Minimally invasive surgical therapies for benign prostatic hyperplasia in the geriatric population: A systematic review

BACKGROUND

Geriatric patients, prone to adverse events (AEs) and low compliance with drugs, may benefit from minimally invasive surgical therapies (MISTs) for managing benign prostatic hyperplasia (BPH). We evaluated the efficacy, safety, and procedural characteristics of MISTs in geriatric patients with BPH.

METHODS

PubMed/MEDLINE database was systematically searched for relevant articles through October 1, 2023. Eligible studies focused on geriatric patients (≥65 years) with BPH who were treated with MISTs and evaluated follow-up surgical, micturition, and/or sexual outcomes. Studies were included if there was separate reporting for age subgroups ≥65 years, or if the mean age minus standard deviation was ≥65 years, or if the first quartile was ≥65 years.

RESULTS

Out of 292 screened studies, 32 (N = 3972 patients) met inclusion criteria and assessed prostatic artery embolization (PAE), Rezum, GreenLight, holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP), diode laser enucleation of the prostate (DiLEP), and Aquablation. Except for Rezum, all MISTs required a planned overnight stay. While PAE and Rezum could be performed under local anesthesia, the other MISTs needed general or spinal anesthesia. Postoperative catheterization duration was longest for PAE (median 14 days) and Rezum (21 days) and shortest for GreenLight (1.9 days). At 12 months postoperatively, all MISTs exhibited significant percent changes in International Prostate Symptom Score (median -69.9%) and quality of life (median -72.5%). Clavien-Dindo Grade 1 AEs ranged widely, with PAE (5.8%-36.8%), Rezum (0%-62.1%), and GreenLight (0%-67.6%) having the largest range, and HoLEP (0%-9.5%), ThuLEP (2%-6.9%), and DiLEP (5%-17.5%) having the smallest. PAE, Rezum, DiLEP, and Aquablation reported no significant changes in the International Index of Erectile Function.

CONCLUSIONS

Although all the MISTs reviewed in this study effectively treat BPH in geriatric patients, differences in procedural characteristics and safety profiles across MISTs were considerable. Physicians should use shared decision-making processes, considering risks and patient characteristics, when choosing a suitable treatment option for their patients.

Post-acute COVID-19 complications in UK doctors: results of a cross-sectional survey

BACKGROUND

As a consequence of their occupation, doctors and other healthcare workers were at higher risk of contracting coronavirus disease 2019 (COVID-19), and more likely to experience severe disease compared to the general population. However, systematic information on post-acute COVID complications in doctors is very limited.

AIMS

This study aimed to determine the symptoms, perceived determinants, health and occupational impact, and consequent needs relating to post-acute COVID complications in UK doctors.

METHODS

An online cross-sectional survey was distributed to UK doctors self-identifying as having Long COVID or other post-acute COVID complications.

RESULTS

Of 795 responses, 603 fulfilled the inclusion criteria of being a UK-based medical doctor experiencing one or more post-acute COVID complications. Twenty-eight per cent reported a lack of adequate Respiratory Protective Equipment at the time of contracting COVID-19. Eighteen per cent of eligible respondents reported that they had been unable to return to work since acquiring COVID.

CONCLUSIONS

Post-acute COVID (Long COVID) in UK doctors is a substantial burden for respondents to our questionnaire. The results indicated that insufficient respiratory protection could have contributed to occupational disease, with COVID-19 being contracted in the workplace, and resultant post-COVID complications. Although it may be too late to address the perceived determinants of inadequate protection for those already suffering with Long COVID, more investment is needed in rehabilitation and support of those afflicted.

Quantitative uptake in 99m Tc-EDDA/HYNIC-TOC somatostatin receptor imaging - the effect of long-acting release somatostatin analogue therapy

PURPOSE

Withdrawal of long-acting release somatostatin analogue (LAR-SSA) treatment before somatostatin receptor imaging is based on empirical reasoning that it may block uptake at receptor sites. This study aims to quantify differences in uptake of 99m Tc-EDDA/HYNIC-TOC between patients receiving LAR-SSA and those who were not.

METHODS

Quantification of 177 patients (55 on LAR-SSA) imaged with 99m Tc-EDDA/HYNIC-TOC was performed, with analysis of pathological tissue and organs with physiological uptake using thresholded volumes of interest. Standardised uptake values (SUVs) and tumour/background (T/B) ratios were calculated and compared between the two patient groups.

RESULTS

SUVs were significantly lower for physiological organ uptake for patients on LAR-SSA (e.g. spleen: SUV max 13.3 ± 5.9 versus 33.9 ± 9.0, P  < 0.001); there was no significant difference for sites of pathological uptake (e.g. nodal metastases: SUV max 19.2 ± 13.0 versus 17.4 ± 11.5, P  = 0.552) apart from bone metastases (SUV max 14.1 ± 13.5 versus 7.7 ± 8.0, P  = 0.017) where it was significantly higher.

CONCLUSION

LAR-SSA has an effect only on physiological organ uptake of 99m Tc-EDDA/HYNIC-TOC, reducing uptake. It has no significant effect on pathological uptake for most sites of primary and metastatic disease. This should be taken into account if making quantitative measurements, calculating T/B ratios or assigning Krenning Scores. There is the potential for improved dosimetric results in Peptide Receptor Radionuclide Therapy by maintaining patients on LAR-SSA.

Factors Influencing Medical Students' Pursuit of Urology: Results From the AUA Census (2019-2021)

INTRODUCTION

Growing interest in urology among medical students highlights the need to understand factors influencing their specialty choice in today's context. We also investigate COVID-19's impact on these factors and any disparities among female and underrepresented in medicine (URiM) students.

METHODS

From 2019 to 2021, the AUA Annual Census survey included medical student-focused questions on demographics, career interests, and decision factors. Responses were analyzed.

