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We reviewed and analyzed the most effective methods to reduce infectious complications (IC) after transrectal prostate biopsy (TRPB). We included only prospective randomized-controlled trials in the analysis. The analysis neither demonstrated any superiority of fluoroquinolones over other antibiotic classes nor of targeted antibiotics over empiric regimens in men undergoing TRPB. However, longer course antibiotics (3 days or more) compared to single dose or day regimens, combination of fluoroquinolones with aminoglycosides compared to fluoroquinolones alone and povidone-iodine rectal cleansing compared to control significantly reduced IC following TRPB. A combination of addition of aminoglycosides to oral antibiotics for 3 days along with povidone-iodine rectal cleansing may be an optimum strategy to minimize the risk of IC after TRPB.

Objective To evaluate the clinical features, pathologic features, and prevalence of human papilloma virus (HPV) in squamous cell carcinoma (SCC) of the bladder. SCC of the bladder is known to be associated with conditions that cause chronic inflammation/irritation. The literature is inconsistent regarding the association of HPV with pure SCC of the bladder. Methods A multi-institutional study identified cases of SCC of the bladder. Pure squamous histology and the absence of urothelial carcinoma in situ were required for inclusion. Clinical and pathologic features were collected, and tissues were evaluated for high-risk HPV using p16 immunohistochemistry and in situ hybridization. Results We identified 207 cases of SCC of the bladder. Risk factors for bladder cancer included smoking (133/207, 64%) and chronic bladder irritation (83/207, 40%). The majority (155/207, 75%) of patients had > pT2 disease. Mean tumor size was 5.6 ± 3.0 cm and 36/207 (17%) patients had lymph node positive disease. p16 immunohistochemistry was positive in 52/204 (25%) cases but high-risk HPV was identified with in situ hybridization in only 1 (0.5%) case. Tumor size, stage, number of lymph nodes removed, number of positive lymph nodes, lymphovascular invasion, perineural invasion, and positive margins each were associated with cancer-specific mortality when adjusted for demographic factors. A multivariate analysis of variable importance further revealed sex and race as important factors in predicting cancer-specific mortality. Conclusion SCC of the bladder is an aggressive histologic subtype. Although bladder SCC can express p16, it is not typically associated with high-risk HPV, although rare cases can occur.

Objective To examine urologic transfers and rate of tertiary center interventions from 4 geographically distinct academic medical centers. Methods Four academic medical centers were selected for this study including Baylor College of Medicine, University of Alabama at Birmingham, University of Kentucky, and University of Pennsylvania Hospital (Penn). Baylor College of Medicine and Penn primarily service large metropolitan city centers and University of Kentucky and University of Alabama at Birmingham primarily service large rural populations. Transfer logs were pulled for each institution over a 2-year period, and a retrospective chart review was performed to evaluate transfer diagnosis and need for procedural management upon admission. Date of transfer, transfer diagnosis, and interventions performed during tertiary center admission were extracted from the transfer log data sets. The transfer diagnosis was categorized into 1 of 11 mutually exclusive categories. Results Overall, 984 urologic transfers were included. Sixty-nine percent (682/984) of patients were transferred to the 2 rural centers, and 30.7% (302/984) were transferred to the 2 metropolitan centers. The most common reason for transfer was nephrolithiasis at 26% (256 of 984 transfers). The overall surgical intervention rate for all urologic transfers in this study was 44.4% (437 of 984 total transfers). Rural center transfers had a lower rate of surgical intervention than metropolitan centers (42.7% vs 48.3%) as well as a markedly higher number of total transfers during the study period (682 vs 302). Conclusion Given that a majority of patients did not require surgical intervention, methods for avoiding unnecessary urologic transfers are warranted.

