Geolani W. Dy

Global Burden of Urologic Cancers, 1990–2013

CONTEXT Kidney, prostate, and bladder cancers increase with age and are influenced partly by modifiable risk factors. Urological cancer rates may increase substantially amid a growing, aging population. OBJECTIVE To describe kidney, bladder, and prostate cancer incidence, mortality, and risk factor-attributable bladder and kidney cancer deaths between 1990 and 2013, by age, sex, and development status. EVIDENCE ACQUISITION Cancer mortality data were derived from global vital registries. Incidence data from cancer registries were transformed to mortality estimates using separately estimated mortality incidence ratios. These sources served as input data for an ensemble modeling approach to estimate bladder, prostate, and kidney cancer mortality. Cause-specific mortality estimates were transformed into incidence estimates using mortality incidence ratios. EVIDENCE SYNTHESIS In 2013, 2.1 million kidney, bladder, and prostate cancers cases occurred worldwide, increasing 2.5-fold since 1990. Mortality increased 1.6-fold between 1990 and 2013. Eight-two percent of new cases in 2013 occurred in individuals aged 60 yr and older. Men from developed countries had the highest age-standardized death rates among all three cancers. Smoking-attributable kidney cancer deaths decreased while obesity-related deaths rose, most prominently in women from developing countries. Smoking-related bladder cancer deaths increased among women from developed countries and decreased among men. CONCLUSIONS Urologic cancer burden has increased globally amid population growth and aging. High income countries face the highest incidence and death rates; however, obesity-attributed kidney cancer deaths are increasing in developing countries. Efforts to expand the global oncologic workforce and reduce preventable factors may lessen cancer disparities in developing countries. PATIENT SUMMARY We describe the impact of population growth, aging, and lifestyle factors such as smoking and obesity, on kidney, bladder, and prostate cancer rates worldwide. More new cancer cases and deaths occur in developed countries compared with developing countries. In addition to preventive efforts, healthcare systems must emphasize training of a urologic oncology workforce.

Transgender-Related Education in Plastic Surgery and Urology Residency Programs

BACKGROUND With increasing public awareness of and greater coverage for gender-confirming surgery by insurers, more transgender patients are likely to seek surgical transition. The degree to which plastic surgery and urology trainees are prepared to treat transgender patients is unknown. OBJECTIVE We assessed the number of hours dedicated to transgender-oriented education in plastic surgery and urology residencies, and the impact of program director (PD) attitudes on provision of such training. METHODS PDs of all Accreditation Council for Graduate Medical Education-accredited plastic surgery (91) and urology (128) programs were invited to participate. Surveys were completed between November 2015 and March 2016; responses were collected and analyzed. RESULTS In total, 154 PDs (70%) responded, and 145 (66%) completed the survey, reporting a yearly median of 1 didactic hour and 2 clinical hours of transgender content. Eighteen percent (13 of 71) of plastic surgery and 42% (31 of 74) of urology programs offered no didactic education, and 34% (24 of 71) and 30% (22 of 74) provided no clinical exposure, respectively. PDs of programs located in the southern United States were more likely to rate transgender education as unimportant or neutral (23 of 37 [62%] versus 39 of 105 [37%]; P = .017). PDs who rated transgender education as important provided more hours of didactic content (median, 1 versus 0.75 hours; P = .001) and clinical content (median, 5 versus 0 hours; P < .001). CONCLUSIONS A substantial proportion of plastic surgery and urology residencies provide no education on transgender health topics, and those that do, provide variable content. PD attitudes toward transgender-specific education appear to influence provision of training.