RESULTS

One hundred ninety-two medical students participated. Thirty-six (24%) identified as female and 19 (13%) as URiM. Common reasons students would choose urology included surgical procedures (93%) and "good lifestyle" among surgical careers (85%), with no differences across gender or URiM status. Compared to pre-COVID (2019), during COVID (2020-2021), a greater proportion of students cited cutting-edge technology (90.1% vs 73.1%, P = .008) and surgical procedures (98.6% vs 87.2%, P = .008) as reasons to choose urology. Reasons for not choosing urology included competitiveness (48%) and poor lifestyle (26%). Female and URiM students expressed concern related to the combined "male dominated/gender discrimination/lack of diversity" aspect (female 33% vs male 3%, P < .001; URiM 25% vs non-URiM 7%, P = .04).

CONCLUSIONS

The AUA Census survey highlights factors influencing medical students' decisions regarding urology. Interest in procedural and technological aspects grew during COVID. Students expressed concern over the field's competitiveness and poor lifestyle, while also acknowledging that urology offers a favorable lifestyle compared to other surgical careers. Female and URiM students expressed ongoing concerns over the combined aspect of gender discrimination and/or the lack of existing diversity in the field.

Imaging After Ureteroscopy: Practice Patterns, Patient Adherence and Impact on Subsequent Management in an Urban Academic Hospital System

OBJECTIVE

To evaluate practice patterns of post-ureteroscopy (URS) imaging, to assess predictors of imaging order, type and completion, and to analyze impact on patient management.

METHODS

We conducted a retrospective review of patients who underwent URS for nephrolithiasis at a single institution between May, 2020 to May, 2021. Patient demographic, clinical and operative characteristics were reviewed, and surgeons' years in practice. Post-URS imaging studies less than 6 months post-operative were reviewed. Changes in patient management were defined as additional imaging tests ordered or subsequent unplanned surgery. Patient, provider and surgical variables were compared between those who had imaging ordered and those who did not.

RESULTS

A total of 289 patients underwent URS. About 234 (81.0%) had post-operative imaging ordered; 147 (62.8%) completed them. Baseline demographics, stone and surgical variables were similar among those who did and did not have imaging ordered and among patients who completed imaging and did not. Pre-operative hydronephrosis was associated with ordering of post-operative imaging (OR = 4.08, P = .01). Urologists in practice less than 5 years were more likely to order post-operative imaging compared to those in practice for more than 5 years (<5: 90.6%, 15+: 53.7%; P <.001). Management changed for 52 of 147 (35.4%) patients who completed imaging; additional imaging was ordered for 38 patients (25.9%) and a second, unplanned surgery was performed for 14 (9.5%).

CONCLUSION

The main predictive factor of ordering post-URS imaging was surgeons' time in practice and pre-operative hydronephrosis. Post-operative imaging changed management in 35.4% of patients. We recommend the development of guidelines encouraging routine imaging for patients following ureteroscopy.

Same-day discharge following minimally invasive partial and radical nephrectomy: a National Surgical Quality Improvement Program (NSQIP) analysis

PURPOSE

Minimally invasive partial nephrectomy (MIPN) and radical nephrectomy (MIRN) have successfully resulted in shorter length of stay (LOS) for patients. Using a national cohort, we compared 30-day outcomes of SDD (LOS = 0) versus standard-length discharge (SLD, LOS = 1-3) for MIRN and MIPN.

METHODS

All patients who underwent MIPN (CPT 50,543) or MIRN (CPT 50,545) in the ACS-NSQIP database from 2012 to 2019 were reviewed. SDD and SLD groups were matched 1:1 by age, sex, race, body mass index, American Society of Anesthesiologists score, and medical comorbidities. We compared baseline characteristics, 30-day Clavien-Dindo (CD) complications, reoperations, and readmissions between SDD and SLD groups. Multivariable logistic regressions were used to evaluate predictors of adverse outcomes.

RESULTS

28,140 minimally invasive nephrectomy patients were included (SDD n = 237 [0.8%], SLD n = 27,903 [99.2%]). There were no significant differences in 30-day readmissions, CD I/II, CDIII, or CD IV complications before and after matching SDD and SLD groups. On multivariate regression analysis, SDD did not confer increased risk of 30-day complications or readmissions for both MIPN and MIRN.

CONCLUSION

SDD after MIPN and MIRN did not confer increased risk of postoperative complications, reoperation, or readmission compared to SLD. Further research should explore optimal patient selection to ensure safe expansion of this initiative.

Inhibition of novel lipoprotein(a) receptor major facilitator superfamily domain containing 5 (MFSD5) reduces development of aortic valve calcification

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Private grant from Kowa Pharmaceuticals to Brigham and Woman's Hospital

Calcific aortic valve stenosis (CAVS) is the most prevent valvular heart disease in the western world increasing exponentially with age, with an 112% increase in CAVS deaths in the last three decades; however no therapeutic treatment is currently available. Recently, lipoprotein(a) [Lp(a)] has been demonstrated to be an independent and causal risk factor for CAVS, yet the understanding of its cellular uptake and catabolism is limited thus underscoring the need for further investigation.

This study aimed to determine a target receptor, unique for Lp(a) on the surface of valvular interstitial cells (VICs) and ascertain the role of the receptor on the development of VIC calcification.

Unbiased ligand-receptor capture mass spectrometry (TriCEPS) was used to identify target receptor, with western blotting, ELISA, qPCR, alizarin red calcium staining and immunofluorescence used to validate the targets in vitro via siRNA inhibition and overexpression. Transmission electron microscopy (TEM) was used to determine uptake of Lp(a) within excised human valves. Identification of small molecule inhibitors was assessed computationally via the L1000 dataset, with the top hit candidate validated in vitro. Genotype-phenotype studies were examined using the United Kingdom Biobank (UKBB) and the Millions Veterans Program. Linear regression was used to evaluate association between aortic stenosis and plasma Lp(a) levels, and a phenotype-wide association analysis was then performed against this generated ‘genotype’.

