Search

BACKGROUND In competitive residency specialties such as Urology, it has become increasingly challenging to differentiate similarly qualified applicants. Residency interviews are utilized to rank applicants, yet they are often biased and do not explicitly address ACGME core competencies. OBJECTIVE We hypothesized a team-based exercise in the urology residency interview centered on building LEGOs assesses core competences. DESIGN From 2014-2017, students interviewing for urology residency at two institutions participated in a LEGO™ building activity. Applicants were assigned to “architect”— describing how to construct a structure — or “builder” — constructing the same structure with pieces—using only verbal cues to assemble the structure. Participants were graded using a rubric assessing competencies of interpersonal communication, problem-based learning, professionalism, and manual dexterity (indicator of procedural skill). The total minimum score was 16 and maximum was 80. SETTING The study took place at two tertiary referral centers: University of Michigan Medical School in Ann Arbor, MI, and University of Utah School of Medicine in Salt Lake City, UT. PARTICIPANTS A total of 176 applicants participated, comprised of applicants interviewing for urology residency at two institutions during the study timeframe. RESULTS For architects and builders, there was a maximum score of 80, and minimum of 34 and 32, respectively. Both distributions show a right shift with mean scores of 64.3 and 65.9, and median scores of 69 and 65.5. Successful pairs excelled with consistent nomenclature and clear directionality. Ineffective pairs miscommunicated with false affirmations, inconsistent nomenclature, and lack of patience. CONCLUSIONS The LEGO™ exercise allowed for standardized assessment of applicants based on ACGME core competencies. The rubric identified poor performers who do not rise to the challenge of a team-based task.

Patients presenting with microhematuria represent a heterogeneous population with a broad spectrum of risk for genitourinary malignancy. Recognizing that patient-specific characteristics modify the risk of underlying malignant etiologies, this guideline sought to provide a personalized diagnostic testing strategy.The systematic review incorporated evidence published from January 2010 through February 2019, with an updated literature search to include studies published up to December 2019. Evidence-based statements were developed by the expert Panel, with statement type linked to evidence strength, level of certainty, and the Panel's judgment regarding the balance between benefits and risks/burdens.Microhematuria should be defined as ≥ 3 red blood cells per high power field on microscopic evaluation of a single specimen. In patients diagnosed with gynecologic or non-malignant genitourinary sources of microhematuria, clinicians should repeat urinalysis following resolution of the gynecologic or non-malignant genitourinary cause. The Panel created a risk classification system for patients with microhematuria, stratified as low-, intermediate-, or high-risk for genitourinary malignancy. Risk groups were based on factors including age, sex, smoking and other urothelial cancer risk factors, degree and persistence of microhematuria, as well as prior gross hematuria. Diagnostic evaluation with cystoscopy and upper tract imaging was recommended according to patient risk and involving shared decision-making. Statements also inform follow-up after a negative microhematuria evaluation.Patients with microhematuria should be classified based on their risk of genitourinary malignancy and evaluated with a risk-based strategy. Future high-quality studies are required to improve the care of these patients.

Purpose In patients with loin pain hematuria syndrome (LPHS), a response to percutaneous renal hilar blockade (RHB) and a multidisciplinary team (MDT) evaluation predicts patient’s potential renal auto-transplantation (RAT) success. Methods A pain assessment was performed using a 0–10 numeric pain rating scale prior to a percutaneous RHB under CT guidance. If the pain score was reduced > 50% immediately after the RHB, patients were evaluated for RAT by a MDT. Pre-operative and 1-year post-operative quality-of-life surveys were administered to each RAT patient. Results 43 LPHS patients were referred for RHB. Of the 38 patients who received a RHB, 31 had > 50% reduction in pain scores. Pre- and post-RHB mean pain scores were 6/10 and 0.7/10, respectively, in patients who had > 50% reduction in pain. 22 of the patients who responded favorably then proceeded to RAT. Twelve patients had at least 1-year follow-up after RAT. All patients had a meaningful decrease in their pain. Mean pain score at 1 year was 0.8/10 for an 85% overall reduction in pain. 92% of patients experienced a ≥ 50% reduction in pain at 1 year. Mean Beck Depression Inventory (BDI) score (0–66) 1 year after RAT decreased from 25.2 pre-op (moderate depression) to 12.8 post-op (minimal depression). Conclusions A MDT approach utilizing a RHB should be considered as a tool to select appropriate LPHS patients for RAT to achieve long-term success in reducing chronic pain and depression while increasing quality of life.

