Faculty Bibliography

As the population increases in the world's poorest countries, the need for surgical interventions will increase. Short-term surgical missions can play an important role in increasing access to solve this disparity by providing much-needed surgical services to vulnerable populations in low-income and middle-income countries. As short-term surgical missions increase, it is important that basic ethical principles are a foundation in service delivery. By following ethical principles outlined in this article, abiding by common moral language, and establishing long-term relationships, a significant contribution can be made to global surgery to increase access and deliver high-quality surgery.

PURPOSE OF REVIEW/OBJECTIVE:This article summarizes the current state of underrepresented minorities (URM) and women within urology. Specific strategies to promote the recruitment and retention of URM and women within urology are discussed. RECENT FINDINGS/RESULTS:Minorities and women remain underrepresented within urology, a disparity that has roots as early as medical school and persists throughout residency and practice. This is likely due to implicit and explicit bias, lack of role models, and persistent disparities in compensation and promotion. Strategies to improve recruitment and retention of these individuals should focus on increasing early exposure to urology, opportunities for mentorship, and support in professional development. Creation of a supportive institutional culture, consideration of alternative career advancement paths, and intentional diversity-focused recruitment efforts are also critical. Successful recruitment and retention of URM and women in urology requires specific, directed efforts to increase opportunities for exposure, mentorship, and career promotion at a programmatic, institutional, and national level.

PURPOSE:Some patients continue to have bothersome lower urinary tract symptoms despite treatment. We examined characteristics associated with bother from lower urinary tract symptoms in a prospective cohort. MATERIALS AND METHODS:In this 1-year prospective, observational cohort study we obtained data on patients with lower urinary tract symptoms who were seeking care at a total of 6 tertiary care centers in the United States. Participants answered the AUA-SI (American Urological Association Symptom Index) global urinary bother question at study entry and 12 months later. Multilevel logistic and linear regression was used to identify factors associated with worsening bother and bother at 12 months, respectively. RESULTS:Of the 756 participants 121 (16%) had worsened lower urinary tract symptom bother during the study period. When adjusted for other variables, worsened lower urinary tract symptom bother was more likely among men who were nonwhite (OR 1.79, 95% CI 0.94-3.40) or who had diabetes (OR 1.68, 95% CI 0.86-3.27) and among women with diabetes (OR 1.77, 95% CI 0.85-3.67), prior treatment of lower urinary tract symptoms (OR 2.58, 95% CI 1.22-5.46) or a higher depression level (OR 1.29, 95% CI 1.10-1.52). Baseline factors associated with more severe bother at 12 months in men included more severe bother at baseline, nonwhite race, worse urinary frequency and incontinence, and higher levels of stress (p <0.05). Among women more severe bother at baseline, urinary urgency and frequency, and worse physical function were associated with more severe bother at 12 months. CONCLUSIONS:Urinary symptom severity at baseline, race, depression and psychological stress were associated with the bother of lower urinary tract symptoms in a prospective cohort of men and women treated at tertiary care facilities. These findings may inform the clinical care of patients with bothersome lower urinary tract symptoms and direct providers to better prognosticate for patients with challenging lower urinary tract symptoms cases.

PURPOSE:Patient-reported outcomes after radical prostatectomy have focused on erectile function. To date, no studies have validated the Patient-Reported Outcome Measurement Information System (PROMIS) Sexual Interest and Satisfaction single item measures in patients with prostate cancer, nor have studies examined how these measures relate to erectile function. In addition, data are lacking with regard to the clinical responsiveness of these measures to treatment. We sought to validate and examine the clinical utility of these measures in men after radical prostatectomy. PATIENTS AND METHODS:We identified men who underwent a robotic radical prostatectomy from May 2014 to January 2016 in the Michigan Urological Surgery Improvement Collaborative. A single item from the PROMIS Global Satisfaction With Sex Life subdomain and a single item from the PROMIS Interest in Sexual Activity subdomain were administered. Erectile function was also assessed. Differences between baseline and 24-month T-scores for both PROMIS interest and satisfaction were examined. Multilevel models were constructed to examine change over time. RESULTS:< .002). CONCLUSION:PROMIS Global Satisfaction With Sex Life and Interest in Sexual Activity single-item measures are fundamental measures in prostate cancer survivorship. Patients are interested in sex despite functional losses and can salvage satisfaction, thereby giving insight into attainable patient-centered survivorship goals for sexual recovery after radical prostatectomy.

