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Introduction:Anticholinergics are associated with cognitive side effects and dementia. Agents such as trospium, fesoterodine and darifenacin have been shown to be less likely to cross the b...

OBJECTIVES To determine contemporary costs of preparing for and applying for a urology residency position for the 2019-2020 American Urological Association Match. METHODS An electronic survey was emailed to all urology residency applicants who applied to Rutgers Robert Wood Johnson Medical School during the 2019-2020 application cycle; it was sent 2 weeks after the Match results were released. We collected information on applicant demographics, interview logistics, and estimated costs incurred applying to residency. RESULTS A total of 26% (64/242) of subjects responded, representing all 8 the American Urological Association sections, international schools, and schools without urology programs. 62% were male, 75% were single, and 52% attended public medical school. Applicants paid for the interview trail using loans (67%), family donations (50%), previous or current income (36%), and scholarships (16%). Subjects completed a median of 2 visiting student rotations (IQR 2-3), applied to 80 programs (IQR 66-99), and attended 16 interviews (IQR 13-18.75). The median cost per applicant for the 2019-2020 Match was $9725 (IQR $6134-12,564). This estimate included expenditures on application fees, visiting student rotations, interview trail travel and lodging, research, interview attire, and professional photos. Subjects who attended public medical school were likely to spend $3546.31 (95% confidence interval: 5630.71-1461.916; P CONCLUSION Urology residency applicants spend almost $10,000 in pursuit of a residency position. These high costs not only contribute to student debt but also may deter applicants from entering the field of urology.

Objectives To determine the feasibility and perceived usefulness of a pre-residency urology boot camp for first and second year urology residents. Methods First and second year urology residents attended a multi-institutional boot camp in July 2019, which consisted of lectures, a hands-on practical, patient simulation session, and networking social event. Attendees completed a pre-course survey where they rated their comfort level in managing interpersonal, post-operative, and urology-specific scenarios on a Likert scale of 0-5. Participants completed follow-up surveys immediately and 6 months after the course regarding confidence in managing the same scenarios and the impact of boot camp on their training. Results 6 urology PGY1s (55%) and 5 PGY2s (45%) from 4 institutions attended the boot camp. On the precourse survey, PGY2s had higher average comfort scores compared to PGY1s for all post-operative scenarios besides hypotension but just 2 urology-specific scenarios, difficult Foley troubleshooting (4 vs 3, P Conclusion A pre-residency boot camp is both feasible and valuable for first- and second-year urology residents for gaining practical medical knowledge and professional networking.

Systemic therapy for first-line metastatic renal cell carcinoma has evolved toward immune checkpoint blockade combinations incorporating a PD-1/L1 inhibitor along with CTLA-4 inhibition or VEGF-targeted therapy. The new treatment paradigm that integrates immunotherapy for treatment-naïve advanced metastatic renal cell carcinoma creates a new therapeutic challenge for clinicians including the optimal way to integrate multidisciplinary care involving surgery, radiotherapy, and application of contemporaneous systemic treatment in subsequent lines of therapy following discontinuation of combination therapy. We outline the available data for the multidisciplinary management of metastatic renal cell carcinoma, systemic therapy options in the post–immune checkpoint blockade setting, and novel therapies in development for advanced renal cell carcinoma. We provide practical considerations to assist clinicians in treatment choice and map future directions for progress.

Female urethral strictures are rare, but underdiagnosed pathologies that can cause voiding dysfunction. These strictures are best managed with open reconstruction, as endoscopic treatments have high rates of failure. A flap urethroplasty can be performed with vaginal, labial or bladder tissue. Meanwhile, graft urethroplasties can utilize vaginal, labial, buccal or lingual tissue. It is important to consider the etiology and type of stricture, local vascularity, and prior attempts at repair when selecting the type of repair. Multiple different techniques have been described with theoretical advantages to each one. While some studies have reviewed a few of the reconstructive techniques to treat female urethral strictures, no single study has accounted for each individual technique. In this review, we discuss techniques captured by a number of systematic reviews and other articles. We will herein focus on reviewing and describing each unique technique of reconstruction in the setting of female urethral stricture.