Introduction Numerous surgical techniques have been described to facilitate closure of the renal parenchymal defect. We sought to describe the operative technique and define the safety and efficacy of using an expanded polytetrafluoroethylene (GORE-TEX; WL Gore and Associates, Flagstaff, AZ) bolster to aid in closure of the renal parenchymal defect at the time of open partial nephrectomy (OPN). Technical Considerations A retrospective review of 175 patients who underwent an OPN using an expanded polytetrafluoroethylene (ePTFE) bolster at the Huntsman Cancer Hospital, University of Utah and Salt Lake City Veterans Affairs Medical Center from March 2005 to February 2013 was conducted. Postoperative complications occurring within 90 days were graded using the Clavien grading system. Conclusion Overall, 57 patients (32.6%) experienced a postoperative complication. Fifteen patients (8.5%) had a Clavien ≥grade-III complication. Ten patients (5.7%) received blood transfusions. Urine leak requiring intervention occurred in 2 patients (1.1%). Delayed hemorrhage requiring nephrectomy and pseudoaneurysm formation were rare, occurring in 1 patient each (0.6%). Infection of the ePTFE material occurred in 2 patients (1.1%). In both cases, it was explanted without requiring nephrectomy. The use of an ePTFE bolster is an effective and safe method of closing the renal parenchymal defect after OPN with an acceptable 90-day postoperative complication rate and a low risk of infection.

Objective To examine our short-term experience of antegrade continence enema (ACE) delivered via a Chait Trapdoor (Cook Medical, Bloomington, IN) in adults with intractable neurogenic bowel. Methods We performed a retrospective review at the Universities of Utah and Minnesota of 15 patients with Chait Trapdoor placed for the purpose of ACE from 2011 to 2013. Our primary outcome was continued utilization of the Chait Trapdoor. Secondary outcomes included volume of ACE used and time to produce a bowel movement. Results All patients had neurogenic bowel refractory to conventional bowel regimen. Mean follow-up was 6 months (range, 1-17 months). Thirteen patients had the Chait Trapdoor placed in the splenic flexure and 2 had it placed in the cecum. Of the 15 patients, 12 (80%) were still using the Chait Trapdoor at last follow-up. A median of 425 mL (range, 120-1000 mL) of fluid was used to produce a bowel movement in 5-120 minutes. Two patients developed postoperative wound infections, requiring return to the operating room (Clavien IIIb). Long-term complications included 5 patients with a dislodged tube requiring replacement by interventional radiology and 2 patients with local cellulitis. Two patients had the Chait Trapdoor moved to a new location to improve efficacy. Conclusion Although the revision, removal, and complication rates were high, 80% of the patients were satisfied with the function and continued to use the Chait Trapdoor. The volume of irrigation required for ACE and the time it takes to produce a bowel movement vary significantly between patients.

The incidence of urolithiasis in children is increasing. However, stone composition studies in this population are limited. We sought to determine the effects of age, gender and geographical location on urinary stone composition in the United States pediatric population.We obtained composition analyses for all urinary stones submitted to a reference laboratory between 2000 and 2009. Stones were excluded if the patient was younger than 1 year or older than 18 years. Stone composition was determined by Fourier transform infrared spectroscopy. Logistic regression analysis was performed to determine associations between stone composition frequency and age, gender and geographical region.A total of 5,245 stones were included in our analysis. Calcium was found in 89.2% of stones. The percentage of stones containing calcium oxalate increased, while magnesium ammonium phosphate and ammonium acid urate containing stones decreased with age. Calcium oxalate and magnesium ammonium phosphate containing stones were more common in females, while uric acid stones were more common in males. Additionally, significant differences in stone composition frequency were noted between males and females in specific age groups and between age groups within the same gender. Geographical distribution was not significantly associated with stone composition.This series is the largest analysis to date of urinary stone composition in the pediatric population in the United States. Age and gender were significantly associated with stone composition, while geographical region was not significantly associated with stone composition.