Ligand-receptor capture mass spectrometry was used to detect novel membrane proteins with specific binding to Lp(a); MFSD5, MRC2, LDLR were identified as possible candidates. MFSD5 RNAscope demonstrated its presence in human aortic valves. Lp(a) uptake in VICs was confirmed via western blot and TEM. MFSD5 siRNA significantly reduced dil-labelled Lp(a) uptake in human VICs (p=0.003) and HEPG2 cells (p=0.0003), conversely MFSD5 overexpression increased uptake (p=0.0345, p=0.0318), whilst specificity of MFSD5 to Lp(a) alone was shown via no change in LDL uptake following MFSD5 inhibition (p=0.616, p=0.991). MFSD5 inhibition reduced RUNX2 (p=0.0124) and Osteocalcin (p&lt;0.001) RNA expression and reduced alizarin red staining following culture in Lp(a) osteogenic media for 21 days (p&lt;0.0033). Druggability of MFSD5 was confirmed by the L1000 database, which identified aminopurvalanol as a binding partner for MFSD5 and significantly reduced Lp(a) uptake within VICs (p=0.0091). MFSD5-loss of function within the UKBB showed no significant cardiovascular association, however 50kb +/- of the MFSD5 gene showed nominal association with hyperlipidaemia and atrial fibrillation.

The current study demonstrates the novel Lp(a) receptor MFSD5 may be responsible for uptake of Lp(a) within VICs, resulting in the development of aortic valve calcification, highlighting the need for further exploration into the role of MFSD5 in aortic valve disease.

POS0057 INDUCIBLE REGULATORY SYNOVIAL MACROPHAGES: A PROOF-OF-CONCEPT STUDY FOR A CELL-BASED TARGETED THERAPY FOR RHEUMATOID ARTHRITIS

Background

Infiltration of monocyte-derived macrophages into the synovial tissue (ST) is a hallmark of rheumatoid arthritis (RA) pathology. These macrophages promote inflammation, local joint effusion, and joint damage via the release of cytokines, oxygen reactive species, and tissue damaging enzymes. However, balancing these, are the ‘regulatory’ macrophages with inflammation-resolving properties, characterised by expression of CD206 and MerTK, dominant within the ST of healthy individuals as well as RA patients in remission (1). Indeed, these cells are believed to actively contribute to the maintenance of remission.

Macrophages are known to exhibit remarkable phenotypic plasticity and understanding the role of this characteristic in regulating inflammation and pathology remains a major challenge, as does the characterization of factors in the microenvironment such as the synovium that control such macrophage characteristics. Importantly, whether the infiltrating, inflammatory macrophages of the RA ST similarly exhibit such phenotypic plasticity, and whether this occurs during the process of reaching remission, remains to be studied.

Objectives

We investigated the phenotypic plasticity of inflammatory synovial macrophages from patients with RA in vitro, investigating their ability to convert from an inflammatory macrophage population into ‘regulatory’ CD206+MerTK+ macrophages. These findings will provide a proof-of-concept as to the utility of these macrophage for a cell-based therapy in resolving inflammation in patients with RA, and will likely extend our understanding of the mechanisms of action of currently used therapeutics.

Methods

Synovial fluid (SF) mononuclear cells were obtained from patients with active early RA (<1 year; fulfilling 2010 ACR/EULAR classification criteria). Cryopreserved SFMCs were cultured for 48hr in the presence of 10 ng/mL interferon(IFN)γ, 50 ng/mL dexamethasone, 10 μg/mL Infliximab, or diluent. Following culture, cells were immunostained and analysed using a Beckman Coulter CytoFLEX flow cytometer and FlowJo software. SF macrophages were characterised by expression of CD14, CD45, CD68 (Figure 1A), and proportions of CD206+ MerTK+ macrophages measured.

Figure 1.

Synovial fluid CD68+macrophage plasticity in vitro. (A) Gating strategy depicting CD68+ CD45+CD14+ SF macrophage determination. (B) Proportions of CD206 and MerTK-expressing SF macrophages after 48hr culture in the presence of 10 ng/mL IFNγ, 50 ng/mL dexamethasone or 10 µg/mL Infliximab, or absence. Data are representative of 5 individual experiments. Data were analysed by two-way ANOVA followed by Dunnett’s multiple comparison test, *p<0.05.

Results

Prior to culture, the CD68+ macrophage populations present in SF were found to be predominantly CD206-MerTK-. After 48 hours of culture, in the absence of any stimulus, there was an increase in proportions of CD206+MerTK+ macrophages. Treatment with either dexamethasone or anti-TNF (Infliximab) resulted in a further increase in proportions of CD206+ MerTK+, M2-like macrophages. In contrast, culture with IFNγ induced a reduction in this population. Importantly, we found that the generated CD206+MerTK+ macrophages were phenotypically stable in culture following removal of these differentiating agents.

Conclusion

Our findings demonstrate that inflammatory SF cells are indeed able to polarise to regulatory, CD206+MerTK+ macrophages in vitro. The findings provide further mechanistic insights into the basis for the therapeutic benefits of glucocorticoids and TNF inhibitors, as well as providing initial proof-of-concept in the use of regulatory macrophages as a cellular-based therapy or therapeutic target for patients with RA.

References

[1]Alivernini S, MacDonald L, Elmesmari A, et al., Distinct synovial tissue macrophage subsets regulate inflammation and remission in rheumatoid arthritis. Nature Medicine. 2020;26(8):1295-306 10.1038/s41591-020-0939-8.