Highlights • CoVID-19 has impacted all aspects of urologic oncology, including resident and fellow training • Integration of virtual learning and telemedicine offer new opportunities and challenges • New collaborative research opportunities have arisen • Current best practices must be assessed so the field can be better prepared for future public health crises • The SUO has an opportunity to play a leading role in adapting trainee education, Coronavirus Disease 2019 (CoVID-19) has impacted all aspects of urologic training. Didactics have shifted to a virtual platform and new approaches to surgical training have been undertaken. There has a been a shift in research away from the laboratory space, with an increased focus on clinical outcomes and multi-institutional collaborations. Finally, there have been impacts on home life, questions about time away from work, case logs and case minimums, as well as how to manage resident and fellow reassignment. Herein, we review the current state of urologic education in the United States, focusing specifically on urologic oncology and highlight opportunities for the future.

The COVID-19 pandemic disrupted conventional medical education for surgical trainees with respect to clinical training, didactics, and research. While the effects of the COVID-19 pandemic on surgical trainees were variable, some common themes are identifiable. As hordes of COVID-19 patients entered hospitals, many surgical trainees stepped away from their curricula and were redeployed to other hospital units to care for COVID-19 patients. Moreover, the need for social distancing limited traditional educational activities. Regarding clinical training, some trainees demonstrated reduced case logs and decreased surgical confidence. For residents, fellows, and medical students alike, most didactic education transitioned to virtual platforms, leading to an increase in remote educational resources and an increased emphasis on surgical simulation. Resident research productivity initially declined, although the onset of virtual conferences provided new opportunities for trainees to present their work. Finally, the pandemic was associated with increased anxiety, depression, and substance use for some trainees. Ultimately, we are still growing our understanding of how the COVID-19 pandemic has redefined surgical training and how to best implement the lessons we have learned.

In the early 2000s, cytoreductive nephrectomy in addition to systemic cytokines became standard of care for treating metastatic renal cell carcinoma. Since that time, the development of novel systemic targeted therapies and immuno-oncologic agents have challenged the utility of cytoreductive nephrectomy in clinical practice. In 2019, the controversial CARMENA study was published, providing the first level one evidence suggesting that cytoreductive nephrectomy combined with targeted therapy yielded no survival advantage over targeted therapy alone in intermediate and poor risk metastatic renal cell carcinoma patients. Later that year, the SURTIME trial demonstrated that patients undergoing targeted therapy with delayed nephrectomy maintained a survival advantage over those that underwent upfront cytoreductive nephrectomy followed by targeted therapy. Both of these studies underscored the importance of patient selection and timing of cytoreductive nephrectomy and systemic therapy. As new immuno-oncologic agents are trialed, particularly in combination, the role of cytoreductive nephrectomy will continue to be questioned. In this narrative review, we discuss the evolution of the role of cytoreductive nephrectomy in treating metastatic renal cell carcinoma through the context of the ever-changing landscape of targeted therapies and immuno-oncologic agents. We assess the evidence for cytoreductive nephrectomy with respect to patient factors, timing of surgery, and combination with other therapies.

Background The role of retroperitoneal lymph node dissection (RPLND) as first-line treatment for testicular seminoma is less well defined than for testicular nonseminomatous germ-cell tumors. We describe utilization of primary RPLND in the United States and report on overall survival (OS) after surgery for these men. Patients and Methods Using 2004-2014 data from the National Cancer Data Base, we identified 62,727 men with primary testicular cancer, 31,068 of whom were diagnosed as having seminoma. After excluding men with benign, non–germ cell, and nonseminomatous germ-cell tumor histologies, those who did not undergo RPLND, those where clinical stage and survival data were unavailable, and those with testicular seminoma who underwent RPLND in the postchemotherapy setting (n = 47), 365 men comprised our final cohort. Descriptive statistics were used to summarize clinical and demographic factors. The Kaplan-Meier method was used to determine OS. Results A total of 365 men with testicular seminoma underwent primary RPLND. At a median follow-up of 4.1 years, there were 16 deaths in the entire cohort. Five-year OS was 94.2%. Subset analysis of men with stage I and IIA/B disease who underwent primary RPLND revealed 5-year OS rates of 97.3% and 92.0%, respectively (P = .035). OS did not significantly differ in patients with stage IIA versus IIB disease (91.8% vs. 92.3%, respectively, P = .907). Conclusion Although RPLND is rarely used as primary therapy in testicular seminoma, OS rates appear to be comparable to rates reported in the literature for primary chemotherapy or radiotherapy. Ongoing prospective trials will clarify the role of RPLND in the management of testicular seminoma.

