Managing Urology Consultations During COVID-19 Pandemic: Application of a Structured Care Pathway

OBJECTIVE: To describe and evaluate a risk-stratified triage pathway for inpatient urology consultations during the SARS-CoV-2 (COVID-19) pandemic. This pathway seeks to outline a urology patient care strategy that reduces the transmission risk to both healthcare providers and patients, reduces the healthcare burden, and maintains appropriate patient care. MATERIALS AND METHODS: Consultations to the urology service during a 3-week period (March 16 to April 2, 2020) were triaged and managed via one of 3 pathways: Standard, Telemedicine, or High-Risk. Standard consults were in-person consults with non COVID-19 patients, High-Risk consults were in-person consults with COVID-19 positive/suspected patients, and Telemedicine consults were telephonic consults for low-acuity urologic issues in either group of patients. Patient demographics, consultation parameters and consultation outcomes were compared to consultations from the month of March 2019. Categorical variables were compared using Chi-square test and continuous variables using Mann-Whitney U test. A P value \u3c.05 was considered significant. RESULTS: Between March 16 and April 2, 2020, 53 inpatient consultations were performed. By following our triage pathway, a total of 19/53 consultations (35.8%) were performed via Telemedicine with no in-person exposure, 10/53 consultations (18.9%) were High-Risk, in which we strictly controlled the urology team member in-person contact, and the remainder, 24/53 consultations (45.2%), were performed as Standard in-person encounters. COVID-19 associated consultations represented 18/53 (34.0%) of all consultations during this period, and of these, 8/18 (44.4%) were managed successfully via Telemedicine alone. No team member developed COVID-19 infection. CONCLUSION: During the COVID-19 pandemic, most urology consultations can be managed in a patient and physician safety-conscious manner, by implementing a novel triage pathway

Kidney stone depiction on fictional television: how accurate are they?

Fictional portrayals of medical conditions on television have been shown to significantly shape understanding and management expectations of the viewing public. Given the high prevalence of kidney stone disease, we aimed to assess the frequency of its portrayal on US television and assess whether its depiction was reflective of the current epidemiology or management of urolithiasis in the US. A detailed search was conducted for English language depictions of kidney stones in fictional television using internet, movie and television database search engines. Television episodes with characters depicting a kidney stone occurrence were independently reviewed by two reviewers and analyzed for genre, initial air date on US television, character age, gender, race and management strategy. Seventeen episodes from 13 different television series portrayed a character with a symptomatic kidney stone. The majority were male (88%). Surgical intervention was performed in 7/17 cases (shockwave lithotripsy n = 1, ureteroscopy n = 2, nephrectomy n = 1, transurethral removal n = 1, unknown n = 2), spontaneous passage or medical expulsive therapy in 7/17 cases and no treatment or resolution portrayed in 3/17 cases. The only surgical complication shown was ureteral avulsion during ureteroscopy. Inpatient management was seen in 9/14 (64%) cases with event resolution. This study identified a number of kidney stone depictions that may be misleading or misrepresent the presentation and management of this condition. Although likely portrayed for plot development and dramatic effect, this could potentially reinforce inaccurate beliefs or misconceptions and future depictions should be mindful of this

Genital Sparing Robot-Assisted Radical Cystectomy with Intracorporeal Neobladder & Paravaginal Repair

OBJECTIVE: Vaginal prolapse is a known complication after radical cystectomy, requiring additional procedures in 10% of the patients. METHODS: The genital sparing technique preserves the uterus, fallopian tubes, ovaries, and vagina, while paravaginal repair involves suturing of the lateral vaginal wall to the arcuate fascia located on the medial aspect of the obturator internus muscle. The procedure begins by placing the patient in a lithotomy position, with a steep Trendelenburg. Standard 6 port cystectomy configuration is utilized with an additional 15 mm port for bowel anastomosis. Initially, the ureters and lateral bladder space are mobilized. Posteriorly a dissection plane is developed separating the bladder from the anterior vaginal wall. Distal dissection is carefully performed in that plane to avoid disrupting the urethral-external sphincter complex. Then the bladder is dropped from anterior attachments, the Dorsal venous complex (DVC) and bladder neck are exposed. Urethra is transected distal to the bladder neck, after circumferential mobilization, to complete the cystectomy, again avoiding disruption of the continence mechanism, and opening the endo-pelvic fascia. Cystectomy and pelvic lymph node dissection are completed in a standard fashion. The arcuate fascia is identified bilaterally for level I paravaginal repair. The lateral aspect of the paravaginal tissue is secured to this ligament, using 3 interrupted Polydioxanone (PDS) sutures, bilaterally. An ileal Hautman\u27s W pouch neobladder is constructed using 50 cm of the small intestine, similar to the previously reported technique. RESULTS: No intra or postoperative complications were noted. Robot dock time was 8 hours and 23 minutes with an EBL of 100 mL. The patient was discharged on post operative day (POD) 6 and Foley catheter with ureteral stents was removed on POD 27 after a cystogram confirmed no leaks. At 6-month follow-up, the patient reported good continence using a single pad, voiding every 3-4 hours. Fluoro-urodynamics demonstrated 651 mL capacity, low-pressure voiding, minimal residual urine, and no reflux. No prolapse was noted on fluoroscopy and pelvic examination with the Valsalva maneuver. The patient reported a good satisfaction level, regarding her urinary symptoms. CONCLUSION: We report satisfactory short-term outcomes of a feasible technique to prevent postcystectomy prolapse; however, long-term follow-up of a larger cohort can help establish its efficacy

Effect of Lesion Location on Prostate Cancer Detection Rate with Magnetic Resonance Imaging Targeted Biopsy in African Americans.