Disclosure of Interests

None declared

Annual prevalence estimation of lymphatic malformation with a cutaneous component: observational study of a national representative sample of physicians

Background

Lymphatic malformations (LMs) represent a potentially life-threatening, rare disease of the lymphatic system characterized by development of abnormal vessels, outpouchings, or cysts filled with lymphatic fluid. There are three morphologic types of LMs based on the size of the individual cysts: macrocystic (typically > 2 cm), microcystic (generally < 2 cm), and mixed (includes aspects of both). Macrocystic LMs typically exist beneath the skin and often can involve vascular components and/or organs. Microcystic LMs often have a cutaneous component and clinically present with lymphorrhea, bleeding, pain, itching, malodor, and functional deficits. There are no treatments approved by the US Food and Drug Administration (FDA) for either macrocystic or microcystic lymphatic malformations. The totality of the epidemiologic literature for LM is limited to the incidence of the disease among various birth cohorts. This is the first nationally representative study to estimate the national managed prevalence for patients with microcystic LM or combined LM with a cutaneous component annually across physician specialties likely to manage this condition. We conducted a retrospective observational survey of a nationally representative sample of patient-care physicians in the United States most likely to manage lymphatic malformations with a cutaneous component (LMC). Once recruited, target physicians participated via an electronic questionnaire. We weighted study physician self-estimates of the number of LMC patients treated in the past 12 months to reflect the specialists’ corresponding proportion in the national universe. All patient information was anonymous; no personally identifiable information was collected.

Results

Of the 420 physicians who visited the study website, 316 agreed to be screened and to participate (75.2% participation rate). Our survey results indicated the estimated number of unique annually managed LMC patients by target specialists is 79,920 (CI 66,600–93,250). This number corresponds to managed prevalence of 24.1 LMC patients per 100,000 population (CI 19.6/100,000–28.4/100,000).

Conclusions

The study indicates that while rare, LMC affects a substantial number of people in the US (79,920) who are being managed by one or more specialists. By better understanding the prevalence of people living with LMC who require treatment, efforts to both increase disease awareness and to identify underserved populations in need of potential new treatments can be better focused.

Updating the landmark literature for the practice of geriatrics: Notable articles from 2012-2019

BACKGROUND

Remaining current on the latest advances in the peer-reviewed literature is a basic tenant of medical education and evidence-based practice. We updated an important prior publication (Vaughan, et al.) identifying landmark articles in geriatric medicine by considering the influence of altmetrics and updating the list with notable articles published between 2012 and 2019.

METHODS

Articles were identified by searching Web of Science and Scopus for highly cited articles clinically relevant to geriatrics or gerontology and by searching the Altmetric Explorer database for relevant articles with high altmetric scores. The results of the literature search were screened and evaluated using a bibliometric score consisting of an adjusted journal impact factor, citation count, and altmetric score.

RESULTS

The top 12 notable articles in geriatrics were selected by a consensus panel and ranked using an expert opinion survey. This process reinforces the concept of combining subjective and objective measures to identify notable articles to be used for the education of healthcare professionals in geriatrics principles of care for older adults.

CONCLUSIONS

While our update was performed approximately 9 years after the initial identification of landmark articles, we propose that future updates are conducted at an interval of every 5 years by the governance of a national professional society.

Cross-sectional and comparative analysis of videos on erectile dysfunction treatment on YouTube and TikTok

The aim of this study was to evaluate the quality of information regarding erectile dysfunction (ED) treatment on YouTube and TikTok. The term "erectile dysfunction" was searched on YouTube and TikTok in July 2021. The first 50 videos on each platform that met inclusion were included. Videos were sorted as reliable or unreliable based on accuracy of video content. Quality of information was evaluated using Patient Education Materials Assessment Tool (PEMAT) and 5-point modified DISCERN. TikTok videos were shorter (0.4 minutes vs. 5.2 minutes, p < 0.001) and had more likes (2294 vs. 1000, p = 0.005), views per month (17,281 vs. 3521, p < 0.001) and subscribers/followers (97,500 vs. 23,000, p = 0.016) than YouTube videos. TikTok videos were less reliable than YouTube videos (TikTok 5/50 [10%] vs. YouTube 21/50 [42%], p < 0.001). YouTube mentioned more about phosphodiesterase type 5 inhibitors (32% vs. 10%, p = 0.007), while TikTok mentioned more about alternative supplements (36% vs. 4%, p < 0.001). YouTube had a higher DISCERN (1.99 vs. 0.98, p < 0.001) and PEMAT actionability scores (64.2% vs. 54.0%, p = 0.039) when compared to TikTok. YouTube videos were of higher quality than TikTok videos. Nevertheless, YouTube had a considerable amount of unreliable information. We recommend a collaborative effort from the medical community to improve information regarding ED treatment on YouTube and TikTok.

#AUAMatch: The Impact of COVID-19 on Social Media Use in the Urology Residency Match

OBJECTIVES

To examine changes in Social Media (SoMe) use among urology residency applicants before and after the COVID-19 pandemic.

METHODS

We distributed surveys to individuals who applied to our residency program for application cycles ending in 2018, 2019, and 2021. The surveys included questions about applicants' SoMe use and perceptions of programs' SoMe use during the application process, both before (2018/2019) and after (2021) the COVID-19 pandemic. The primary outcome was SoMe use for professional purposes.

RESULTS

We received survey responses from 33% (162 of 496) and 29% (84 of 294) of applicants from the 2018/2019 and 2021 cohorts, respectively. There was a significant increase in professional SoMe use in the 2021 cohort (80%) compared with the 2018/2019 cohort (44%) (P < .001). In 2021 compared to 2018/2019, more applicants used SoMe to connect directly with residents (69% vs 34%, P < .001) and with faculty members (65% vs 15%, P < .001). Applicants in 2021 compared to 2018/2019 more often found SoMe to be useful for making decisions about applying to (33% vs 10%), interviewing at (26% vs 7%), and ranking programs (20% vs 9%) (all P < .05). Twitter was the most common platform for applicants to access program information, increasing from 38% to 71%.

CONCLUSION

The COVID-19 pandemic ushered in a period of unprecedented SoMe usage among urology applicants, who used it to learn about and connect with residency programs in new ways. The use of SoMe by residency programs has become an important component of trainee recruitment and is likely to continue in the future.