PURPOSE The American Urological Association (AUA) Annual Meeting serves as the premier platform for presenting unpublished research in urology. Among selected abstracts, podium presentations represent the most impactful submissions. While podium presentations receive a large audience through conference attendance and social media posts, it is unclear how often they manifest as publications in peer-reviewed journals. MATERIALS AND METHODS Podium presentations from the 2017 AUA Annual Meeting were reviewed. Abstracts were assessed for publication between January 1, 2015 and May 31, 2020 allowing for a 3-year window of publication and accounting for publications prior to the submission deadline. Abstract authors were individually searched with key terms being added sequentially until

Background: Prostate cancer (PCa) phenotypes vary from indolent to aggressive. Molecular subtyping may be useful in predicting aggressive cancers and directing therapy. One such subtype involving deletions of chromodomain helicase DNA binding protein 1 ( CHD1), a tumor suppressor gene, are found in 10–26% of PCa tumors. In this study, we evaluate the functional cellular effects that follow CHD1 deletion. Methods: CHD1 was knocked out (KO) in the non-tumorigenic, human papillomavirus 16 (HPV16)-immortalized prostate epithelial cell line, RWPE-1, using CRISPR/Cas9. In vitro assays such as T7 endonuclease assay, western blot, and sequencing were undertaken to characterize the CHD1 KO clones. Morphologic and functional assays for cell adhesion and viability were performed. To study expression of extracellular matrix (ECM) and adhesion molecules, a real-time (RT) profiler assay was performed using RWPE-1 parental, non-target cells (NT2) and CHD1 KO cells. Result: Compared to parental RWPE-1 and non-target cells (NT2), the CHD1 KO cells had a smaller, rounder morphology and were less adherent under routine culture conditions. Compared to parental cells, CHD1 KO cells showed a reduction in ECM and adhesion molecules as well as a greater proportion of viable suspension cells when cultured on standard tissue culture plates and on plates coated with laminin, fibronectin or collagen I. CHD1 KO cells showed a decrease in the expression of secreted protein acidic and rich in cysteine (SPARC), matrix metalloproteinase 2 (MMP2), integrin subunit alpha 2 (ITGA2), integrin subunit alpha 5 (ITGA5), integrin subunit alpha 6 (ITGA6), fibronectin (FN1), laminin subunit beta-3 precursor (LAMB3), collagen, tenascin and vitronectin as compared to parental and NT2 cells. Conclusion: These data suggest that in erythroblast transformation specific (ETS) fusion-negative, phosphatase and tensin homolog ( PTEN) wildtype PCa, deletion of CHD1 alters cell-cell and cell-matrix adhesion dynamics, suggesting an important role for CHD1 in the development and progression of PCa.

The novel coronavirus (COVID-19) pandemic has created many unique challenges in urology resident training. Urologists are operating at a fraction of normal volume to conserve personal protective equipment and prevent viral spread. Many residency programs have organized rotating skeleton crews to perform clinical duties while a portion of residents work from home. In some regions, urology residents have been deployed to emergency rooms, intensive care units, and medical floors to care for COVID-19 patients. With these interruptions in urologic education, many questions remain about how residents will proceed with their clinical and didactic training. During these unprecedented times, many residencies have transitioned their didactic sessions to video-based platforms, allowing educators to reach larger numbers of learners. This perspective addresses how innovative virtual education programs created during the pandemic can be developed into a national video-based curriculum for urology residents, incorporating both didactics and surgical skill training.

Lymph node involvement in renal cell carcinoma (RCC) portends a poor prognosis. However, the role of lymph node dissection (LND) at the time of tumor resection is not fully understood. Conflicting data have been published regarding the survival implications of LND during RCC surgery, and the optimal patient population for which LND might be beneficial has yet to be identified. Based on recent data characterizing the outcomes of node-positive RCC, some have advocated for revising the current staging guidelines to better reflect these findings. Given the paucity of high-quality evidence supporting or refuting the routine use of LND in RCC, further research is needed to shed light on this important topic. There are a number of ongoing clinical trials evaluating the role of perioperative (neoadjuvant and adjuvant) systemic therapy, which include patients with node-positive RCC, and will serve to guide changes in treatment practices for this patient population moving forward.