Successful pregnancy in patients with exstrophy-epispadias complex

INTRODUCTION With advances in genitourinary reconstructive surgery, women with exstrophy-epispadias complex (EEC) have improved health and quality of life, and may reach reproductive age and consider pregnancy. Despite literature suggesting impaired fertility and higher risk with pregnancy, childbirth is possible. Medical comorbidities, including müllerian anomalies, contribute to increased risk of obstetric and urologic complications during pregnancy. OBJECTIVES We reviewed our experience with EEC patients who achieved pregnancy to investigate (1) urological characteristics of women who achieved pregnancy; (2) pregnancy management, complications, and delivery; and (3) neonatal outcomes. We developed recommendations for managing pregnancy in women with EEC. STUDY DESIGN/RESULTS This was a retrospective chart review of 36 female patients with EEC seen at our institution between 1996 and 2013. Female patients less than 18 years, and patients who did not have documented pregnancy were excluded. This resulted in a total of 12 patients with 22 pregnancies. All women with successful pregnancy had bladder exstrophy. The majority had undergone prior bladder augmentation (75%) and were on self-catheterization programs (92%). Thirty-six percent had symptomatic urinary tract infections (UTIs) during pregnancy. Five women had more than one pregnancy. There were four terminations of pregnancy. Of 18 desired pregnancies, there were four spontaneous abortions (SABs) (22%) and 16 live births (78%). The cesarean delivery (CD) rate was 100% (14/14), of which the majority were vertical (classical) uterine incisions with a paramedian skin incision. With the exception of one patient, there were no CD surgical complications. The mean gestational age at delivery was 36 weeks (Range 25 4/7 to 39 4/7 weeks) among eight pregnancies with known gestational age. There were no stillbirths, one neonatal death and no birth defects. DISCUSSION Women with EEC can have successful pregnancies, though at increased risk for preterm delivery and SABs. In our cohort, the rate of SAB is similar to that described in prior studies. Symptomatic UTIs likely due to self-catheterization were common. Cesarean delivery using a paramedian skin incision and classical uterine incision were not associated with major complications in this cohort. Limitations include reliance on retrospective data and small sample size. The strength of this study is the longitudinal detailed management of pregnancies in EEC women by a single team over time. A multidisciplinary approach to providing a continuum of care from pediatrics through adolescence to adulthood optimizes successful transitions, reproductive health, and successful pregnancies. Based on our experience, an algorithm providing guidance for pregnancy management was developed.

Variable Resource Utilization in the Prenatal and Postnatal Management of Isolated Hydronephrosis

OBJECTIVE To characterize contemporary resource utilization and medical outcomes for infants with antenatal hydronephrosis and their mothers from a national claims database. We hypothesize that management of isolated hydronephrosis (IHN) varies widely, with decreased imaging following the 2010 Society for Fetal Urology Consensus Statement. MATERIALS AND METHODS Using MarketScan claims from 2007 to 2013, we identified infants 0-12 months of age with hydronephrosis and linked mothers. Those with urologic diagnoses more specific than hydronephrosis, additional urologic comorbidities, or postnatal surgeries were excluded. Resource utilization including prenatal and postnatal imaging, laboratory studies, hospital admissions, and medical outcomes within the first year was captured. Demographics, maternal characteristics, utilization measures, and outcomes were compared across imaging intensity groups based on number of postnatal ultrasounds received using bivariate analysis. RESULTS Among 801,919 mother-child pairs, 8610 infants (1.1%) had hydronephrosis or a related diagnosis. A total of 5876 (68.2%) met inclusion criteria for IHN. Patients underwent a mean 5.3 ± 3.5 prenatal and 2.1 ± 1.3 postnatal ultrasounds before age 1. Imaging practices were unchanged following the Society for Fetal Urology consensus statement. CONCLUSION Antenatal hydronephrosis prevalence in an insured population is consistent with published ranges. Prenatal imaging in IHN is variable and potentially excessive. Future study into the efficacy of evidence-based pathways in reducing excess utilization is warranted.

Neonatal Circumcision and Urinary Tract Infections in Infants With Hydronephrosis

Using an employer-based insurance data set, we describe in this study the association of circumcision with UTIs within 1 year of life in infants with hydronephrosis. BACKGROUND: Boys with urinary tract abnormalities may derive a greater benefit from newborn circumcision for prevention of urinary tract infection (UTI) than the general population. However, the effect of newborn circumcision on UTI is not well characterized across the etiological spectrum of hydronephrosis. We hypothesized that boys with an early diagnosis of hydronephrosis who undergo newborn circumcision will have reduced rates of UTI. METHODS: The MarketScan data set, an employer-based claims database, was used to identify boys with hydronephrosis or hydronephrosis-related diagnoses within the first 30 days of life. The primary outcome was the rate of UTIs within the first year of life, comparing circumcised boys with uncircumcised boys and adjusting for region, insurance type, year of birth, and infant comorbidity. RESULTS: A total of 5561 boys met inclusion criteria, including 2386 (42.9%) undergoing newborn circumcision and 3175 (57.1%) uncircumcised boys. On multivariate analysis, circumcision was associated with a decreased risk of UTI in both boys with hydronephrosis and healthy cohorts: odds ratio (OR) 0.36 (95% confidence interval [CI] 0.29–0.44) and OR 0.32 (95% CI 0.21–0.48), respectively. To prevent 1 UTI, 10 patients with hydronephrosis would have to undergo circumcision compared with 83 healthy boys. Among specific hydronephrosis diagnoses, circumcision was associated with a reduced risk of UTI for those with isolated hydronephrosis (OR 0.35 [95% CI 0.26–0.46]), vesicoureteral reflux (OR 0.35 [95% CI 0.23–0.54]), and ureteropelvic junction obstruction (OR 0.35 [95% CI 0.20–0.61]). CONCLUSIONS: Newborn circumcision is associated with a significantly lower rate of UTI among infant boys with hydronephrosis.