Objective To determine what factors of published urology research articles are associated with future citations. Methods We identified all primary research articles published between 1997 and 2007 in Journal of Urology, British Journal of Urology International, Urology, and European Urology. Only 50 articles in this period had accrued 0 or 1 citation in a 10-year period following publication. We compared the characteristics of the articles in the low citation cohort to the 50 articles with the highest number of citations from the same journals and time period. Student's t tests, Wilcoxon rank-sum tests, chi-squared tests, and Fisher's exact tests were used to analyze the data with predetermined level of significance set to P Results There were many significant differences between the 2 cohorts. When compared to the cohort of articles with 0 or 1 citation, highly cited articles were significantly more likely to be a clinical study, multi-institutional and multinational effort, and related to the field of urologic oncology. They were also significantly more likely to have a larger sample size, a statistically significant primary finding, more authors, more references, and more tables, as well as longer title, abstract, and overall manuscript word counts. Conclusion Very few articles published in the major urology journals accrued 0 or 1 citation over a 10-year period. This suggests that the vast majority of articles selected for publication are used for further future research. Nevertheless, there were distinct differences between the 2 cohorts, showing that certain factors are associated with articles being cited more frequently.

Most renal masses in the United States are incidentally detected via abdominal imaging. This has led to an increase in the incidence of small renal masses (≤4 cm). Active surveillance is, an oncologically safe option in slow growing and indolent tumors in other organs and has recently become more widely studied in small renal masses. For selected patients, particularly those who harbor significant comorbidities, active surveillance is a safe option for small renal masses. Renal biopsy may be helpful in the decision making process, but remains an optional component for the active surveillance of small renal masses.

Phosphatase and tensin homolog (PTEN) and ETS-related gene (ERG) mutations are commonly found in prostate cancer. Although mouse studies have demonstrated that PTEN and ERG cooperatively interact during tumorigenesis, human studies examining these genes have been inconclusive. A systematic PubMed search including original articles assessing the pathogenesis of PTEN and ERG in prostate cancer was performed. Studies examining ERG's prognostic significance have conflicting results. Studies examining PTEN and ERG simultaneously found these genes are likely to occur together, but cooperative tumorigenesis functions have not been conclusively established. PTEN mutations are associated with a range of prognostic features. However, the practical clinical utility of this information remains to be determined.

Objective To investigate clear cell papillary (CCP) renal cell carcinoma (RCC), an uncommon tumor of low malignant potential characterized by low-grade, clear cells, showing papillary and tubular architecture. This relatively newly described entity is still being characterized. We present our series of CCP RCC with new clinical and imaging findings. Materials and Methods We reviewed the clinical, pathologic, and imaging findings of 28 CCP RCCs in 21 patients identified from our institution between 2010 and 2016. Results Sixteen of 21 (76%) patients were African American with an equal male-to-female ratio. Mean follow-up was 26.1 ± 16.9 months. Mean age at diagnosis was 58.3 ± 10.7 years, and mean preoperative creatinine was 2.7 ± 2.9 mg/dL. End-stage renal disease or chronic kidney disease was present in 10 of 21 (47.6%) patients. Mean tumor size was 2.2 ± 1.5 cm. All cases were stage pT1, and 25 of 28 (89%) tumors were grade 2. No necrosis or sarcomatoid features were identified. Two patients had synchronous clear cell RCC and 1 patient had synchronous papillary RCC. No recurrence or metastases were identified. On imaging, the majority of the lesions were solid, with relatively low-level enhancement, similar to papillary RCC, with regions of heterogeneous hyper-enhancement, similar to clear cell RCC. The rate of growth on serial imaging was comparable with that observed for other low-staged RCCs. Conclusion In our series, CCP RCC was seen more commonly in African American patients and associated with end-stage renal disease or chronic kidney disease. Imaging characteristics are similar in both clear cell RCC and papillary RCC. A nephron-sparing approach is recommended when surgically feasible.

Objective To identify risk factors for urologic reconstruction during surgery for endometriosis. Patients and Methods We retrospectively identified patients in a surgical pathology database undergoing surgery for endometriosis at our institution from 2010 to 2015 and subsequently identified those patients with ureteral involvement. Patients were categorized as requiring minimal urologic surgery (eg, ureterolysis only) or more extensive urologic surgery (eg, ureteral reimplant). All patients were undergoing surgery for endometriosis, and preoperative risk factors were then identified to predict the need for intraoperative extensive urologic surgery. Results Of 386 women undergoing surgery for endometriosis, 82 (21%) women required a surgical procedure on the ureter. Fifteen of these 82 patients (18.3%) with ureteral involvement required urologic surgical expertise in the form of either ureteral reimplantation with or without psoas hitch, or ureterolysis with ureteral stenting or omental wrap. The remaining 67 underwent ureterolysis alone or no intervention. The presence of flank pain, any urinary symptom, or hydronephrosis on preoperative imaging was a significant predictor of the need for major urologic intervention. Conclusion In patients with endometriosis undergoing surgery who complain of flank pain, any urinary symptom, or have hydronephrosis on preoperative imaging, one should have a high suspicion for needing to perform urologic reconstruction during surgery. Planning for this additional operation can afford the opportunity for appropriate urologic consultation and patient counseling.