Highlights • COVID-19 has resulted in the delay of elective, possibly curative surgeries for RCC • We examined the oncologic impact of surgical delay in cT1b-T2b RCC • Surgical delays up to 3 months do not increase the risk of pT3a up-staging • Surgical delays up to 3 months do not appear to compromise overall survival • Triaging surgery for RCC should incorporate patient and tumor characteristics, Purpose During COVID-19, many operating rooms were reserved exclusively for emergent cases. As a result, many elective surgeries for renal cell carcinoma (RCC) were deferred, with an unknown impact on outcomes. Since surveillance is commonplace for small renal masses, we focused on larger, organ-confined RCCs. Our primary endpoint was pT3a up-staging and our secondary endpoint was overall survival (OS). Materials and Methods We retrospectively abstracted cT1b-T2bN0M0 RCC patients from the National Cancer Database (NCDB), stratifying them by clinical stage and time from diagnosis to surgery. We selected only those patients who underwent surgery. Patients were grouped by having surgery within 1 month, 1-3 months, or >3 months after diagnosis. Logistic regression models measured pT3a up-staging risk. Kaplan Meier curves and Cox proportional hazards models assessed OS. Results 29,746 patients underwent partial or radical nephrectomy. Delaying surgery >3 months after diagnosis did not confer pT3a up-staging risk among cT1b (OR=0.90; 95%CI: 0.77–1.05, p=0.170), cT2a (OR=0.90; 95%CI: 0.69–1.19, p=0.454), or cT2b (OR=0.96; 95%CI:0.62–1.51, p=0.873). In all clinical stage strata, non-clear cell RCCs were significantly less likely to be up-staged (p6 months, also showed no increase in up-staging risk. Conclusions Delaying surgery up to, and even beyond, 3 months does not significantly increase risk of tumor progression in clinically localized RCC. However, if deciding to delay surgery due to COVID-19, tumor histology, growth kinetics, patient comorbidities, and hospital capacity/resources, should be considered.

The Coronavirus Disease 2019 pandemic placed urologic surgeons, and especially urologic oncologists, in an unprecedented situation. Providers and healthcare systems were forced to rapidly create triage schemas in order to preserve resources and reduce potential viral transmission while continuing to provide care for patients. We reviewed United States and international triage proposals from professional societies, peer-reviewed publications, and publicly available institutional guidelines to identify common themes and critical differences. To date, there are varying levels of agreement on the optimal triaging of urologic oncology cases. As the need to preserve resources and prevent viral transmission grows, prioritizing only high priority surgical cases is paramount. A similar approach to prioritization will also be needed as nonemergent cases are allowed to proceed in the coming weeks. While these decisions will often be made on a case-by-case basis, more nuanced surgeon-driven consensus guidelines are needed for the near future.

The COVID-19 pandemic has impeded health care delivery and may permanently transform the patient-urologist relationship. Here we examine the long-term implications of COVID-19 pandemic on this relationship and explore the impact it has on urologic care in the post-COVID-19 era.

INTRODUCTION AND OBJECTIVE:People have eaten genitourinary offal, or non-muscle meat, since biblical times. We present a brief history of the use of kidneys and testes as food in both ancient and c...

INTRODUCTION AND OBJECTIVE:Mirabegron was approved by the FDA in 2012 as the first beta-3 agonist to treat overactive bladder (OAB). This study aims to examine how prescribing patterns have changed...

Testicular torsion is a common pediatric emergency. Predisposing factors and other risk factors for testicular torsion have not been fully elucidated. This case report highlights teenage brothers who each experienced right-sided testicular torsion at nearly the same age, just 1 year apart. Because of their parents' urgency in seeking medical attention, the affected testicles in both patients were salvaged. We also review the current literature in regards to etiology, inheritance, and patient and parental education.

