Search

Introduction: A variety of procedures for the endoscopic surgical treatment of symptomatic benign prostatic hyperplasia (BPH) refractory to medical therapy have existed for decades. The present study examined trends in surgeon compensation for these treatments within Canada., Methods: The physician fee schedule for BPH surgery across 10 Canadian provinces for the years 2010 and 2023 were obtained. A descriptive study examined first the provincial reimbursement for transurethral resection of prostate (TURP) and laser ablative/enucleation surgery; second, the difference in TURP reimbursement between 2010 and 2023; and third, the annual change in TURP reimbursement juxtaposed with the annual change in the provincial Consumer Price Index (CPI) and annual salary for the working population aged 35-44., Results: Seven of 10 Canadian provinces reimburse laser BPH surgery equally to TURP. The average provincial TURP reimbursement is $545, ranging from $451 in Ontario to $688 in Saskatchewan. Since 2010, TURP reimbursement has varied by province from a 0% net change in Ontario to an increase of 21% in Nova Scotia. Reimbursement for TURP has increased at a slower pace than the local CPI, and for half of the provinces at a slower pace than the annual salary for people aged 35-44., Conclusions: The compensation model for endoscopic BPH surgery does not have a unified structure in Canada that is consistent across provinces, nor does it keep up with inflation, possibly impacting future recruitment, increasing geographic disparities, and most importantly, limiting the adoption of new BPH therapies.

Introduction: Bladder exstrophy-epispadias complex is a rare condition that necessitates numerous surgical procedures during a patient's youth to achieve adequate urine storage and continence. This study aimed to identify the specific needs and functional challenges faced by adults who underwent pediatric bladder exstrophy reconstructions and assess the management of these issues in an adult population., Methods: A retrospective chart review was conducted for all bladder exstrophy complex patients who underwent surgery at a young age and were subsequently referred to our center between 2005 and 2020. Inclusion criteria included patients with cloacal or classical bladder exstrophy older than 18 years. We recorded the reasons for referral, management of contemporary complaints, types of past and present urinary reconstructions, and their current functional status., Results: The study included 38 patients. The primary reasons for referral were incontinence (39%) and catheterization difficulties (24%). Management typically involved partial or complete surgical revision of their urinary reservoir, occasionally combined with a bladder neck procedure. Ultimately, only three patients continued to experience incontinence, while none reported catheterization issues after undergoing treatment at our center. Long-term exstrophy-related reconstruction complications included urinary tract infections (39%), stones (29%), stenosis (24%), fistulas (13%), chronic renal disease (16%), metabolic abnormalities (3%), and cancer (3%)., Conclusions: Adults who have previously undergone bladder exstrophy reconstruction exhibit a wide range of urologic reconstructions. Their needs often revolve around continence and catheterization concerns. Most patients with satisfactory functional outcomes perform self-catheterization through a continent cutaneous channel and have either a continent pouch or an augmented bladder.

Introduction: Urethral mesh perforation is a rare complication of mid-urethral sling resulting in a lack of clear management guidelines. Thus, we aimed to determine management options and their respective outcomes in terms of erosion resolution and continence., Methods: A literature review was performed by extracting studies from the PubMed, Cochrane, and Google Scholar from January 1996 to December 1, 2022. Only French and English language studies were included. A total of 227 papers were screened and assessed for eligibility., Results: Forty-eight studies were included in the final analysis, for a total of 224 patients. Treatment options consisted of conservative, endoscopic, transurethral, and transvaginal approaches. Conservative treatment was associated with a 100% risk of persistence or recurrence of urethral perforation, while the failure rates for endoscopic, transurethral, and transvaginal approaches were 33%, 7.5%, and 7%, respectively. Most patients suffered from stress urinary incontinence after reconstructive management. The most common symptoms at the time of presentation were overactive bladder and pain. The mean time between the onset of symptoms and diagnosis was 10 months. About half of the urethral mesh perforations were diagnosed within the first years after the initial sling insertion., Conclusions: Multiple management options for sling penetration of the urethra have been described in the literature. Transvaginal sling resection with consecutive tissue interposition seems to carry the lowest risk of erosion recurrence; however, all treatment options are associated with a high relapse rate for stress urinary incontinence.

