messages using hashtags (designated with a # symbol) for easy browsing and asynchronous communication. Twitter’s emphasis on economy of words and user-friendly interfaces for smartphones, tablets, and computers make it an ideal tool to discuss a growing body of medical literature. Australian urologist Henry Woo started the world’s first Twitter-based journal club in medicine [1]. Urologists have been at the forefront of adopting Twitter for academic purposes [2e4]. PUJC (@pedurojc) will moderate discussions on one featured peer-review journal article each month beginning the last Sunday at 5 pm Eastern Standard Time (EST) or Coordinated Universal Time (UTC) minus 5 hours (10 pm accounting for Daylight Savings). Discussion will last 48 hours, permitting seamless commentary across time zones. Using the hashtag #pedurojc, anyone with an internet account can view the discussion on Twitter, and anyone with a registered Twitter account can participate. Discussion will conclude at 5 pm EST (10 pm UTC) the following Tuesday.

Robotically assisted ureteroscopy for kidney exploration

Ureteroscopy is a minimally invasive procedure for diagnosis and treatment of urinary tract pathology. Ergonomic and visualization challenges as well as radiation exposure are limitations to conventional ureteroscopy. Therefore, we have developed a robotic system to “power drive” a flexible ureteroscope with 3D tip tracking and pre-operative image overlay. The proposed system was evaluated using a kidney phantom registered to pre-operative MR images. Initial experiments show the potential of the device to provide additional assistance, precision, and guidance during urology procedures.

Congenital infundibulopelvic stenosis: Indications for intervention, surgical technique, and review of literature.

INTRODUCTION Congenital infundibulopelvic stenosis (IFPS) is a rare renal dysmorphism marked by dilated calyces proximal to diminutive infundibulum and renal pelvises. The entity is theorized to exist on the spectrum of congenital obstructive renal diseases between ureteropelvic junction obstruction and multicystic dysplasia. OBJECTIVE This case series sought to review and present the surgical management of three cases of IFPS with progressive renal insufficiency. MATERIALS AND METHODS After Institute Review Board approval, we reviewed three cases of IFPS treated by a single surgeon over a 20-year period. All cases displayed evidence of progressive renal decline. The first case of a 16-year-old female had IFPS in a solitary kidney, with previous contralateral nephrectomy of a multicystic dysplastic kidney. The second case, a 17-year-old male, presented after blunt trauma to the ipsilateral flank. The third case of a 10-year-old female presented with microhematuria, mild azotemia and bilateral IFPS. RESULTS Our current surgical management has evolved from renal sinus exposure and multiple infundibuloplasties in the first case to preoperative three-dimensional mapping of the dilated calyceal system with intraoperative ultrasonography for selective calicocalicostomies draining to a lower pole ureterocalicostomy in the third case. Our first case, treated with multiple infundibuloplasties experienced slow renal decline into her 20s, and the later cases, treated with calicocalicostomies, have experienced stable to mild loss of renal function with ongoing nephrological follow-up. DISCUSSION IFPS is a complex pediatric urology problem without a clear treatment algorithm. The goal of surgical intervention is to offer an opportunity to halt or reduce progressive renal insufficiency. Our current surgical approach utilizes preoperative three-dimensional modeling via magnetic resonance urography to guide placement of multiple calicocalicostomies draining to a lower pole ureterocalicostomy. CONCLUSIONS Not all cases of IFPS require surgical intervention. We have intervened in cases of IFPS with progressive hydronephrosis or worsening renal insufficiency with acceptable results.

Featuring: Implications of fellowship expansion on future pediatric urologist surgical volumes.

The February Pediatric Urology Journal Club featured a look at the impact of the current number of pediatric urology fellowship training positions future case volumes [1]. Authors Travis Groth (@groth_travis), Christopher Cooper (@coopeduro) and John Kryger (@johnkryger3) joined the discussion [2]. The study employed a mathematical model to predict the effect of number of fellowship graduates on future case volume per surgeon. Using two different models, they found that the current number of pediatric urology fellowship positions will lead to a significant decrease in the case volume per surgeon. The model assumed that all fellowship positions would be filled every year, that all fellows graduate, establish their practice in the United states and devote 100% of an assumed 30-year career to pediatric urology. They also assumed that the birth rate would stay static over the next 30 years, despite data that it has been declining over past decades. All of these assumptions contribute to the limitations of the model. Given the projections in the manuscript there were concerns about the effect on surgical skills, particularly prolonging the learning curve associated with surgical skills if case volumes per surgeon decrease. However, it was noted that decreased case volumes may be seen as a positive thing for those who desire a better work-life balance.

Managing Renal Cell Carcinoma Associated Paraneoplastic Syndrome with Nephron-sparing Surgery in a Patient with von Hippel-Lindau

A patient with germline von Hippel-Lindau (VHL) gene alteration and history of multiple tumors present with classical paraneoplastic syndrome (PNS) associated with renal cell carcinoma (RCC). She underwent open nephron sparing surgery with resolution of symptoms. She remained without recurrence of RCC for the initial 2 years of her follow-up. To the best of our knowledge, this case represents the first in which PNS was specifically resolved using a partial nephrectomy in a patient with VHL. This case report provides initial evidence for the potential role of nephron sparing surgery in the management of paraneoplastic symptoms associated with hereditary RCC.

V10-12 ROBOTIC (DA VINCI XI) URETERAL REIMPLANT WITH BOARI FLAP

INTRODUCTION AND OBJECTIVES: Ureteral reimplant is most commonly performed due to trauma and oncologic disease affecting the distal ureter necessitating removal and reconstruction. The most commonly utilized procedures to aid in ureteral reimplant are the psoas hitch and the Boari bladder flap repair (BFR). Both maneuvers allow more proximal lesions to be treated with implantation instead of nephrectomy. Psoas hitch involves mobilizing the contralateral bladder attachments and securing the bladder dome to the psoas tendon of the affected side. BFR, most commonly performed in conjunction with a psoas hitch, involves incising a section of bladder, rotating it toward the affected ureter and tubularizing it for anastomosis with the remaining healthy ureter. With the open BFR first performed on humans in 1947, minimally invasive techniques have been described in recent years with similar outcomes. Recent advances in robotic technology may increase the feasibility and safety of robotic assisted laparoscopic BFR in selected patients. METHODS: We present our experience utilizing the Da Vinci Xi robotic system to perform a robotic assisted BFR. RESULTS: Our patient is a 64 year-old white male with history of high grade T1 bladder cancer who was found to have blood emanating from the left ureteral orifice on surveillance cystoscopy as well as two filling defects at the junction of the mid and distal ureter on retrograde pyelogram. Due to his baseline history of hypertension, diabetes, and marginal baseline renal function; he elected to undergo robotic left distal ureterectomy with left pelvic lymph node dissection, psoas hitch, BFR and stent placement. Intraoperative cystoscopy and ureteroscopy aided the robotic procedures, and the operation went without complication with an EBL of 200mL. At follow up visit 2 weeks post-operatively, our patient was recovering well, however, cystogram revealed a small leak. At post-operative week 3, CTUrogram and repeat cystogram revealed leak resolution, and the foley catheter was removed. Ureteral stent was removed at postoperative week 6. CONCLUSIONS: Robotic Boari bladder flap repair is safe and effective in carefully selected patients. Due to the ability to side dock the robot, the Da Vinci Xi robotic system enabled concurrent intraoperative cystoscopy and ureteroscopy. This allows for more accurate identification of the lesion and precise division of the ureter.