Objective:Alvimopan use has reduced the length of hospital stay in patients undergoing major abdominal surgeries and radical cystectomy. Retroperitoneal lymph node dissection for testicular cancer may be associated with delayed gastrointestinal recovery prolonging hospital length of stay. We evaluate whether alvimopan is associated with enhanced gastrointestinal recovery and shorter hospital length of stay in men undergoing retroperitoneal lymph node dissection for testicular cancer.Materials and methods:From 2010 to 2016, 29 patients underwent open, transperitoneal bilateral template retroperitoneal lymph node dissection. Data for patients who received alvimopan were prospectively collected and compared to a historical cohort of patients who did not receive alvimopan. Primary outcome measures were length of stay and recovery of gastrointestinal function. Descriptive statistics were reported. Time-to-event outcomes were evaluated using cumulative incidence curves and log rank test. Factors associated with length of stay were analyzed for correlation using multiple linear regression.Results:Of 29 men undergoing retroperitoneal lymph node dissection, eight received alvimopan and 21 did not. The two cohorts were well matched, with no significant differences. In the alvimopan cohort compared with those who did not receive alvimopan median time to return of flatus was 2 versus 4 days ( p=0.0002), and median time to first bowel movement was 2.5 versus 5 days ( p=0.046), respectively. Median length of stay in the alvimopan cohort was 4 days versus 6 days in those who did not receive alvimopan ( p=0.074). In adjusted analyses, receipt of alvimopan did not influence length of stay.Conclusion:Alvimopan may facilitate gastrointestinal recovery after retroperitoneal lymph node dissection for testicular cancer. Whether this translates into reduced length of stay needs to be determined by randomized controlled trials using larger cohorts.Level of evidence:3b.

Parkinson’s disease (PD), caused by degeneration of dopaminergic neurons, leads to motor and autonomic symptoms. A large proportion of PD patients experience lower urinary tract symptoms (LUTS) and voiding dysfunction, associated with poor quality of life. Deep brain stimulation (DBS) is an adjunctive therapy used in combination with medication for Parkinsonian motor symptoms and is currently being explored to treat PD-related LUTS. This review discusses the current literature on the effects of DBS on lower urinary tract function and whether this modality can be used to modulate PD-related LUTS and voiding dysfunction.

INTRODUCTION AND OBJECTIVES:Circumcision, a commonly performed surgery by urologists regarded as the oldest known surgery, was first documented by the ancient Egyptians. A brit milah, translated fr...

357 Background: The American Urological Association (AUA) annual meetings serve as a large platform for unpublished research. Among the selected abstracts, podium presentations represent the most impactful submissions. Furthermore, between large meeting attendance and social media promotion, authors can disseminate their findings to a potentially large audience prior to final manuscript publication. While all AUA abstracts do undergo peer review, it is not with the same level of scrutiny that full-length manuscripts receive. Thus, we investigated the publication rates, impact factors, and time to publication of urologic oncology podium presentations at the AUA. Methods: Of 875 podium presentation abstracts from the 2017 AUA Annual meeting, 394 (45.0%) were classified as urologic oncology. We chose 2017 to allow for a three-year window for publication. Abstracts were assessed for subsequent publication between January 1, 2015 and May 31, 2020 with a pre-determined PubMed search protocol. Abstract authors were searched for individually, with key terms being added sequentially until

A 41-year-old female patient presented with left-sided flank pain and gross hematuria temporally unrelated to her menstrual cycle. Abdominal computed tomography scan showed a large left-sided solid, enhancing kidney mass radiographically consistent with renal cell carcinoma. Following surgical resection, histopathological examination revealed polypoid endometriosis. Polypoid endometriosis is rare and mimics a neoplasm clinically, radiographically, and on gross examination. Patients with polypoid endometriosis often present with symptoms related to mass effect rather than classic endometriosis hallmark symptoms such as dyspareunia, dysmenorrhea, and cyclic abdominal pain. Treatment includes surgical resection.

Background: Radical cystectomy (RC) with ileal conduit (IC) or continent diversion (CD) is standard treatment for high-risk non-invasive and muscle-invasive bladder cancer. Objective: Our aim is to study contemporary trends in the utilization of ICs and CDs in patients undergoing RC. Methods: Using the National Inpatient Sample 2001–2012, we identified all patients diagnosed with a malignant bladder neoplasm who underwent RC followed by IC or CD. Patient demographics, comorbidities, length of stay (LOS), and in-hospital complications, mortality, and costs were compared. Multivariable logistic regression analysis, Chi square, and t-tests were used for analysis. Results: Between 2001–2012, approximately 69,049 ICs and 6,991 CDs were performed. CDs increased from 2001 to 2008, but declined after 2008 (p