To evaluate the benefit of an antimicrobial prophylaxis protocol using rectal swab cultures in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy in our Veterans Affairs population. Between June 1, 2013, and June 1, 2014, we implemented an antimicrobial prophylaxis protocol using rectal swab cultures on selective media containing ciprofloxacin for all men scheduled for TRUS-guided prostate biopsy. Data from 2759 patients from Jan 1, 2006 to May 31, 2013, before protocol implementation served as historical controls. Patients with fluoroquinolone (FQ)-susceptible organisms received FQ monotherapy, while those with FQ-resistant organisms received targeted prophylaxis. Our objective was to compare the rate of infectious complications 30 days after prostate biopsy before and after implementation of our antimicrobial protocol. One hundred and sixty-seven patients received rectal swab cultures using our protocol. Seventeen (14 %) patients had FQ-resistant positive cultures. Patients with positive FQ-resistant culture results were more likely to have had a history of previous prostate biopsy and a positive urine culture in the last 12 months (p = 0.032, p = 0.018, respectively). The average annual infectious complication rate within 30 days of biopsy was reduced from 2.8 to 0.6 % before and after implementation of our antimicrobial prophylaxis protocol using rectal swab cultures, although this difference was not statistically significant (p = 0.13). An antimicrobial prophylaxis protocol using rectal culture swabs is a viable option for prevention of TRUS-guided prostate biopsy infectious complications. After implementation of an antimicrobial prophylaxis protocol, we observed a nonsignificant decrease in the rate of post-biopsy infectious complications when compared to historical controls.

Objective To compare the outcomes of first-attempt IVF–intracytoplasmic sperm injection (ICSI) cycles when using fresh testicular biopsy samples vs. frozen biopsy samples. Design Retrospective chart review of 92 consecutive first-attempt IVF-ICSI cycles. Setting Two IVF programs. Patient(s) Forty consecutive first-attempt IVF-ICSI patients using sperm from fresh testicular biopsy samples and 52 consecutive first-attempt IVF-ICSI cycles using frozen testicular biopsy samples. Intervention(s) Testicular biopsy, IVF-ICSI with fresh and frozen-thawed spermatozoa. Main outcome measure(s) Fertilization rates, embryo quality, pregnancy, delivery, and spontaneous abortion rates. Result(s) A significantly increased ICSI fertilization percentage was obtained with frozen testicular biopsy samples (76.5 % ± 3.1 % ) vs. fresh biopsy samples (68.3 % ± 2.6 % ). However, embryo quality, pregnancy, and delivery rates were higher in the fresh biopsy group. Mean embryo score was 4.54 ± 0.31 and 3.62 ± 0.2 in the fresh vs. frozen group, respectively. Chemical pregnancy rates (60 % vs. 49.1 % ), clinical pregnancy rates (56.4 % vs. 41.2 % ), and delivery rates (48.7 % vs. 31.2 % ) were each higher in the fresh group vs. frozen group. Accordingly, the spontaneous abortion rate was lower in the fresh group (21.7 % ) vs. the frozen group (33.3 % ). Conclusion(s) Although the use of frozen biopsy samples has logistical advantages, we conclude it may be advantageous to use fresh testicular biopsy samples in IVF–ICSI cases whenever possible, as fresh specimens yielded significantly improved embryo quality, generally higher pregnancy rates, and lower spontaneous abortion rates.