PURPOSE: The updated PI-RADS™ (Prostate Imaging Reporting and Data System) version 2 defines different grading parameters for lesions located in the peripheral zone vs the transition zone. It has contributed to the implementation of magnetic resonance imaging targeted biopsy. In this study we evaluated the efficacy of magnetic resonance imaging targeted biopsy among African American patients with additional consideration for lesion location on magnetic resonance imaging. MATERIALS AND METHODS: We performed a retrospective review of magnetic resonance imaging targeted biopsy at a single institution where a racially diverse population is treated. A single radiology group read the prostate multiparametric magnetic resonance imaging scans and followed PI-RADS version 2 algorithms to categorize lesions. RESULTS: A total of 214 lesions from 125 men were included in the analysis, of which 162 (75.7%) were in the peripheral zone and 52 (24.3%) were in the transition zone. There were 64 lesions from African American patients and 150 from Caucasian patients with tumor location distributed proportionately. The 48 anterior lesions (22.4%) had a higher PI-RADS version 2 score and trended toward a larger size. The overall cancer detection rate was 50%, which did not differ significantly between prostate zones (p = 0.5468) or racial groups (p = 0.2294). The cancer upgrade rate was 41% and it also did not differ significantly between prostate zones (p = 0.5134) or racial groups (p = 0.2365). Anterior lesions had a higher cancer detection rate (p = 0.0117) and trended toward a higher cancer upgrade rate (p = 0.0781). CONCLUSIONS: This study provides evidence that magnetic resonance imaging targeted biopsy is equally effective in African American and Caucasian men, and does not preferentially identify prostate cancer in the peripheral zone or the transition zone

Systematic Biopsy Does Not Contribute to Disease Upgrading in Patients Undergoing Targeted Biopsy for PI-RADS 5 Lesions Identified on Magnetic Resonance Imaging in the Course of Active Surveillance for Prostate Cancer.

OBJECTIVE: To compare the utility of the systematic 12-core prostate biopsy (SB) combined with magnetic resonance imaging (MRI)-targeted lesion biopsy (MRI-TB) vs MRI-TB alone in the diagnosis of high PI-RADS lesions. MATERIALS AND METHODS: Patients undergoing MRI-TB + SB for suspicious MRI lesions were retrospectively reviewed. These patients had a previous prostate biopsy and were evaluated with MRI to assess the need for a repeat biopsy. Pathologic findings of MRI-TB combined with a SB were compared to those of the patients\u27 previous SB. An upgrade was defined as an increase in the Gleason Score of any prior biopsy. A no-upgrade (NU) MRI-TB was defined as a MRI-TB that did not lead to disease upgrading when compared to SB. RESULTS: A total of 148 patients were analyzed in this study. Of the 255 total lesions (247 lesions with PI-RADS ≥3), 141 were upgraded from the previous biopsy (55.3%). Of these, 104 were upgraded by the MRI-TB (40.8%), and 87 lesions were upgraded by the SB (34.1%). The MRI-TB had a NU rate of 26.2% for all lesions. On subanalysis, the NU rates of PI-RADS 3, 4, and 5 MRI-TBs were 39.3%, 21.2%, and 3.4%, respectively. CONCLUSION: The NU rate for the MRI-TB in a PIRADS-5 lesion is meager. Men with a PI-RADS 5 lesion may be safely managed with the MRI-TB alone without combining with SB. Men with PI-RADS 3 and 4 lesions should benefit from SB in addition to MRI-TB for accurate management of their disease

The effect of multiplicity of PI-RADS 3 lesions on cancer detection rate of confirmatory targeted biopsy in patients diagnosed with prostate cancer and managed with active surveillance

BACKGROUND AND OBJECTIVE: To determine the effect of multiplicity of prostate imaging reporting and data system assessment category 3 (PI-RADS 3) lesions on cancer detection rate (CDR) of confirmatory targeted biopsy of such lesion in patients diagnosed with prostate cancer and managed with active surveillance. METHODS: This study was conducted at a single academic institution. There were 91 men with ≥ 1 PI-RADS 3 lesion detected through magnetic resonance imaging (MRI) after systematic prostate biopsy in the course of management of patients diagnosed with prostate cancer with active surveillance. We compared the CDRs based on targeted biopsy of PI-RADS 3 lesions that occurred (1) as solitary lesions, (2) as 1 of multiple PI-RADS 3 only lesions, or (3) with ≥ 1 higher grade lesion. RESULTS: Median age was 65.0 years (interquartile range 59.5-70.0), median prostate specific antigen was 5.95 ng/ml (interquartile range 4.30-8.83), and median prostate specific antigen density was 0.161 ng/ml(2) (0.071-0.194). Forty-three men had solitary PI-RADS 3 lesions, 22 had multiple PI-RADS 3 only lesions, and 26 had multiple lesions with \u3e/= 1 higher grade lesion. The overall CDR (Gleason score \u3e/= 3+3) based on confirmatory MRI targeted biopsy in a given PI-RADS 3 lesion in each group was 23%, 45%, and 54%, respectively (P=0.0274). The CDRs for clinically significant disease (Gleason score \u3e/= 3+4) were 16%, 32%, and 35%, respectively (P=0.1701). CONCLUSIONS: Coexisting lesions increase the CDR of confirmatory MRI targeted biopsy of PI-RADS 3 lesions in patients managed with active surveillance. Risk stratification algorithms for PI-RADS 3 lesion to guide biopsy and management decisions may consider including multiplicity of lesions

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