534 Background: RPLND as first-line treatment for testicular seminoma is less well defined than for testicular nonseminomas. Furthermore, RPLND performed in the post-chemotherapy (PC) setting for seminoma patients with a PET avid residual mass > 3 cm can be technically challenging. We describe utilization of RPLND in the primary and PC settings and report on overall survival rates following surgery for these men. Methods: Using 2004-2014 data from the National Cancer Database, we identified 62,727 men with 1° testicular cancer, of which 31,068 men were diagnosed as having seminoma. After excluding men with benign, non-germ cell, and nonseminoma histologies, those who did not undergo RPLND, and those whose clinical stage (CS) or survival data were unavailable, 412 men comprised our final cohort. Men were further stratified according to whether they had 1° RPLND vs PC-RPLND, with 1° RPLND defined as RPLND performed for CS IA-IIB without prior chemotherapy, and PC-RPLND classified as RPLND performed for CS IIA-IIIC after chemotherapy. Descriptive statistics were used to summarize clinical and demographic factors. The Kaplan-Meier method was used to determine overall survival. Results: From 2004-2014, 412 men with testicular seminoma underwent RPLND, of which 89% and 11% were in the 1° and PC settings, respectively. There were no significant differences in clinical or demographic characteristics when comparing men in these 2 groups. The majority of men with testicular seminoma undergoing PC-RPLND were treated at an academic center (63.8%) or comprehensive community cancer program (21.3%). The median follow-up was 4.1 years. Of 372 patients with available survival data, five-year overall survival was 94.2% and 89.0% in the 1° RPLND and PC- RPLND groups, respectively. Conclusions: Though RPLND is rarely used as 1° therapy in testicular seminoma, overall survival rates appear to be excellent, as they do for men with testicular seminoma after PC-RPLND. Ongoing trials evaluating the use of RPLND for early metastatic, low-volume disease will clarify its role in the management of testicular seminoma.

Open radical cystectomy (ORC) is the current gold standard treatment for muscle invasive bladder cancer. As surgeons become more proficient in minimally invasive and robotic surgical techniques, the number of patients undergoing robotic-assisted radical cystectomy (RARC) is increasing. Although minimally invasive methods are on the rise, research that critically compares open surgery with robotic methods is limited. In this review, we surveyed and appraised the current literature comparing ORC and RARC with regards to perioperative, functional, and oncologic outcomes in order to distinguish the benefits and disadvantages of each method. Here we report that RARC is associated with several perioperative advantages over ORC such as lower estimated blood loss and transfusion rate, and possibly faster gastrointestinal recovery, lower narcotic requirement, and shorter length of stay. ORC is less costly and permits less time in the operating room. Recent data suggests that there is no difference between ORC and RARC when comparing urinary continence and postoperative quality of life. Moreover, ORC and RARC are both associated with similar rates of obtaining positive surgical margins, lymph node yield, and recurrence. However, RARC patients had an increased likelihood of having distant metastases to extrapelvic lymph nodes and the peritoneum. At this point, it is unclear if ORC or RARC has superior patient outcomes, and more research is needed to ascertain management-altering conclusions.

424 Background: Alvimopan use in enhanced recovery programs has reduced the hospital LOS in patients undergoing major abdominal surgeries. Retroperitoneal lymph node dissection (RPLND) for testicular cancer may be associated with delayed GI recovery prolonging hospital LOS. In this study, we evaluate whether alvimopan is associated with enhanced GI recovery and shorter hospital LOS in men undergoing RPLND for testicular cancer. Methods: From 2010 to 2016, 29 patients underwent RPLND by a single surgeon (23 post-chemotherapy). All patients underwent bilateral template dissection. Data for patients who received alvimopan was prospectively collected and compared to a historical cohort of patients who did not receive alvimopan. Primary outcomes measured were hospital LOS and recovery of GI function. Mann-Whitney Wilcoxon and Chi square tests were used to determine statistical significance between the two groups. Results: Of 29 men who underwent RPLND, 8 received alvimopan and 21 did not. There were no differences in preoperative or operative variables between the groups (Table). Median hospital LOS for men receiving alvimopan was 4 days compared to 6 days for those who did not (p=0.074). The median time to return of flatus in men receiving alvimopan was 2 days compared to 4 days for those who did not (p=0.0023). The median time to first bowel movement (BM) in men receiving alvimopan was 2.5 days compared to 4 days for those who did not (p=0.0028). Conclusions: Alvimopan significantly reduced the median time to return of flatus and to first BM after RPLND. Furthermore, there was a trend towards shorter hospital LOS in those receiving alvimopan. [Table: see text]