Prostate cancer survivors have unique needs that encompass diagnosis and treatment-related side effects. The provision of services for prostate cancer survivors is often limited by resources, time constraints in traditional clinic visits, payment, and patient and provider comfort with discussion of sensitive topics including sexual and urinary health, both of which are largely impacted by treatment. Telemedicine, the remote delivery of health care services using telephone, mobile, web, and video platforms, allows for potential cost savings, in addition to ease and comfort as patients can engage in telemedicine-based resources in the comfort of their homes. Furthermore, survivors prefer to seek information online making telemedicine approaches for prostate cancer survivorship care an ideal combination. A majority of the telemedicine-based interventions used the web, followed by telephone, mobile, and video platforms. In limited studies, telemedicine delivery of survivorship care has equal efficacy to traditional care delivery. In addition, although older patients did not use the Internet regularly, they were willing to adapt to Internet usage if it had the potential to increase their quality of life. Telemedicine delivery of prostate cancer survivorship care is acceptable, feasible, cost-effective, and potentially preferred by prostate cancer survivors. Additionally, it emphasizes knowledge, self-management and self-monitoring serving to increase self-efficacy. This specialized care allows for greater access and reaches a wider catchment area compared to traditional clinic visits. This is especially important as the number of prostate cancer survivors increases and healthcare systems incorporate alternatives to traditional in-person care.

OBJECTIVE:The purpose of this study is to compare the attenuation and homogeneity of renal neoplasms with those of cysts on contrast-enhanced CT. MATERIALS AND METHODS/METHODS:A total of 129 renal neoplasms and 24 simple cysts were evaluated. Two readers determined whether each mass was qualitatively heterogeneous or homogeneous. Mean, minimum, and maximum attenuation values were measured. Statistical analysis was performed. RESULTS:A total of 116 heterogeneous renal cell carcinomas (RCCs) (99 clear cell, four papillary, four oncocytic, seven chromophobe, and two unclassified RCCs), 13 homogeneous RCCs (10 papillary, two oncocytic, and one chromophobe RCC), and 24 cysts (all of which were homogeneous) were evaluated. All homogeneous RCCs had mean attenuation values of more than 42 HU, whereas renal cysts had mean attenuation values of up to 30 HU (p < 0.001). Two readers qualitatively and identically categorized all RCCs as homogeneous or heterogeneous (κ = 1.0; p < 0.001). CONCLUSION/CONCLUSIONS:Homogeneous simple renal cysts can have mean attenuation values of up to 30 HU, as determined by contrast-enhanced CT, whereas homogeneous RCCs have mean attenuation values as low as 42 HU, with no overlap occurring between the two groups. These data suggest that further evaluation of a homogeneous renal mass with a mean attenuation value of 30 HU or less on a contrast-enhanced CT scan likely is unwarranted.

OBJECTIVES/OBJECTIVE:Venous invasion is common in advanced renal cell carcinoma (RCC) due to the unique biology of this cancer. The presence of a tumor thrombus often makes clinical management challenging. In this review, we detail specific preoperative, perioperative, and surgical strategies involving the care of the complex kidney cancer patient with venous tumor involvement. METHODS:We performed a comprehensive review of selected peer-reviewed publications regarding RCC tumor thrombus biology, medical and surgical management techniques, and immediate and long-term outcomes. RESULTS:The perioperative management may require special imaging techniques, preoperative testing, very recent imaging, and consultation with other surgical services. There are various approaches to these patients as the clinical presentation, stage of disease, primary tumor size, level of thrombus, degree of venous occlusion, presence of bland thrombus, and primary tumor laterality influence management. Select patients with metastatic disease can do well with cytoreductive nephrectomy and thrombectomy. Those with localized disease have a high risk of recurrence; however, some patients can exhibit durable survival with surgery alone. The evolving surgical and medical treatments are discussed. CONCLUSIONS:Even when these surgeries are performed in high volume centers, significant perioperative complications are common and greater complications are seen with higher thrombus extent. If surgery is attempted, it is important for urologic oncologists to follow strict attention to specific surgical principles. These general principles include complete vascular control, avoidance of thrombus embolization, close hemodynamic monitoring, and institutional resources for caval resection/replacement and venous bypass if necessary.

PURPOSE/OBJECTIVE:Despite the high morbidity of repeat renal surgery in patients with multifocal recurrent renal carcinoma, in most patients adequate renal function is preserved to obviate the need for dialysis. To our knowledge the economic burden of repeat renal surgery has not been evaluated. We provide a cost analysis for patients requiring repeat renal surgery on a solitary kidney. MATERIALS AND METHODS/METHODS:We reviewed the charts of patients treated at the National Cancer Institute who required repeat renal surgery from 1989 to 2010. Functional, oncological and surgical outcomes were evaluated and the costs of repeat renal surgery were calculated. We then compared costs in a cohort of 33 patients who underwent repeat renal surgery on a solitary kidney and in a hypothetical patient cohort treated with uncomplicated nephrectomy, fistula placement and dialysis. All costs were calculated based on Medicare reimbursement rates derived from CPT codes. Cost analysis was performed. RESULTS:Despite a high 45% complication rate, 87% of patients maintained renal function that was adequate to avoid dialysis and 96% remained metastasis free at an average followup of 3.12 years (range 0.3 to 16.4). Compared to the hypothetical dialysis cohort, the financial benefit of repeat renal surgery was reached at 0.68 years. CONCLUSIONS:Repeat renal surgery is a viable alternative for patients with multifocal renal cell carcinoma requiring multiple surgical interventions, especially when left with a solitary kidney. Despite the high complication rate, renal function is preserved in most patients and they have an excellent oncological outcome. The financial benefit of repeat renal surgery is reached at less than 1 year.