Evidence of Resilience in Kidney Donors: A New York Statewide Cohort Analysis

INTRODUCTION

Donor nephrectomy (DN) is a procedure performed to provide recipients with a kidney to treat end-stage renal disease. The following analysis evaluated depression diagnosis in DN patients compared to controls.

METHODS

DN patients and matched controls were identified between 2000 and 2009 from the Statewide Planning and Research Cooperative System database. Cohorts were tracked for depression incidence. Multivariable logistic regression was used to determine independent predictors of a postoperative depression diagnosis.

RESULTS

The total study cohort included 2108 DN cases and 2108 controls. In both donors and controls, the baseline rate of depression was 0.95% (n = 20). The 5-year incidence of depression diagnosis after exposure increased in both cohorts (donors: 2.5%, n = 53; controls: 7.2%, n = 152; P < .001). The 5-year relative risk for developing depression was 2.65 (CI 1.59-4.42, P = .0002) in donors and 7.60 (CI 4.79-12.07, P < .001) in controls. On multivariable regression, being a donor was associated with reduced risk of developing postoperative depression (OR = 0.322, CI 0.233-0.445, P < .001), and the greatest risk factor for postoperative depression was a prior depressive diagnosis (OR = 7.811, CI 3.814-15.997, P < .001).

CONCLUSION

Our analysis shows that the strongest risk factor for depression was a prior diagnosis of depression. However, willingness to undergo donor nephrectomy is associated with less subsequent depression than the control population, suggesting that kidney donors may be a more resilient cohort.

Urology Virtual Education Programs During the COVID-19 Pandemic

Purpose of Review

This article aims to describe the impact of the COVID-19 pandemic on American urology trainees, with a focus on virtual learning initiatives.

Recent Findings

Urological education was forced to rapidly adapt to the COVID-19 pandemic in 2020. Significant challenges included quarantines, redeployment of residents and faculty, and suspension of regularly scheduled conferences. In response, urologists across the country adopted web-based platforms to develop virtual lecture series to fill the gap. Popular programs for residents included UCSF’s COViD (Collaborative Online Video Didactics) series and the New York Section of the American Urological Association’s EMPIRE (Educational Multi-institutional Program for Instructing REsidents) series.

Summary

Virtual education programs have enabled urology trainees to pursue their education during the pandemic. While the long-term impact of the pandemic on urology training remains unknown, some good may be found in the innovative solutions that have arisen in urology education.

The intravesical injection of highly purified botulinum toxin for the treatment of neurogenic detrusor overactivity

INTRODUCTION

We aimed to assess safety and efficacy of incobotulinumtoxinA for the treatment of neurogenic detrusor overactivity (NDO).

METHODS

We identified patients with NDO confirmed on urodynamics (UDS) and reported urgency incontinence (UI) in those who received intravesical incobotulinumtoxin A injection for neurogenic bladder between November 2013 and May 2017. Parameters studied were daytime frequency, daily incontinence episodes, daily pad use, clean intermittent catheterization (CIC) volumes, symptom scores (UDI6, IIQ7, PGII), and complications.

RESULTS

We examined 17 male patients who met inclusion criteria and underwent incobotulinumtoxinA injection. Mean age was 61.2±15.4 years. Fourteen patients (82%) were taking oral antimuscarinics prior to the incobotulinumtoxin A injection. There were improvements in the following parameters: average daily pads (4.5 to 3.3, p=0.465), daily urinary frequency (9.4 to 4.6, p=0.048), daily incontinent episodes (2.5 to 0.4, p=0.033), CIC volumes (400 to 550 mL, p=0.356), hours in between CIC (3.6 to 5.2, p=0.127), and the validated questionnaires UDI6 (30.6 to 7.4, p=0.543) and IIQ7 (52.4 to 6.8, p=0.029). There were no documented symptomatic urinary tract infections (UTIs) within 30 days of injection or reports of de novo urinary retention. Nine of 17 patients (53%) reported being dry at their first postoperative visit.

CONCLUSIONS

In this preliminary pilot study of a small cohort of males with NDO and UI, significant improvements were seen following incobotulinumtoxinA injection in daily frequency, incontinence episodes, hours in between CIC, and quality of life. Larger-scale and long-term studies are required to confirm these results, but initial findings are promising for wider use of this formulation.

Magnetic-Assisted Robotic and Laparoscopic Renal Surgery: Initial Clinical Experience with the Levita Magnetic Surgical System

Introduction: The Levita™ Magnetic Surgical System (LMSS) is a new device that can provide retraction using magnets and can reduce the number of ports used during laparoscopic and robotic procedure. It is U.S. Food and Drug Administration (FDA) approved for laparoscopic cholecystectomy, bariatric operation, and robotic radical prostatectomy. Our objective was to evaluate the safety and feasibility of the magnetic surgical system during renal procedure. Methods: We performed a prospective, single-center, single-arm, open-label study to assess the safety and performance of the LMSS. The system includes a deployable, single-use magnetic grasper and a reusable external magnet. Selected patients undergoing either laparoscopic or robotic renal procedure from April 2019 to August 2019 were included. Robotic procedures were performed with the da Vinci Xi or single-port (SP) surgical platforms. Preoperative demographic, intraoperative data, and postoperative data were collected and analyzed. Results: Ten procedures were performed using the LMSS. Cases included Xi robotic partial nephrectomy (n = 3), Xi robotic radical nephrectomy (n = 2), SP robotic partial nephrectomy (n = 2), SP robotic pyeloplasty (n = 1), laparoscopic donor nephrectomy (n = 1), and laparoscopic radical nephrectomy (n = 1). No cases required conversion to an open procedure. Issues included one small liver capsular tear from the device jaws necessitating fulguration and occasional robotic "recoverable fault" errors when the external magnet was placed too close to the robotic arms. All patients were discharged home on postoperative day 1 or 2, and there were no readmissions within 30 days. Conclusions: This is the first report on the use of the LMSS for renal procedure. Its use for laparoscopic and robotic renal procedure appears safe and feasible. The grasper is especially useful for exposing the renal hilum during dissection and the ureteropelvic junction during SP robotic procedures, mimicking multiport techniques. Further study is required to optimize use of the LMSS and evaluate its cost effectiveness.