Laparoscopic adrenalectomy has been demonstrated by many institutions to be a safe and effective approach to benign adrenal lesions. As surgical skills improve, it will most likely be comparable with open adrenalectomy in overall cost. Although it is technically demanding and takes slightly longer than open surgery, the benefits to the patient in terms of hospital stay, convalescence, and cosmetic results have been conclusively reported. The decision to use a transperitoneal or retroperitoneal access is mostly a function of surgeon preference, with similar outcomes by either approach. It is more important that the surgeon be comfortable with the selected approach. Laparoscopic adrenalectomy has become the gold standard for benign adrenal lesions.

Objectives. Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures. Methods. A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions. Results. From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3.1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively. Conclusions. Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

In the past 15 years there have been significant advancements in minimally invasive surgery, best characterized by laparoscopic intervention. Urologic diagnostic applications of laparoscopy have existed since the mid-1970s, when it first was used to explore for nonpalpable testes. 4 It was not until the early 1990s, however, with improvement in video-optics and instrumentation, that laparoscopic surgery gained real credibility. Since then, laparoscopic pelvic lymph node dissection, 15 varix ligation, 5 nephrectomy, 3 bladder neck suspension, 1 pyeloplasty, 12 and an ever-growing list of extirpative and reconstructive urologic procedures have been performed and evaluated. 8 With the improvement of cross-sectional imaging (CT and MR imaging scans), incidental adrenal lesions are detected more commonly, whereas functioning adrenal tumors continue to be rare but they normally require medical or surgical treatment. Open adrenalectomy may be performed by a posterior, flank, or transperitoneal anterior approach; however, in many cases a substantial incision must be made to access the deep retroperitoneal location of the often small and elusive adrenal tumor. Postoperative pain is considerable, often requiring the use of epidural catheters for analgesia. Increased risk of infection, especially in patient's with Cushing's syndrome, may result because of large painful incisions in the upper abdomen with development of atelectasis and pneumonia. Morbidity of open adrenalectomy has been reported to be as high as 40%, with mortality in the range of 2% to 4%. 10,11 The laparoscopic approach to the adrenal gland offers a minimally invasive procedure with markedly improved postoperative characteristics. Laparoscopic adrenalectomy first was reported by Gagner 7 in 1992 and has subsequently been found to have great use among European and Asian urologists. 9,13 This article describes the authors' indications for and approach to laparoscopic adrenalectomy and their preliminary results.

Objective To determine the origin of large plaque-like cellular and acellular masses of debris found in the semen of a patient with otherwise normal semen quality and secondary infertility. Design A prospective case study. Setting Academic andrology laboratory. Patient(s) Secondary infertility patient presenting for routine semen evaluation. Intervention(s) Following diagnosis of a seminal infection, the patient was treated with an antibiotic. Main outcome measure(s) Semen quality parameters, semen culture, and electron microscopy identification of cytolysosomal spermophagy. Result(s) Semen culture identified a rare infection with Ralstonia picketti and electron microscopy showed massive neutrophil and cytolysosomal spermophagy. Both were eliminated after antibiotic therapy. Conclusion(s) This case study documents a rare infection of the reproductive tract with Ralstonia picketti . Analysis of large seminal masses determined their origin to be primarily from acellular cytolysosomes. The presence of such masses in semen should be further evaluated, including semen culture.

