Publications by authors named "Simon L Conti"

25 Publications

  • Page 1 of 1

How Can the COVID-19 Pandemic Lead to Positive Changes in Urology Residency?

Front Surg 2020 24;7:563006. Epub 2020 Nov 24.

Department of Urology, IEO European Institute of Oncology IRCCS, Milan, Italy.

The COVID-19 outbreak, in a few weeks, overloaded Italian hospitals, and the majority of medical procedures were postponed. During the pandemic, with hospital reorganization, clinical and learning activities performed by residents suffered a forced remodulation. The objective of this study is to investigate how urology training in Italy has been affected during the COVID-19 era. In this multi-academic study, we compared residents' training during the highest outbreak level with their previous activity. Overall 387 (67.1%) of the 577 Italian Urology residents participated in a 72-h anonymous online survey with 36 items sent via email. The main outcomes were clinical/surgical activities, social distancing, distance learning, and telemedicine. Clinical and learning activity was significantly reduced for the overall group, and after categorizing residents as those working only in COVID hospitals, both "junior" and "senior" residents, and those working in any of three geographical areas created (Italian regions were clustered in three major zones according to the prevalence of COVID-19). A significant decrease in outpatient activity, invasive diagnostic procedures, and endoscopic and major surgeries was reported. Through multivariate analysis, the specific year of residency has been found to be an independent predictor for all response modification. Being in zone 3 and zone 2 and having "senior" resident status were independent predictors associated with a lower reduction of the clinical and learning activity. Working in a COVID hospital and having "senior" resident status were independent predictors associated with higher reduction of the outpatient activity. Working in zone 3 and having "senior" resident status were independent predictors of lower and higher outpatient surgical activity, respectively. Working in a COVID hospital was an independent predictor associated with robotic surgical activity. The majority of residents reported that distance teaching and multidisciplinary virtual meetings are still not used, and 44.8% reported that their relationships with colleagues decreased. The COVID-19 pandemic presents an unprecedented challenge, including changes in the training and education of urology residents. The COVID era can offer an opportunity to balance and implement innovative solutions that can bridge the educational gap and can be part of future urology training.
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http://dx.doi.org/10.3389/fsurg.2020.563006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732553PMC
November 2020

Safety and Feasibility of Outpatient Surgery in Benign Prostatic Hyperplasia: a Systematic Review and Meta-Analysis.

J Endourol 2021 Mar 4. Epub 2021 Mar 4.

Department of Maternal Infant and Urologic Sciences, "Sapienza" Rome University, Policlinico Umberto I Hospital, Rome, Italy.

Most of the endourologic procedures along the urinary tract have been widely practiced as outpatient operations, including surgery for benign prostatic hyperplasia (BPH). This systematic review and meta-analysis was conducted to assess safety and feasibility of outpatient surgery for patients suffering from symptomatic BPH candidate for endoscopic disobstruction. PubMed, Web of Science, Cochrane, and Embase were searched up until March 30, 2020. Methodological index for nonrandomized studies (MINORS) tool was utilized to assess the quality of included studies, and a pooled measure of failure rate (FR) or event rate (ER) estimate was calculated. Further sensitivity analysis, subgroup analysis, and meta-regression were conducted to investigate contribution of moderators to heterogeneity. Twenty studies with a total of 1626 patients treated according to outpatient criteria for endoscopic BPH surgery were included. In total, 18 studies reporting data on immediate hospital readmission and/or inability to discharge after endoscopic procedure presented FR estimates ranging from 1.7% to 51.1%. Pooled FR estimate was 7.8% (95% confidence interval [CI]: 5.2-10.3); Heterogeneity:  = 76.85; degree of freedom = 17,  < 0.001;  = 75.12%. Subgroup analysis according to surgical technique revealed difference among the three approaches with pooled FR of 3% (95% CI: 1-4.9), 7.1% (95% CI: 3.9-10.4), and 11.8% (95% CI: 7-16.7) for transurethral resection of the prostate, Green-light, and holmium laser vaporesection, respectively ( < 0.001). At meta-regression analysis, none of the retrieved covariates was able to significantly influence the cumulative outcomes reported. ER for postoperative complications and early outpatient visit showed a pooled estimate of 18.6% (95% CI: 13.2-23.9) and 7.7% (95% CI: 4.3-11), respectively. Our analysis revealed how transurethral procedures for BPH on an outpatient setting are overall reliable and safe. Of note, there were significant outcome differences between groups with regard to type of surgical procedure, perioperative prostate volume, and discharge protocol suggesting the need for further prospective analysis to better elucidate the best strategy in such outpatient conduct.
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http://dx.doi.org/10.1089/end.2020.0538DOI Listing
March 2021

Capturing the Perspective of Prospective Urology Applicants: Impacts of COVID-19 on Medical Education.

Urology 2020 12 30;146:36-42. Epub 2020 Sep 30.

University of Washington, Seattle, WA.

Objective: To capture the perspective of prospective urology applicants experiencing unique challenges in the context of COVID-19.

Methods: A voluntary, anonymous survey was distributed online, assessing the impact of COVID-19 on a large sample of US medical students planning to apply to urology residencies. Themes of (1) specialty discernment, (2) alterations to medical education, and (3) the residency application process were explored.

Results: A total of 238 medical students, 87% third and fourth years, responded to the survey. While 85% indicated that the pandemic had not deterred their specialty choice, they noted substantial impacts on education, including 82% reporting decreased exposure to urology. Nearly half of students reported changes to required rotations and 35% reported changes to urology-specific rotations at their home institutions. Students shared concerns about suspending in-person experiences, including the impact on letters of recommendation (68% "very concerned) and program choice (73% "very concerned"). Looking to the possibility of virtual interactions, students identified the importance of small group and one-on-one communication with residents (83% "very important") and opportunities to learn about hospital facilities (72% "very important").