Introduction: There are no clinical guidelines for the manipulation of chronic indwelling ureteral stents. The goal of this study was to survey, through a simulated case, how urologists initially manage a patient with a chronic ureteral stent presenting with urosepsis., Methods: An online questionnaire was shared from July 1 to August 31, 2021, through social media (Twitter) and email lists. The scenario described a 50-year-old female, known for a chronic indwelling ureteral stent, presenting to the emergency department with fever, tachycardia, and flank pain. In the scenario, the stent was in adequate position and the last exchange had been performed one month prior. Respondents could choose between treating with antibiotics and keeping the same exchange schedule, urgent stent exchange, or an alternative management that they defined. P<0.05 was considered significant., Results: A total of 396 participants completed the survey. Responses from 48 countries were collected, with 135 (34.1%) respondents from Canada. Half (50%) of respondents had more than 10 years of experience. Most (79.3%) respondents opted for initial empiric antibiotic therapy, while 16.2% opted for urgent stent exchange. A total of 19 (4.9%) medical specialists completed the survey. Non-urologists opted more frequently than urologists (42.1% vs. 16.2%) for urgent stent exchange (p=0.0111)., Conclusions: This questionnaire allowed us to explore the various managements proposed by urologists in a patient with urosepsis and chronic indwelling ureteral stent. Most urologists opted for initial medical management. Further clinical studies could help determine the necessity for ureteral stent manipulation in urosepsis, and, if present, its ideal timing.

Although salvage prostate bed radiotherapy is highly effective in biochemically-relapsing prostate cancer patients following prostatectomy, relapses remain frequent and improvements are needed. Randomized phase 3 trials have shown the benefit of adding androgen-depriving therapy to irradiation, but not all patients benefit from this combination. Preclinical studies have shown that novel agents targeting the androgen receptor, DNA repair, PI3K/AKT/mTOR pathways, or the hypoxic microenvironment may help increase the response to prostate bed irradiation while minimizing potential side effects. This perspective review focuses on the most relevant molecules that may have an impact when combined with salvage radiotherapy, and underlines the strategies that need to be developed to increase the efficacy of salvage post-prostatectomy radiotherapy in prostate cancer patients., Competing Interests: SS: coordinating investigator of the GETUG 33 CARLHA 2 study funded by Janssen. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Cailleteau, Sargos, Saad, Latorzeff and Supiot.)

Introduction: We aimed to compare objective structured clinical examinations (OSCE) performance of residents from four Canadian urology programs, based on resident and station characteristics. We also aimed to evaluate OSCE contents by station type and subspecialty., Methods: Scores of 109 postgraduate year (PGY)-3 to PGY-5 residents were retrospectively reviewed from 19 OSCEs from May 2008 to February 2019. Scores were grouped by station type/subspecialty, PGY level, medical graduate type (Canadian medical graduate [CMG], international medical graduate [IMG]), sex, and choice of fellowship/practice. Linear mixed modelling was performed to obtain least square means to account for repeated measures., Results: Score increases from PGY-3 to PGY-5 were significant for all station types and subspecialties (p≤0.001). Scores were similar between male and female residents, and between CMGs and IMGs, except in visual recognition examinations (VREs) (males: 44.3±1.0, females: 39.0±1.6, p=0.005; IMG: 47.3±1.7, CMG: 41.6±0.9, p=0.004). Relative to uro-oncology stations, scores were lower in andrology (p=0.010) and functional urology (p<0.001). More female residents chose pediatric (14.3% vs. 1.5%, p=0.024) and functional urology fellowships (17.9% vs. 2.9%, p=0.021). More male residents chose endourology/robotic fellowships (30.9% vs. 10.7%, p=0.042). No associations between subspecialty scores and choice of fellowship/practice were found. Oral stations and VREs were more frequent than telephone stations. Uro-oncology and pediatric urology were more frequent than other subspecialties., Conclusions: Scores improved with higher PGY level. IMGs and male residents scored better in VREs. Scores were lower in functional urology. There was no correlation between subspecialty score and choice of fellowship/practice. Subspecialties and forms of evaluation were not equally represented.

Introduction: We sought to evaluate population-based costs variations and predictors of outlier costs for percutaneous nephrolithotomy (PCNL) in the U.S., Methods: Using the Premier Healthcare Database, we identified all patients diagnosed with kidney/ureter calculus who underwent PCNL from 2003-2015. We evaluated 90-day direct hospital costs, defining high- and low-cost surgery as those >90th and <10th percentile, respectively. We constructed a multilevel, hierarchical regression model and calculated the pseudo-R 2 of each variable, which translates to the percentage variability contributed by that variable on 90-day direct hospital costs., Results: A total of 114 581 patients underwent PCNL during the 12-year study period. Mean cost in the low-cost group was $5787 (95% confidence interval [CI] 5716-5856) vs. $38 590(95% CI 37 357-39 923) in the high-cost group. Cost variations were substantially impacted by patient (63.7%) and surgical (18.5%) characteristics and less so by hospital characteristics (3.9%). Significant predictors of high costs included more comorbidities (≥2 vs. 0: odds ratio [OR] 1.81; p=0.01) and hospital region (Northeast vs. Midwest: OR 2.04; p=0.03). Predictors of low cost were hospital bed size of 300-499 beds (OR 1.35; p<0.01) and urban hospitals (OR 2.77; p=0.01). Factors less likely to be associated with low-cost PCNL were more comorbidities (Charlson Comorbidity Index [CCI] ≥2: OR 0.69; p<0.0001), larger hospitals (OR 0.61; p=0.01), and teaching hospitals (OR 0.33; p<0.0001)., Conclusions: Our contemporary analysis demonstrates that patient and surgical characteristics had a significant effect on costs associated with PCNL. Poor comorbidity status contributed to high costs, highlighting the importance of patient selection.