Objective To determine if article Altmetric scores correlate with journal impact factor and citation count in the urologic literature. Methods We identified the top 10 most-cited articles for the 15 urology journals with the highest impact factor in 2013 and 2016. Citation count and Altmetric scores were recorded for each of the articles. The journal impact factor and date of Twitter account development were recorded for each of the journals. The variables were analyzed in Microsoft excel using Pearson's correlation testing. Results A total of 300 articles were analyzed. In 2013, Altmetric scores and citation number showed a significant positive correlation (r = 0.164, P = .045), although Altmetric scores did not correlate with journal impact factor (r = 0.005, P = .957). In 2016, there was significant positive correlation between Altmetric scores and citation number (r = 0.268, P = .0009), as well as between Altmetric scores and journal impact factor (r = 0.201, P = .014). The total citation count decreased from 15,235 in 2013 to 8622 in 2016 while the total Altmetric score increased from 1135 in 2013 to 2563 in 2016. Older Twitter accounts were not associated with increasing correlations between Altmetric score and bibliometrics in either 2013 (r = 0.221, P = .54) or 2016 (r = 0.083, P = .819). Conclusion At this point in time, Altmetric score is only weakly correlated with citation counts in the urology literature. Altmetrics and traditional bibliometrics should be viewed as complements to one another rather than surrogates when determining research dissemination and impact.

To investigate whether presence of multifocality on multi-parametric magnetic resonance imaging would increase the likelihood of detecting clinically-significant prostate cancer in a PI-RADS 4 lesion.We identified patients with at least 1 PI-RADS 4 lesion who underwent multi-parametric magnetic resonance imaging-ultrasound fusion prostate biopsy. Patients were grouped into 1 of 4 cohorts-cohort 1 (a PI-RADS 4 index lesion and an additional PI-RADS 2 or 3 lesion), cohort 2 (single lesion with PI-RADS 4), cohort 3 (2 or more PI-RADS 4 lesions), or cohort 4 (a PI-RADS 4 lesion and an index lesion with PI-RADS 5). We compared the rate of grade group (GG) ≥ 2 pathology on targeted biopsy of PI-RADS 4 lesions between cohorts and evaluated clinical and radiological factors associated with cancer detection.The overall rate of GG ≥ 2 pathology in the PI-RADS 4 lesions was 35.2%. The rate of GG ≥ 2 pathology in the cohorts 1, 2, 3, and 4 was 21.7%, 36.3%, 49.1%, and 42.7%, respectively (P.001). On multivariable analysis, age (OR1.06, P.001), clinical stage T2 (OR1.59, P= .03), prostate-specific antigen density (OR1.43, P.001), peripheral zone lesion (OR1.62, P = .04), and study cohort (cohort 2 vs 1, OR1.93, P = .006; and cohort 3 vs 1, OR3.28, P.001) were significantly associated with the risk of GG ≥ 2 in the PI-RADS 4 lesion.On targeted biopsy of the PI-RADS 4 lesions, the proportion of GG ≥ 2 pathology is approximately 35%. Rate of GG ≥ 2 detection in PI-RADS 4 lesions might differ based on their location, multifocality, and PI-RADS classifications of other lesions identified.