Pneumothorax is a rare but known complication of adult urological laparoscopic surgery and has been described occasionally in children as well. The etiologies for pneumothorax during such procedures are discussed as is the management of pneumothorax in this setting. We investigate the occurrence of pneumothorax during laparoscopic pediatric urological procedures in children.Pneumothorax developed during urological laparoscopic procedures in 4 pediatric patients (3 females, 1 male). Patient age ranged from 8 months to 11 years (mean 5.4 years). Laparoscopic surgical procedures performed included right upper pole partial nephrectomy, left upper pole partial nephroureterectomy, removal of left multicystic dysplastic kidney and bilateral Cohen reimplantation of ureters. Procedures were performed with a maximum insufflation pressure of 15 mm Hg. During the same time period as these four cases, a total of 285 laparoscopic urologic procedures were performed at our institution.Pneumothorax was suspected due to decreased oxygen saturations, subcutaneous emphysema, increased respiratory effort and decreased chest lung sounds unilaterally. Pneumothorax was confirmed with chest x-rays. Operative time ranged from 171 to 249 minutes (mean 199.5). Duration of surgery before pneumothorax developed ranged from 75 to 239 minutes (mean 176, median 168). Conservative management of pneumothorax was used in 3 patients and a pigtail chest tube was used in 1. In all cases the estimated blood loss was minimal.Urologists performing laparoscopy in children should be aware of the possibility of a pneumothorax developing during the procedure. Evaluation for decrease in O2 saturation should include a search for pneumothorax in these patients. Close observation generally suffices for management.

Recent advances in laparoscopic surgery as well as increasing experience with these techniques have led to the selection of laparoscopic surgery for many urological procedures. A lesser number of pediatric laparoscopic surgical studies have been reported. Few pediatric comparative laparoscopic versus open surgical procedure studies have been published. We compared 2 groups of similar pediatric patients who underwent partial nephrectomy via the laparoscopic or open technique.A total of 22 consecutive partial nephrectomies were performed in pediatric patients 3 months to 15 years old. Of these procedures 11 chosen according to surgeon preference were performed laparoscopically and 11 were done by the open technique. Clinical data were obtained by chart review and compared retrospectively in the 2 groups. Demographic data, operative time and blood loss, the perioperative complication rate, hospital stay and costs, postoperative analgesic use and followup findings were compared.Mean operative time in the laparoscopic and open groups was 200.4 and 113.5 minutes, respectively (p0.0005). Blood loss was less than 50 cc in all patients. In the laparoscopic and open groups mean hospital stay was 25.5 and 32.6 hours (p = 0.068), and mean cost was $6,125 and $4,244 (p = 0.016), respectively. Patients in the laparoscopic group required fewer doses of analgesics than those who underwent open surgery (mean 10.9 versus 21, p = 0.041).Our findings show that increased operative time and costs are disadvantages of pediatric laparoscopic nephrectomy compared with open techniques. Conversely decreased hospital stay, lower analgesic requirements and cosmesis support the use of laparoscopy for pediatric partial nephrectomy. These differences must be considered when deciding which technique is best for overall patient care.

Long-term outcomes of a minimally invasive method of correcting vesicoureteral reflux are presented with a discussion of the modification in our original technique.A total of 29 children (46 refluxing ureters), 14 months to 18 years old, underwent percutaneous endoscopic trigonoplasty (PET) between December 1994 and June 1996. Follow-up ranged from 19 to 37 months. Reflux was grade 1 in 2, grade 2 in 16, grade 3 in 19, grade 4 in 8, and grade 5 in 1. The technique was a Gil-Vernet method in the first 23 patients and Cohen reimplantation in the last 6 patients.Resolution of reflux was observed to decrease from 63% to 47% with long-term (30-37 months') follow-up using the Gil-Vernet technique. Resolution was greater with unilateral reflux than bilateral reflux (83% v. 27%, respectively). The Cohen technique resulted in resolution of reflux in 83%; however, the operating time nearly doubled when compared with the Gil-Vernet group. In both groups, failure was unrelated to grade of reflux, age, operative sequence, or bladder instability.Although showing an improvement in resolution of reflux over the Gil-Vernet PET procedure, the Cohen PET reimplant has a lower success rate than traditional open operative reimplants. The PET also requires more operating time and two operating surgeons. Despite some advantages in the promptness of recovery, we do not recommend PET by either technique at this time. Future modifications may make this approach more tenable.