Reconstructive Management Pearls for the Transgender Patient

Purpose of ReviewA growing number of transgender patients are seeking gender-affirming genital reconstructive surgery (GRS). These complex procedures have high complication rates. We describe common surgical pitfalls in GRS and approaches for minimizing complications.Recent FindingsPenile inversion vaginoplasty has been associated with excellent cosmetic and functional outcomes. A robotic-assisted dissection may minimize risk of rectal injury. As a younger transgender population chooses pubertal suppression, alternative sources for lining the vaginal canal, such as enteric vaginoplasties, may be more widely utilized. Since adoption of microvascular techniques in phalloplasty, transmasculine individuals have potential for a sensate neophallus and penetrative intercourse. Urethral complications are common and challenging to manage; techniques using flap coverage may minimize ischemia-related strictures. Innovations in prosthesis placement require adaptations to neophallus anatomy.SummaryA growing number of transgender individuals are seeking genital reconstruction. Ongoing innovation in surgical technique is needed to improve patient outcomes.

MP61-14 EFFECT OF NEWBORN CIRCUMCISION ON URINARY TRACT INFECTIONS IN PATIENTS WITH AN EARLY DIAGNOSIS OF HYDRONEPHROSIS.

pediatrics), patient demographics, VCUG outcome, and guideline adherence were evaluated with bivariate statistics and logistic regression. Subgroup analysis of patients 2-24 months was completed. RESULTS: VCUGs from 1,115 consecutive patients were reviewed. 747 patients were excluded (243 for known genitourinary anomalies, 262 for known VUR, 171 for antenatal hydronephrosis without UTI, and 71 for incomplete records). 368 patients (67% female, median age 12.5 months [range 4.6-49]) were included in the primary analysis. 188 patients (51%) were aged 2-24 months. VCUG ordering patterns were similar among urologists and nephrologists (35% of VCUGs) and among pediatricians and other specialists (65% of VCUGs). Thus, these specialties were grouped for analysis. 61% of VCUGs were ordered in accordance with the 2011 AAP guidelines; urologists/nephrologists were more likely to adhere to ordering guidelines than pediatricians/other specialists (76% vs 52%, OR 2.93 [1.8-4.7], p<0.0001). Subgroup analysis in patients 2-24 months revealed similar findings (76% vs 52%, OR 3.0 [1.5-6.1], p1⁄40.002). VCUGs were abnormal in 117/368 patients (32%) overall and 49/188 (26%) patients 2-24 months. Guideline adherence was associated with increased likelihood of abnormal VCUG among all patients (36% of appropriately ordered vs. 25% of inappropriately ordered studies were abnormal, p1⁄40.03), but there was no association in patients 2-24 months (26% of studies were abnormal in each group, p1⁄40.98). CONCLUSIONS: At our institution, 2011 AAP UTI guideline adherence for VCUG ordering was more likely among urologists/nephrologists than pediatricians. While adherence increased the diagnostic yield of VCUG studies in the full cohort, there was no association in children 2-24 months. Further multi-center evaluation is necessary to determine whether ordering recommendations should be revised.

Prosthetic Considerations in Neophallic Reconstruction

Purpose of ReviewPhalloplasty may be performed in patients with acquired or congenital penile insufficiency or transgender individuals who desire phallic construction. Demand for neophallus creation and prosthesis placement has increased in recent years with growing coverage for gender affirming surgery among transgender patients. This report describes consideration of prosthetic implantation in neophallic reconstruction. Recent FindingsProsthesis implantation in a neophallus requires special consideration regarding avoidance of critical structures, proximal prosthesis anchoring, and distal cushioning in patients without native corpora cavernosa. Neophallus prostheses are associated with increased risk of infection, extrusion, erosion, and device migration relative to standard prostheses, with a high revision rate.SummaryImplanters should have a thorough understanding of neophallic reconstructive technique prior to proceeding with device placement. Current literature on this subject consists predominantly of retrospective reviews and case reports with variable outcome measures. The creation of validated assessment tools will provide more meaningful data to inform provider counseling and patient expectations.