BACKGROUND Renal hilar clamping during a robotic partial nephrectomy is essential for a successful, nephron-sparing tumor resection. Standard robotic bulldog clamps are modified to accommodate multiport robotic surgical systems with alterations including knobs to fit robotic forceps and reduced spring tension. Despite the lower spring tension, a standard robotic bulldog clamp cannot be loaded and opened using one Single Port robotic arm. The angled path instrument cables take through multiple robotic arm articulations lowers the maximum force generated by Single Port instruments to below what is necessary to load and open a robotic bulldog clamp. OBJECTIVE To share institutional knowledge gained regarding safe and efficient hilar clamp placement and removal using the da Vinci Single Port Surgical System with a standard robotic bulldog clamp. As the da Vinci Single Port system gains wider use, knowledge of this technique will reduce surgeon trial-and-error during first experiences using the Single Port system with bulldog clamps. MATERIAL Video obtained during two partial nephrectomies, da Vinci Single Port Surgical System, Scanlan Reliance 25 mm curved robotic bulldog clamp, Final Cut Pro video editing software. RESULTS A controlled sequence of steps for renal hilar clamping and subsequent clamp removal using a standard robotic bulldog clamp with the da Vinci Single Port Surgical System. CONCLUSION The demonstrated technique for intracorporeal loading, opening, and placement of a standard robotic bulldog clamp using the da Vinci Single Port Surgical System is feasible and efficient.

OBJECTIVES: To determine if MRI/ultrasound fusion-targeted prostate biopsy (TB) would lead to increased recommendations of aggressive radiotherapy treatments for higher risk prostate cancer compared to systematic biopsy (SB) results. METHODS: Clinicopathologic data of 533 men who underwent both TB and SB from 2014-2017 was analyzed. TB was performed in addition to SB in patients with detection of MRI suspicious lesions. Three patient cohorts were established: (1) biopsy naïve (80/533,15.0%), (2) active surveillance (185/533,34.7%), and (3) prior negative biopsy (268/533,50.3%). Cancer risk categorical criteria were established with recommended radiotherapy treatment for each. Variation of risk classification due to biopsy method for all patients and within each cohort were analyzed using either a chi-squared statistic or Fisher’s Exact test. McNemar’s pairwise analyses were performed for all risk categories between TB and SB to assess the effects of TB on high-risk cancer identification and subsequent radiotherapy recommendations. RESULTS: Number of patients within cancer risk categories (1.“No Cancer or Low-Risk”; 2.“More Favorable Intermediate-Risk”; 3.“Less Favorable Intermediate-Risk”; 4.“High-Risk”) varied significantly based on TB and SB pathology among all patients combined(p

Objective To present our experience with laparoscopic partial nephrectomy (LPN) for hilar tumors and evaluate intermediate oncologic and renal functional outcomes. Materials and Methods A retrospective review of LPN cases performed in 488 patients was performed. Hilar lesions were defined as renal cortical tumors in direct physical contact with the renal artery, vein, or both, as identified on preoperative imaging and confirmed intraoperatively. The clinicopathologic parameters, perioperative course, complications, and oncologic and 6-month renal functional outcomes were analyzed. Results A total of 488 patients underwent LPN, of which 43 were hilar. The mean tumor size for hilar and nonhilar tumors was 3.6 cm and 3.1 cm, respectively. The mean operative time was shorter for hilar as compared with nonhilar tumors (129.1 minutes vs 141.8 minutes). Mean estimated blood loss was greater in LPN for hilar tumors (311.65 mL vs 298.4 mL). There were no statistically significant differences noted in any of the perioperative parameters investigated despite a higher nephrometry complexity score in the hilar group. Change in estimated glomerular filtration rate at 6 months showed a decrease of 10.9 mL/min and 8.8 mL/min for hilar and nonhilar tumors, respectively ( P = NS). There was 1 recurrence detected in the hilar group, with a median follow-up of 41.6 months. Conclusion In the hands of an experienced laparoscopist, LPN can safely be performed for hilar tumors, with preservation of perioperative outcomes and durable renal functional and oncologic outcomes.