Marine plastics threaten giant Atlantic Marine Protected Areas

There has been a recent shift in global perception of plastics in the environment, resulting in a call for greater action. Science and the popular media have highlighted plastic as an increasing stressor [1,2]. Efforts have been made to confer protected status to some remote locations, forming some of the world's largest Marine Protected Areas, including several UK overseas territories. We assessed plastic at these remote Atlantic Marine Protected Areas, surveying the shore, sea surface, water column and seabed, and found drastic changes from 2013-2018. Working from the RRS James Clark Ross at Ascension, St. Helena, Tristan da Cunha, Gough and the Falkland Islands (Figure 1A), we showed that marine debris on beaches has increased more than 10 fold in the past decade. Sea surface plastics have also increased, with in-water plastics occurring at densities of 0.1 items m^-3; plastics on seabeds were observed at ≤ 0.01 items m^-2. For the first time, beach densities of plastics at remote South Atlantic sites approached those at industrialised North Atlantic sites. This increase even occurs hundreds of meters down on seamounts. We also investigated plastic incidence in 2,243 animals (comprising 26 species) across remote South Atlantic oceanic food webs, ranging from plankton to seabirds. We found that plastics had been ingested by primary consumers (zooplankton) to top predators (seabirds) at high rates. These findings suggest that MPA status will not mitigate the threat of plastic proliferation to this rich, unique and threatened biodiversity.

Assessment of the T-SPOT.CMV interferon-γ release assay in renal transplant recipients: A single center cohort study

Background

The measurement of CMV specific cellular immunity in organ transplant recipients could contribute additional acuity to serology based, CMV infection risk stratification, facilitating optimisation of immunosuppression and anti-viral prophylaxis.

Methods

A pilot study of renal transplant recipient (RTR’s) responses in the T-SPOT.CMV ELISPOT based assay. 108 RTR’s were recruited 3 months post-transplantation, immediately prior to the cessation of stratified anti-viral prophylaxis, used in recipients from seropositive donors. RTR’s were monitored for CMV viremia and disease. Cellular responses to peptides derived from CMV IE1 and pp65 were measured, using the T-SPOT.CMV assay.

Results

At recruitment, no CMV specific cellular immunity was detected by T-SPOT.CMV in CMV seronegative recipients (IE1 ≤ 1spot / 2.5x10⁵ PBMC’s; pp65 ≤ 3 spots / 2.5x10⁵ PBMC’s). At recruitment, CMV sero-positive recipients who made a robust response to both IE1 (>25 spots / 2.5x10⁵ PBMC’s) and pp65 (>50 spots / 2.5x10⁵ PBMC’s), were less likely to develop high level viremia than those who responded to one or neither antigen (0/28 vs 5/25; p<0.02).

Conclusions

In CMV seronegative RTR’s, CMV specific cellular immunity measured by T-SPOT.CMV was not detected prior to cessation of anti-viral prophylaxis. This differs from recent reports of CMV specific cellular immunity in a proportion of CMV seronegative RTR’s, associated with protection from CMV infection. In seropositive RTR’s, a dual response to IE1 and pp65 at recruitment, was associated with protection from subsequent viremia. This suggests that assessing the diversity of response to CMV antigens, may enhance risk stratification in this group.

A protocol to recover needles lost during minimally invasive surgery

Background and Objectives:

The loss of an instrument during a surgical procedure is a potentially dangerous medical event. Retained surgical needles are reported to cause chronic pain, chronic irritation, and organ injury. Surgical needles lost during minimally invasive surgery are particularly difficult to retrieve because of their diminutive size and the camera's limited visual field, often prompting protracted recovery attempts that can add to surgical costs. Few detailed recommendations exist for the recovery of a misplaced needle.

Methods:

A survey was administered to minimally invasive surgeons across the United States to glean observations on the incidence of lost surgical needles and recovery techniques. Survey results were incorporated into an evidence-based protocol designed to expedite the recovery of lost surgical needles.

Results:

Three hundred five minimally invasive surgeons from 11 surgical subspecialties completed the survey. Sixty-four percent of participants reported having experienced a lost surgical needle, with a minimum of 112 needles lost during the past 1 year alone. Urologists, pediatric surgeons, and bariatric surgeons reported higher rates of needle loss than surgeons practicing other subspecialties (P = .001). Removal of a needle through a minimally invasive port and laparoscopic suturing were the 2 most common situations resulting in lost needles. A systematic visual search, abdominal radiography, fluoroscopy, and the use of a magnetic retriever were reported as the most successful strategies for needle recovery.

Conclusions:

On the basis of survey results and current literature, our protocol incorporates a camera survey of the abdomen, intraoperative fluoroscopic radiography, port inspection, and a quadrant-based systematic visual search for the recovery of needles lost during minimally invasive surgery.

Abstract P1-16-04: First-line chemotherapy for breast cancer patients by site of care (SOC): Treatment patterns, cost and quality indicators

Background: Previous studies found differences in treatment patterns and costs by SOC for first-line chemotherapy treatment for both early stage and metastatic breast cancer (esBC and mBC) in commercial populations. This study extends the research to a predominantly Medicare population comparing chemotherapy treatment patterns, cost and quality of care in physician office (PO) and hospital outpatient (HO) centers.