This paper aims to compare the approved second-line treatment options in metastatic renal cell carcinoma. A network meta-analysis (NMA) using the frequentist approach and generalized pairwise modeling was computed for the approved drugs in this setting. The results of this NMA showed that the combination of lenvatinib and everolimus yielded the lowest hazard ratio (HR) for progression-free survival (HR: 0.4; 95% CI: 0.21-0.75) and overall survival (HR: 0.55; 95% CI: 0.30-1.00). The great efficacy of this combination is limited by the prevalence of grade 3-4 adverse events (70.6%) leading to treatment discontinuation in 17.6%. This NMA is to the best of our knowledge, the first analysis of the approved regimens for the second-line treatment of metastatic renal cell carcinoma.

Objective: To evaluate the impact of the specialty (urologist vs radiologist) of the physician obtaining percutaneous renal access (RA) on perioperative outcomes, complications, and costs of percutaneous nephrolithotomy (PCNL)., Materials and Methods: We used data from a national hospital discharge database to identify patients undergoing PCNL between 2003 and 2015. Procedure codes related to RA were linked to physician specialty. We examined patient demographics, Charlson comorbidity index, postoperative complications, length of stay (LOS), and direct hospital costs, as well as hospital and surgeon characteristics stratified by specialty of the physician obtaining RA. A multivariable regression model was created adjusting for potential confounders., Results: We identified 40,501 patients undergoing PCNL between 2003 and 2015. Urologists obtained access in 17.0% of cases. RA by urologists was associated with a lower 90-day complication rate (5.0% vs 8.3%, p < 0.001) and lower rates of prolonged hospitalization ≥4 days (22.5% vs 42.1%, p < 0.001). On multivariable analysis, RA by urologists was associated with lower rates of any complication (Clavien 1-5) (odds ratios [OR] 0.70, p ≤ 0.001), shorter LOS (OR 0.67, p < 0.001), and lower direct hospital costs (OR 0.65, p < 0.001)., Conclusion: In the United States, radiologists obtain percutaneous RA in the majority of PCNLs. Access by urologists is associated with lower overall complications, shorter hospitalizations, and lower direct hospital costs. Coding errors and absence of stone complexity information may limit the cogency of our findings and requires further investigation.

Purpose: To investigate the contemporary trends and perioperative outcomes of percutaneous nephrolithotomy (PCNL) by using a population-based cohort., Materials and Methods: Using the Premier Healthcare Database, we identified 225,321 patients in whom kidney/ureteral calculi were diagnosed and who underwent PCNL at 447 different hospitals across the United States from 2003 to 2014. Outcomes included 90-day postoperative complications (as classified by the Clavien-Dindo system), prolonged hospital length of stay, operating room time, blood transfusions, and direct hospital costs. Temporal trends were quantified by estimated annual percentage change (EAPC) by using least-squares linear regression analysis. Multivariable logistic regression was performed to identify predictors of outcomes., Results: PCNL utilization rates initially increased from 6.7% (2003) to 8.9% (2008) (EAPC: +5.60%, p = 0.02), before plateauing at 9.0% (2008-2011), and finally declining to 7.2% in 2014 (EAPC: -4.37%, p = 0.02). Overall (Clavien ≥1) and major complication (Clavien ≥3) rates rose significantly (EAPC: +12.2% and +16.4%, respectively, both p < 0.001). Overall/major complication and blood transfusion rates were 23.1%/4.8% and 3.3%, respectively. Median operating room time and 90-day costs were 221 minutes (interquartile range [IQR] 4) and $12,734 (IQR $9419), respectively. Significant predictors of overall complications include higher Charlson comorbidity index (CCI) (CCI ≥2: odds ratio [OR] 2.08, p < 0.001) and more recent year of surgery (2007-2010: OR 3.20, 2011-2014: OR 4.39, both p < 0.001). Higher surgeon volume was significantly associated with decreased overall (OR 0.992, p < 0.001) and major (OR 0.991, p = 0.01) complications., Conclusions: Our contemporary analysis shows a decrease in the utilization of PCNL in recent years, along with an increase in complication rates. Numerous patient, hospital, and surgical characteristics affect complication rates.