Objective To report an international, multi-institutional series of laparoendoscopic single-site pyeloplasty (LESS-P) with analysis of functional outcomes. Materials and Methods LESS-P cases performed between October 2007 and June 2012 at 7 institutions worldwide per individual institutional protocols, entry criteria, and techniques were included. Patient characteristics, operative indications, perioperative outcomes, and postoperative follow-up were retrospectively collected and analyzed. Results The study included 140 adult patients (age 39.9 ± 15.7 years; body mass index 24.8 ± 4.2 kg/m 2 ; 15% with previous abdominal surgery) who underwent unilateral LESS-P, most of whom (94.3%) had dismembered reconstructions. Mean operative time was 202.1 ± 47 minutes with an estimated blood loss of 61.2 ± 44.6 mL. Robotic laparoendoscopic single-site surgery was applied in 31 patients (22.1%). A single 2-3 mm accessory port was used in 44 patients (31.4%) and a single 5-12 mm accessory port was added in 9 patients (6.4%), whereas 10 patients (7.1%) were converted to conventional multiport laparoscopy. No patients required conversion to open surgery, nor were any intraoperative complications reported. Length of hospitalization was 2.4 ± 1.6 days. The overall 90-day postoperative complication rate was 18.6%, mostly low-grade complications (Clavien I-II). With a mean follow-up of 14.0 ± 10.8 months, 93.4% had resolution of symptoms and 94.4% had radiographic evidence demonstrating resolution of ureteropelvic junction obstruction. Assessment of drainage with diuretic nuclear renal scan provided evidence of improvement in 86.5% of patients on their first postoperative renal scan. Conclusion This study highlights the most comprehensive experience with LESS-P reported to date. Outcome measures parallel those of large published series of conventional laparoscopic pyeloplasty. Despite these encouraging findings, longer follow-up is needed to determine the efficacy and durability of this approach for the treatment of ureteropelvic junction obstruction.

The introduction of widespread prostate-specific antigen screening brought about an increase in the detection of clinically low-risk prostate cancer. Many of these patients are overtreated by radical prostatectomy and radiation. Comparatively, focal therapy for prostate cancer offers the advantage of decreased rates of incontinence and impotence. The 12-core extended sextant transrectal ultrasound-guided needle biopsy is unable to safely identify candidates for focal therapy. Multiparametric magnetic resonance imaging (MRI) and MRI/ultrasound fusion-guided biopsy can detect more clinically significant prostate cancers and aid in accurate detection of higher-grade disease. MRI/ultrasound fusion-guided prostate biopsy is recommended as a modality of choice for selection of patients for focal therapy.

Objective To review the diagnosis and management of nephrogenic adenoma (NA), an uncommon benign lesion found in the urinary tract. This lesion arises from a proliferation of implanted renal tubular cells. Although more common in adults, it can occur in all ages. NAs can recur and cause significant morbidity in patients. NAs are also a potential diagnostic pitfall as they can clinically and histologically mimic malignancy in the urinary tract. Materials and Methods We performed an Institutional Board Review approved search of our surgical pathology database from 2005 to 2015 for cases of NA. A retrospective chart review was performed with a focus on the clinical, pathologic, and radiographic findings in these patients. Results We identified 32 cases of NA in 31 patients. Lesions were most common in Caucasian males (male-to-female ratio of 2:1) with an average age at diagnosis of 55 years (range 25-77). Bladder was the most common site of occurrence (81.2%), followed by ureter (9.4%), urethra (6.3%), and intrarenal collecting system (3.1%). Most patients (72%) were symptomatic and presented with hematuria (41%), lower urinary tract symptoms (28%), pelvic or flank pain (6%), hydronephrosis (19%), or urinary incontinence (13%). NA was asymptomatic and identified incidentally in 9 (28%) patients. One patient (3%) had a renal transplant and 8 (26%) patients had diabetes mellitus. Twenty-six (84%) patients were managed with endoscopic resection of their tumors. Conclusion NAs are benign lesions that may cause significant morbidity and mimic malignant tumors. There should be increased suspicion in patients with predisposing factors.

To identify occult metastases within lymph nodes (LNs) reported as negative by routine histologic evaluation. In patients with high-grade, muscle-invasive urothelial carcinoma (UC) of the bladder, pelvic lymphadenectomy during radical cystectomy demonstrates a survival advantage, increasing with the number of LNs removed, even if negative for metastatic disease. This finding may potentially be explained by the presence of occult metastases.Radical cystectomy specimens with high-grade UC invading the perivesical tissue and negative LNs (pT3N0) between 2000 and 2014 were reviewed. Five levels were cut for each LN block. Two sections were cut per level: 1 stained for hematoxylin and eosin and 1 for AE1/AE3. Micrometastases were defined as tumor deposits0.2 mm but2 mm. Isolated tumor cells were defined as ≤0.2 mm. Medical records and survival data were reviewed.We identified 21 cases, consisting of 370 lymph nodes. Six of 21 patients (29%) had occult metastases, including 5 occult metastatic UC and 1 occult metastatic prostate adenocarcinoma. There were 10 positive LNs; 2 macrometastases, 2 micrometastases, and 6 with ITCs. Two of 6 patients (33%) had lymphovascular invasion identified in the primary tumor. Kaplan-Meier analysis showed no significant difference in overall survival between the group of patients who remained N0 versus those upstaged due to discovery of occult metastases (P-value = .42).In patients with pT3 UC undergoing cystectomy, we demonstrated the presence of occult metastases in 29% of patients. The high percentage of occult metastases present in these cases possibly explains the proven survival advantage of removing "negative" LNs. This finding might also have implications in the histologic evaluation of LNs.