We retrospectively reviewed the records of patients with prenatal hydronephrosis to characterize those in whom it was more likely to resolve with conservative management.We studied 51 patients in a 4-year period who presented with nonspecific unilateral hydronephrosis diagnosed by prenatal and confirmed by postnatal sonography. Patients were followed with sequential nuclear renograms with furosemide washout to evaluate function and drainage. In all cases a nonoperative approach was attempted. Pyeloplasty was performed only for poor or decreasing kidney function and/or drainage.Four of the 51 patients were lost to followup, 21 of the remaining 47 (45%) eventually underwent surgery, and 26 (55%) had complete normalization of renal function and washout pattern without surgery. There was no statistically significant correlation between hydronephrosis grade on initial postnatal sonography and the likelihood of nonsurgical resolution. However, the shape of the washout curve on nuclear renography was informative for predicting outcome, since 86% of the cases with a nonobstructive drainage pattern normalized without surgery, while 62% with indeterminate and only 18% with obstructive curves resolved with conservative management (p0.01). Notably in 83% of the cases of normalization without surgery resolution occurred before age 18 months. Also, an initial obstructed washout pattern was more likely to be associated with a poor outcome. Of the 6 patients with less than 40% final differential function 5 had an obstructed washout pattern on the initial nuclear renogram.Patients diagnosed by prenatal ultrasound with apparent unilateral ureteropelvic junction obstruction generally do well with conservative treatment. However, those who present with an obstructed washout pattern are less likely to have resolution without surgery and more likely to have poor final differential function.

We compare the effectiveness and efficiency of laparoscopic adrenalectomy to open surgical management of adrenal disorders.A retrospective comparison was undertaken of 21 patients who underwent transperitoneal laparoscopic adrenalectomy between April 1996 and May 1997 with 17 patients who underwent open adrenalectomy between October 1994 and January 1996. Any patient suspected of having primary adrenal carcinoma and/or an adrenal lesion larger than 6 cm. was excluded from the study.Patient demographics were matched well. Mean laparoscopic surgical time was 79 minutes longer than for open surgery. After overcoming the learning curve, the surgical time decreased by 59 minutes in the last 10 laparoscopic adrenalectomies. All laparoscopic intraoperative complications were managed without the need for open surgical conversion. Postoperative characteristics demonstrated significant benefits in the laparoscopic group (p=0.001) with respect to days to return to full diet (1.7 versus 4.6), analgesic pain requirements and days of hospitalization (2.7 versus 6.2).Laparoscopic adrenalectomy offers significant postoperative benefits to patients with benign adrenal disease requiring surgical intervention. The surgical time is longer than that for open adrenalectomy but there was an encouraging reduction in time after overcoming the laparoscopic learning curve. Laparoscopic adrenalectomy is an excellent choice for tumors smaller than 6 cm. Its role for larger lesions and/or primary adrenal carcinoma is currently under investigation.

In situ Holmium laser lithotripsy is a safe, effective procedure for the treatment of impacted urethral stones. This procedure can be performed transurethrally as an outpatient with minimal tissue trauma and render patients stone free. The authors utilized this procedure in 2 patients whose anatomy did not allow the calculi to be manipulated into the urinary bladder in a retrograde manner. Because of its successful use elsewhere in the urinary tract, we believe that Holmium laser lithotripsy may be the treatment of choice for impacted urethral stones. J Pediatr Surg 36:E16. Copyright © 2001 by W.B. Saunders Company.

Purpose: We investigated whether measurement of contralateral renal length in newborns with unilateral hydronephrosis may help to assess clinically significant hydronephrosis in the affected kidney.Materials and Methods: We reviewed our experience with 53 newborns who had unilateral hydronephrosis presumed secondary to ureteropelvic junction obstruction. We divided the patients according to the presence of mild hydronephrosis and no obstruction on a furosemide renogram, severe hydronephrosis and obstruction on a furosemide renogram or a unilateral multicystic kidney.Results: We found no significant correlation between findings on the affected and opposite normal sides. Contralateral hypertrophy, hypotrophy and normal sized kidneys were frequent findings.Conclusions: We conclude that measurement of contralateral renal length is not helpful in the evaluation of newborns with unilateral hydronephrosis.