489 Background: Adrenal cancers have traditionally been treated using an open surgical approach. With advances in minimally invasive surgery (MIS), adrenal tumors have become more amenable to MIS resection. We report a study on the utilization and outcomes of surgery for adrenal cancers on a national level. Methods: Data on patients who underwent open, laparoscopic, or robotic adrenalectomy for adrenal cancer (ICD-9 code 194.0) from 2003-2013 were extracted from the nationally representative Premier Hospital Database. Surgeon specialty, patient demographics, hospital characteristics, intraoperative and perioperative data, and complications were compared. Data were analyzed using univariate and multivariate logistic regression analyses. Results: 4,781 adrenalectomies were performed for malignant disease. Surgery was more commonly performed in patients >50 years of age (83%), men (64%), and white race (80%). There was no significant difference in rate of adrenalectomy with regards to comorbidities, insurance status, teaching vs. non-teaching hospital, hospital bed size, or geographic region. Adrenalectomy for malignant disease was more commonly performed by non-urologists (66 vs. 34%; p=0.011). Among non-urologists, open surgery was most common followed by laparoscopic and robotic approaches (56.3% vs. 37.4% vs. 6.4%, respectively) as compared to urologists (48.8% vs. 38.4% vs. 12.9%, respectively). There was no difference in complication rate or operative time between surgeon types. On multivariate regression analysis, the best predictor of major complication was a Charlson Comorbidity Index (CCI) >2 (OR 6.1, 95% CI 2.9-12.5; p2 was associated with a higher rate of post-op complications, while surgical approach did not influence complication rate. These findings indicate that MIS can be performed safely for adrenal cancers. Prospective study of MIS for adrenal cancer is needed to evaluate its oncologic efficacy.

Many aerobic organisms encounter oxygen-deprived environments and thus must have adaptive mechanisms to survive such stress. It is important to understand how mitochondria respond to oxygen deprivation given the critical role they play in using oxygen to generate cellular energy. Here we examine mitochondrial stress response in C. elegans, which adapt to extreme oxygen deprivation (anoxia, less than 0.1% oxygen) by entering into a reversible suspended animation state of locomotory arrest. We show that neuronal mitochondria undergo DRP-1-dependent fission in response to anoxia and undergo refusion upon reoxygenation. The hypoxia response pathway, including EGL-9 and HIF-1, is not required for anoxia-induced fission, but does regulate mitochondrial reconstitution during reoxygenation. Mutants for egl-9 exhibit a rapid refusion of mitochondria and a rapid behavioral recovery from suspended animation during reoxygenation; both phenotypes require HIF-1. Mitochondria are significantly larger in egl-9 mutants after reoxygenation, a phenotype similar to stress-induced mitochondria hyperfusion (SIMH). Anoxia results in mitochondrial oxidative stress, and the oxidative response factor SKN-1/Nrf is required for both rapid mitochondrial refusion and rapid behavioral recovery during reoxygenation. In response to anoxia, SKN-1 promotes the expression of the mitochondrial resident protein Stomatin-like 1 (STL-1), which helps facilitate mitochondrial dynamics following anoxia. Our results suggest the existence of a conserved anoxic stress response involving changes in mitochondrial fission and fusion., Author Summary Oxygen deprivation plays a role in multiple human diseases ranging from heart attack, ischemic stroke, and traumatic injury. Aerobic organisms use oxygen to generate cellular energy in mitochondria; thus, oxygen deprivation results in energy depletion. Low oxygen can be catastrophic in tissues like the nervous system, which has high-energy demands and few glycolytic reserves. By contrast, other cells, including stem cells and cancerous cells within tumors, adapt and thrive in low oxygen. We are just beginning to understand how different organisms and even different cell types within the same organism respond to low oxygen conditions. The response of mitochondria to oxygen deprivation is particularly critical given their role in aerobic energy production. In addition, mitochondria actively injure cells during oxygen deprivation through the generation of reactive oxygen species, the disruption of calcium homeostasis, and the activation of cell death pathways. Here we use a genetic approach to show that mitochondria undergo fission during oxygen deprivation and refusion upon oxygen restoration. The hypoxia response pathway and the oxidative stress response pathway together modulate this response. We identify a new factor, stomatin-like protein, as a promoter of mitochondrial fusion in response to oxygen deprivation stress. Our findings uncover a new mechanism – regulated mitochondrial dynamics – by which cells adapt to oxygen deprivation stress.