Methods: First-line chemotherapy or biologic therapy for esBC and mBC patients was compared by SOC. Patients initiating infusion therapy in 2008–2012 were identified in Humana medical claims data. First-line length of therapy (LOT) in days and number of infusions (NI) were calculated. SOC cohort (HO vs PO) was based on where the patient received ≥90% of their infusions. Total healthcare costs based on medical and pharmacy claims were assessed. Differences in quality indicators, use of infusions or hospitalizations 30 days prior to death were evaluated. SOC differences were assessed using X2, T-tests and Wilcoxon Rank Sum (Wil) tests. P-values are for X2 and Wil tests. Cost-related results are from generalized linear models adjusted for age, sex, comorbidity and geographic region. LOT and NI are presented as median (IQR).

Results: A total of 2,784 esBC patients (73% PO and 27% HO) and 1,602 mBC patients (64% PO and 36% HO) were identified. Most patients (67%) were Medicare beneficiaries. Mean comorbidity index was similar by SOC for esBC patients (PO 4.2, HO 4.1, p=0.3308) but higher in HO for mBC patients (PO 7.5, HO 7.9, p=0.0003). LOT in days for esBC was greater in the PO for anthracycline-based therapy, PO 64(43-72), HO 47(43-64), p=0.0420 and taxane-based therapy, PO 64(64-106), HO 64(64-76), p=0.0005. NI for esBC was greater in the PO for patients on biologic and cytotoxic therapy, PO 21(17-29), HO 18(16-25), p=0.038 and taxane–based therapy PO 4(4-6), HO 4(4-4), p=0.0005.

No difference in LOT by SOC was seen for mBC patients; however, patients on taxane-based therapy had a greater NI at the PO 6(4-12) vs HO 5.5(4-9), p=0.0225.

Total healthcare costs were higher in the HO vs PO setting for esBC and mBC patients. Costs were 22% higher in the HO $51,191 vs PO $41,943, p&lt;0.0001 for esBC patients and 17% higher in the HO $58,105 vs PO $49,591, p&lt;0.0001 for mBC patients.

There were no statistically significant differences in use of infusions or hospitalizations 30 days prior to death among Medicare patients. Among 223 esBC and 369 mBC Medicare patients who died, use of infusions prior to death was 24% for HO and 16% for PO among esBC, p=0.2357 and 23% for HO and 26% for PO among mBC, p=0.5319. Hospitalizations prior to death were 59% for HO and 59% for PO for esBC, p=0.9940 and 60% for HO and 55% for PO for mBC, p=0.3105.

Conclusion: Differences by site of care, particularly in healthcare costs, were found in a mostly Medicare population of esBC and mBC patients. Patients in the HO setting had shorter length of therapy and fewer infusions, but had higher total healthcare costs than those in the PO setting. Quality indicators, infusions and hospitalizations prior to death were similar by site of care. Future research will focus on other quality indicators and patient satisfaction.

Citation Format: Masaquel A, Hopson S, Casebeer A, Drzayich-Jankus D, Tao Z, Stemkowski S, Howe A, Patton J, Small A, Barnett B. First-line chemotherapy for breast cancer patients by site of care (SOC): Treatment patterns, cost and quality indicators. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-16-04.

High prevalence of the liver fluke Amphimerus sp. in domestic cats and dogs in an area for human amphimeriasis in Ecuador

Background

Amphimerus sp. is a liver fluke which recently has been shown to have a high prevalence of infection among an indigenous group, Chachi, who reside in a tropical rainforest in the northwestern region of Ecuador. Since it is unknown which animals can act as a reservoir and/or definitive hosts for Amphimerus sp. in this endemic area, a study was done to determine the prevalence of infection in domestic cats and dogs. This information is important to understand the epidemiology, life cycle and control of this parasite.

Methodology/Findings

In July 2012, three Chachi communities located on Rio Cayapas, province of Esmeraldas, were surveyed. A total of 89 of the 109 registered households participated in the study. Of the 27 cats and 43 dogs found residing in the communities, stool samples were collected from 14 cats and 31 dogs (total of 45 animals) and examined microscopically for the presence of Amphimerus eggs. The prevalence of infection was 71.4% in cats and 38.7% in dogs, with similar rates of infection in all three communities. Significantly more cats were infected than dogs (p = 0.042).

Conclusions/Significance

The data show a high rate of Amphimerus sp. infection in domestic cats and dogs residing in Chachi communities. It can be concluded that these animals act as definitive and reservoir hosts for this liver fluke and that amphimeriasis is a zoonotic disease. These findings provide important epidemiological data which will aid in the development and implementation of control strategies against the transmission of Amphimerus.

Amphimerus sp. is a fluke that infects the bile ducts of its definitive hosts. Recently, it has been shown that an indigenous Amerindian group, the Chachi, living in a rural and remote tropical area of Ecuador, are infected with this parasite. The epidemiology and life cycle of this parasite remains elusive, and research is needed to understand the mode of transmission and zoonotic potential of the parasite. It was hypothesized that the domestic animals of the Chachi households may act as definitive and reservoir hosts for Amphimerus infection. Hence, the presence and prevalence of infection in these animals residing in communities endemic for human amphimeriasis was investigated. Some 45 animal stool samples were examined microscopically for the presence of Amphimerus eggs. The results showed an infection rate of 71.4% in cats and 38.7% in dogs. The data provided evidence that these domestic animals act as both definitive and reservoir hosts for the parasite and that amphimeriasis is a zoonotic disease. The implementation of a mass treatment/control program must target both humans and animals in order to minimize the transmission of this liver fluke.

