John M. DiBianco

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.

Ultrasound Guided, Freehand Transperineal Prostate Biopsy: An Alternative to the Transrectal Approach

Introduction There is growing interest in the use of transperineal prostate biopsy due to the advantages of decreased infection risk and improved cancer detection rates. However, brachytherapy stepper units and templates may increase costs and operative time for the practicing urologist. We present the safety, feasibility and early outcomes of a single urologists experience with ultrasound guided freehand transperineal prostate biopsy as an alternative to transrectal ultrasound guided biopsy. Methods A retrospective review of all prospectively performed ultrasound guided freehand transperineal prostate biopsies between January 1, 2012 and April 30, 2014 was performed. Primary outcome measurements were safety and feasibility. Results A total of 274 ultrasound guided freehand transperineal prostate biopsies were performed in 244 patients. Operative and total operating room use times were 7.9 and 17.5 minutes, respectively, with an average of 14.4 cores obtained during each procedure. The overall cancer detection rates for all procedures, those in biopsy naïve patients and those performed for active surveillance were 62.8%, 56.4% and 89%, respectively. New diagnoses of prostate cancer occurred in 41.2% of patients with 10% positive after a previous negative transrectal ultrasound guided biopsy. Complications (Clavien grade I or greater) including systemic infection, urinary retention and hematuria or pain requiring physician or hospital intervention did not occur. Conclusions The use of ultrasound guided freehand transperineal prostate biopsy for the suspicion or surveillance of prostate cancer is feasible and safe. The results were encouraging with respect to the primary outcome measurements. Ultrasound guided freehand transperineal prostate biopsy with the patient under local anesthesia is currently under investigation. Large, prospective, randomized, multiple operator studies to evaluate the comparative effectiveness of freehand transperineal prostate biopsy and transrectal ultrasound guided biopsy techniques are recommended.

The impact of radical cystectomy and urinary diversion on suicidal death in patients with bladder cancer

PURPOSE: Compared to the general population, suicide is more common in the elderly and in patients with cancer. We sought to examine the incidence of suicide in patients with bladder cancer and evaluate the impact of radical cystectomy in this high-risk population. METHODS: Patients diagnosed with urothelial carcinoma from 1988 to 2010 were identified in the Survey, Epidemiology, and End Results (SEER) database. Contingency tables of suicide rates and standardized mortality ratios (SMRs) and 95% confidence intervals were calculated. Multivariable logistic regression models were performed to generate odds ratios (ORs) for the identification of factors associated with suicide in this population. RESULTS: There were 439 suicides among patients with bladder cancer observed for 1,178,000 person-years (Standard Morbidity Ratio [SMR] = 2.71). All demographic variables analyzed had a higher SMR for suicide compared to the general population, in particular age ≥80 years (SMR = 3.12), unmarried status (SMR = 3.41), and white race (SMR = 2.60). The incidence of suicide was higher in the general population for patients who underwent radical cystectomy compared to those who did not (SMR = 3.54 vs SMR = 2.66). On multivariate analysis, the strongest predictors of suicide were male gender (vs female; OR = 6.63) and distant disease (vs localized; OR = 5.43). CONCLUSIONS: Clinicians should be aware of risk factors for suicide in patients diagnosed with bladder cancer, particularly older, white, unmarried patients with distant disease, and/or those who have undergone radical cystectomy. A multidisciplinary team-based approach, including wound ostomy care trained nursing staff and mental health care providers, may be essential to provide care required to decrease suicide rates in this at-risk population.

Suicide Risk in Patients With Bladder Cancer: A Call to Action.

Suicide prevention represents a unique challenge for health care providers. Many of those who commit suicide have a physical illness that may contribute to suicidal ideation, and reports suggest that a cancer diagnosis doubles suicide rates. 4 Our study in the current issue of Journal of Wound, Ostomy and Continence Nursing specifi cally delineated the impact of radical cystectomy on suicidal death in patients with bladder cancer. We found there was a trend toward increased suicide rates in all age groups, with the greatest risk in patients older than 70 years. The impact of age and suicide in these patients is important when you consider that both suicide and bladder cancer are more prevalent in older patients. Patients with bladder cancer were also found to have an increased risk of suicide at any time after diagnosis, highlighting the morbidity associated with intervention and potential psychological distress associated with disease surveillance and followup. Other demographic factors associated with an increased risk of suicide for patients with bladder cancer included white race, male gender, and single marital status. Of particular interest to WOC nurses, we found that patients with bladder cancer who underwent radical cystectomy were at higher risk for suicide compared to patients who did not undergo surgical intervention. In addition to the stress of a cancer diagnosis, patients who require a radical cystectomy often undergo weeks of neoadjuvant chemotherapy. Furthermore, radical cystectomy patients will have concomitant urinary diversion that their daily habits, whether the urinary diversion is an orthotopic neobladder, continent cutaneous diversion, or Benjamin T. Harper, BS , Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta. Zachary Klaassen, MD, Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta. John M. DiBianco, MD, Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta. Grace Yaguchi, BS, Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta. Rita P. Jen, MD, MPH, Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta. Martha K. Terris, MD, Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta. The authors declare no confl icts of interest. Correspondence: Zachary Klaassen, MD, Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, 1120 15th St, Augusta, GA 30912 ( zklaassen@gru.edu ). Suicide Risk in Patients With Bladder Cancer A Call to Action

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.

Contract Costs Associated with Maintaining Flexible Ureteroscopes: A Single Center Experience

Introduction: We compared the cost of flexible ureteroscope processing and maintenance contracts offered by a scope manufacturer and a third‐party company. Methods: Use and repairs of the Storz 11278AU1 Flex X2 Flexible Ureteroscope are prospectively recorded at our large, 371‐bed, acute care hospital. A retrospective analysis of the processing of ureteroscopic instruments during a 3‐year period (2011 to 2013) was completed. We compared the handling of ureteroscopes between 1 year under a third‐party contractor (Integrated Medical Systems International, Inc. [IMS]) and 2 prior years under the manufacturer (KARL STORZ) contract. Results: From January 1, 2011 through October 1, 2012 our institution used the manufacturer for the processing of ureteroscopic instruments. From January 1, 2013 through December 9, 2013 our institution used the third‐party contractor IMS for repairs. The number of procedures performed per repair/exchange during the manufacturer contract was 19.9 and the number of procedures performed per repair/exchange during the third‐party contract was 11. The third‐party contract resulted in a reduction of procedures performed per repair/exchange by 52%. Adjusted for inflation, the yearly cost of ureteroscope repairs was

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

125,715 during the manufacturer contract and

MP04-13 VALIDATION OF THE PROSTATE CANCER PREVENTION TRIAL RISK CALCULATOR 2.0 IN MULTIPARAMETRIC MRI ERA

158,040 during the third‐party contract. By analyzing the costs incurred in 2013, if our institution had maintained the manufacturer contract for all 3 years, the estimated repair cost would have resulted in a savings of

Metabolic Syndrome and Nephrolithiasis Risk: Should the Medical Management of Nephrolithiasis Include the Treatment of Metabolic Syndrome?

32,325. Conclusions: Using the manufacturer repair contract is more cost‐effective than using that of third‐party companies.

MP53-14 COST EFFECTIVENESS OF MAGNETIC RESONANCE/ULTRASOUND FUSION PROSTATE BIOPSY VS STANDARD OF CARE (TRANSRECTAL ULTRASOUND (TRUS)-GUIDED BIOPSY)

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.