OBJECTIVES Little is known about the effect of obesity as quantified by the body mass index on the serum levels of sex hormones, antisperm antibodies, and postoperative fertility of men undergoing vasectomy reversal. The aim of the present study was to investigate the effect of obesity on sex hormone levels, the presence of antisperm antibodies, and fertility after vasectomy reversal. METHODS We identified 500 patients with complete clinical and laboratory data who had undergone vasectomy reversal by a single surgeon. Data on postoperative vas patency and pregnancy were available for 315 and 334 patients, respectively. RESULTS Postoperative vas patency was observed in 93.2%, 91.9%, and 93.3% of normal weight, overweight, and obese patients, respectively (P = .931). Pregnancy was achieved by the partners of 63.9%, 60.2%, and 55.6% of the normal weight, overweight, and obese patients, respectively (P = .672). An increased body mass index was associated with lower serum testosterone levels (P < .001). Significant associations were found between both patient age (P = .007) the and presence of IgA antisperm antibodies (P = .006) with the body mass index. In the logistic regression analyses, the age of the female partner was the only independent predictor of postoperative pregnancy (P = .039). CONCLUSIONS Our results have highlighted that no specific testing before vasectomy reversal can aid in predicting the fertility outcome and that patients should be counseled that the age of their female partner will have an effect on their likelihood of conceiving after vasectomy reversal. In overweight and obese patients, the clinical signs of hypogonadism should be examined and the serum testosterone level should be investigated.

OBJECTIVES To investigate the significance of body mass index (BMI) as an independent predictor of biochemical recurrence in men treated with surgery for clinically localized adenocarcinoma of the prostate. METHODS A total of 1877 obese patients who underwent radical prostatectomy were matched to overweight and normal-weight patients in a 1:1 ratio on the basis of propensity scores. This resulted in an overall study population of 5631 men. Clinicopathologic characteristics and biochemical recurrence outcomes after surgery were compared between the three BMI cohorts. RESULTS Normal-weight patients exhibited lower-grade disease compared with overweight and obese patients (P = 0.021). Lower BMI was also significantly associated with lower rates of positive surgical margins (P

Objectives To demonstrate the use of optical coherence tomography (OCT) for imaging of the cavernous nerve (CN) and periprostatic tissues. The rates of nerve preservation and postoperative potency after radical prostatectomy might improve with better identification of the CN using emerging intraoperative imaging modalities. OCT is an imaging modality that allows for real-time, high-resolution, cross-sectional imaging of tissues. Methods Seven male Sprague-Dawley rats underwent surgery using a midline celiotomy to expose the bladder, prostate, and seminal vesicles. The CNs and major pelvic ganglion were identified. Visual identification of the CN was further confirmed by electrical stimulation with simultaneous intracorporeal pressure measurements. OCT images of the CN, major pelvic ganglion, bladder, prostate, and seminal vesicles were acquired and correlated directly with the histologic findings. Once a baseline technique for the scanning and interpretation of the acquired images was established using the rat model, OCT was used to image ex vivo human prostatectomy specimens. Results OCT provided unique imaging characteristics, differentiating the CN from the bladder, prostate, seminal vesicles, and periprostatic fat. OCT images of the CN and prostate correlated well with the histologic findings. OCT of ex vivo human prostatectomy specimens revealed findings similar to those with the rat experiments, with, however, less dramatic architecture visualized in part because of the thicker capsule and more dense stroma of human prostates. Conclusions The results of our study have shown that OCT provides real-time, high-resolution imaging of the CN in the rat model with excellent correlation to the histologic findings. This study provides a basis for the intraoperative use of this emerging technology during nerve-sparing prostatectomy.