The relationship of sex role to physical and psychological health

This study examined the relationship of sex-role typology, medical and psychiatric symptomatology, and personality functioning in adolescents. Seventy-nine males and 101 females with an average age of 18.3 were administered the Bem Sex Role Inventory (BSRI), Offer Self Image Questionnaire (OSIQ), Self Rating Depression Scale (SRDS), and Cornell Medical Index (CMI). In comparison to males, females reported significantly more medical and psychiatric symptomatology, including depression. Females were also found to have more concern and empathy for others and a better developed superego. They reported greater involvement in making future plans and were more conservative in their sexual attitudes. Sex-role typology yielded no significant differences on the medical and psychiatric scales, but consistent differences were found on the OSIQ, a measure of adolescent personality functioning. In general, the results indicated that androgynous teenagers in every case differed from the undifferentiated ones, with the masculine and feminine groups occupying a mid-position. Androgynous individuals always showed a more favorable adjustment. Undifferentiated individuals had a poorer defensive structure, less adequate coping mechanisms and affective integration, more confusion about body boundaries, and more difficulty in object relations. Androgynous individuals, in short, possessed adaptive capabilities and resources, such as effective coping techniques, emotional integration, communication skills, and a well-defined self-concept (i.e., ego strength and a high level of psychological integration). Since these results were obtained on a measure constructed solely to assess adolescent functioning, it seems possible to screen and identify adolescents who may be entering adulthood lacking the emotional, social, and occupational capacity to function in an optimal fashion.

Association of the Charlson comorbidity index and hypertension with survival in men with metastatic castration-resistant prostate cancer

OBJECTIVES

The independent prognostic effect of comorbidities on outcomes in men with metastatic castration-resistant prostate cancer (mCRPC) is unclear. We sought to determine whether the Charlson comorbidity index (CCI) and hypertension (HTN) are associated with overall survival (OS) independent of known clinical prognostic factors in mCRPC.

PATIENTS AND METHODS

A retrospective analysis was conducted on 221 patients with mCRPC treated with docetaxel plus prednisone combined with AT-101 (bcl-2 antagonist) or placebo on a prospective randomized phase II trial. The Cox regression analysis was performed to identify whether the CCI or HTN or both (by medical history) independently predicted OS after adjusting for baseline variables known to be associated with OS. The Wilcoxon rank sum test and the Fisher exact test were used to compare data by comorbidity groups (CCI as a continuous variable, CCI = 6 vs. CCI ≥ 7 and HTN vs. no HTN).

RESULTS

The CCI was 6 in 116 patients (52.7%), 7 in 70 (31.8%), 8 in 23 (10.5%), 9 in 4 (1.8%), and 10 in 7 patients (3.2%). HTN was present in 107 (48.6%) patients. Patients with CCI of ≥ 7 were older and exhibited worse performance status and anemia than patients with CCI of 6 (P<0.05). The CCI was not independently predictive of OS on univariable and multivariable analyses. HTN alone or in combination with the CCI was borderline significantly associated with OS (P ~ 0.09) on both univariable and multivariable analyses.

CONCLUSIONS

The CCI did not predict OS independent of known prognostic factors in mCRPC. Age, performance status, and anemia may adequately capture comorbidities in the context of mCRPC, given their association with higher CCI. Further prospective study of comorbidities in a larger data set may be warranted. The study of HTN in a larger data set may also be warranted given its borderline-independent association with OS.

An evaluation of selected methods for the decontamination of cattle hides prior to skinning

The effectiveness of different decontamination treatments in reducing microbial loads on cattle hides was assessed. The 10-s hide treatments were conducted using a wet-and-dry vacuum cleaner filled with one of the liquids (heated to 50 °C) indicated below, followed or not by 10-min drying in the air. Also, the hide was clipped, followed or not by 10-s singeing using a hand-held blowtorch. Before and after each decontamination treatment, the hide was sampled (100 cm(2) areas) by a sponge-swabbing method to compare the total viable counts of bacteria (TVC). The largest bacterial reduction (P<0.001; 2.31log(10) cfu/cm(2)) was achieved by singeing of previously clipped hide. Treatment of hide with a food industry sanitizer solution (10% Betane Plus) resulted in significant reductions of 1.80 (P<0.001) and 1.98log(10) cfu/cm(2) (P<0.001) without and with subsequent drying, respectively. Treatment of hide with a food industry disinfectant (P3-Topactive DES) significantly reduced TVC by 0.97 (P<0.001) and 1.18log(10) cfu/cm(2) (P<0.001) without and with subsequent drying, respectively. Treatments of hide with water alone or with a food-safe detergent solution (Formula 963B), or hide clipping alone, did not produce significant decontamination effects. Since hide contamination is associated with microbial contamination of the carcasses, the results indicate that post-killing/pre-skinning hide decontamination (used alone, or in combination with carcass decontamination) has a potential to improve microbial meat safety. Nevertheless, further research is required to optimise the efficacy of these treatments in the reduction of specific pathogens under commercial conditions.

Takotsubo cardiomyopathy: an Australian single centre experience with medium term follow up

BACKGROUND

Takotsubo cardiomyopathy (TC) is increasingly recognised in patients presenting with features of acute coronary syndrome. We present a single centre experience of TC with medium term follow up.

METHODS

Fifty-two consecutive patients presenting with a diagnosis of TC were included. The clinical presentation, complications, baseline and follow-up echocardiograms and cardiac magnetic resonance imaging were analysed.

RESULTS

Fifty-one patients were female. A stressful event preceded presentation in 37 (71%) patients. Chest pain was the most common symptom (83%). Two patients presented with an out-of-hospital cardiac arrest. ST segment elevation (40%) and global T wave inversion (44%) were the most frequent electrocardiogram changes. Left ventricular assessment demonstrated typical apical ballooning in 41 patients and 11 patients demonstrated the mid-wall variant. In-hospital complications occurred in 11 patients (21%) and included acute pulmonary oedema (n = 2), cardiogenic shock (n = 5); two of whom had a significant left ventricular outflow gradient, atrial fibrillation (n = 1), left ventricular thrombus (n = 2) and a cerebrovascular event (n = 2). Left ventricular function at presentation and follow up was compared in 40 patients. The mean ejection fraction in this group at presentation was 47% (20-70%) compared with that at follow up of 63% (44-76%). There were no significant complications or recurrences at follow up.

CONCLUSIONS

While TC is a reversible condition with low rates of complications and recurrence at follow up it is, as demonstrated in our cohort, associated with significant in-hospital morbidity in a proportion of patients.