Conclusion: Despite the impacts of COVID-19 on medical education, prospective urology applicants appear to remain confident in their specialty choice. Students' biggest concerns involve disruption of away rotations, including impacts on obtaining letters of recommendation and choosing a residency program.
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http://dx.doi.org/10.1016/j.urology.2020.09.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525272PMC
December 2020

Evaluation of Patient Treatment Preferences for 15 to 20 mm Kidney Stones: A Conjoint Analysis.

J Endourol 2021 Jan 21. Epub 2021 Jan 21.

Department of Urology, Stanford University School of Medicine, Stanford, California, USA.

Ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) are standard treatments for intermediate-size (15-20 mm) kidney stones but differ in their postoperative recovery, stone-free rates, and complication risks. We aimed to evaluate what affects patient treatment preferences. Patients with urinary stone disease completed a choice-based conjoint analysis exercise assessing four treatment attributes associated with URS and PCNL. A sensitivity analysis using a market simulator was performed, and the relative importance of each attribute was calculated. Differences in treatment preferences by demographic subgroup were assessed. A total of 58 patients completed the conjoint analysis exercise. Stone-free rate was the most important treatment attribute, while the length of hospital stay and cosmesis were less important. Overall, sensitivity analysis based on market simulation scenarios predicted an almost equal preference for URS (52.4%) compared with PCNL (47.6%) for treatment of an intermediate-size stone. Older patients (>65 years old) expressed their stronger preferences for lower infection rates and shorter hospital stays, and were more likely to prefer URS (67.2%, 95% confidence interval [CI]: 52% to 82.5%) compared with younger patients (20-34 years old) (20.3%, 95% CI: 0% to 41.5%) who preferred higher procedure success rates and fewer repeat procedures. Conjoint analysis predicts nearly equal patient preference for URS or PCNL for the treatment of intermediate-size kidney stones. Older patients prefer the lower urinary tract infection risk and shorter hospital stay associated with URS, while younger patients prefer higher stone-free rates associated with PCNL. These results can help guide urologists in counseling patients and improve the shared decision-making process.
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http://dx.doi.org/10.1089/end.2020.0370DOI Listing
January 2021

Urinary Stone Disease in Pregnancy: Current Management Practices in a Large National Cohort.

Urology 2020 Aug 18;142:60-64. Epub 2020 Apr 18.

Department of Urology, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.

Objective: To define current national practice patterns of imaging modalities and urologic procedures in pregnant women with urinary stone disease.

Methods: Using the IBM MarketScan national insurance claims database, we identified pregnant women with urinary stone disease and their corresponding gestational age between 2011 and 2016 using administrative claims data. We then assessed each encounter for urinary stone disease or stone-related urologic procedure during their pregnancy. We abstracted demographic information as well as codes for stone procedures and imaging.

Results: We identified 14,298 pregnant women with urinary stone disease during the study period. Of the 12,315 undergoing abdominal imaging (86.1%), magnetic resonance imaging was used in 2.8%, x-ray in 9%, and ultrasound in 74.3%. Computed tomography was not used as a diagnostic modality during pregnancy. Procedural intervention was performed in 749 women (5.2%): 476 (3.3%) ureteral stent placement without definitive stone treatment, 93 (0.6%) percutaneous nephrostomy placement, and 180 (1.3%) ureteroscopy (URS) for definitive stone treatment. URS was most commonly performed before 34 weeks gestation with only 27 cases (15%) performed after.

Conclusion: This large national cohort reveals the current imaging and procedural practice patterns for urinary stone disease during pregnancy and provides a critical baseline as these practice patterns evolve in the future.
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http://dx.doi.org/10.1016/j.urology.2020.03.050DOI Listing
August 2020

Urinary Stone Disease in Pregnancy: A Claims Based Analysis of 1.4 Million Patients.

J Urol 2020 05 18;203(5):957-961. Epub 2019 Nov 18.

Department of Urology, Stanford University School of Medicine, Stanford, California.

Purpose: Urinary stone disease during pregnancy is poorly understood but is thought to be associated with increased maternal and fetal morbidity. We determined the prevalence of urinary stone disease in pregnancy and whether it is associated with adverse pregnancy outcomes.

Materials And Methods: We identified all pregnant women from 2003 through 2017 in the Optum® national insurance claims database. We used diagnosis claims to identify urinary stone disease and assess medical comorbidity. We established the prevalence of urinary stone disease during pregnancy stratified by week of pregnancy. We further evaluated associations among urinary stone disease, maternal complications and pregnancy outcomes in univariable and multivariable analyses.

Results: Urinary stone disease affects 8 per 1,000 pregnancies and is more common in white women and women with more comorbid conditions. In fully adjusted models pregnancies complicated by urinary stone disease had higher rates of adverse fetal outcomes including prematurity and spontaneous abortions. This analysis is limited by its retrospective, administrative claims design.

Conclusions: The rate of urinary stone disease during pregnancy is higher than previously reported. Urinary stone disease is associated with adverse pregnancy outcomes.
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http://dx.doi.org/10.1097/JU.0000000000000657DOI Listing
May 2020

Ultra-Low-Dose CT: An Effective Follow-Up Imaging Modality for Ureterolithiasis.

J Endourol 2020 02 10;34(2):139-144. Epub 2020 Jan 10.

Department of Urology, Stanford University School of Medicine, Stanford, California.

Classically, abdominal X-ray (KUB), ultrasound, or a combination of both have been routinely used for ureteral stone surveillance after initial diagnosis. More recently, ultra-low-dose CT (ULD CT) has emerged as a CT technique that reduces radiation dose while maintaining high sensitivity and specificity for urinary stone detection. We aim to evaluate our initial experience with ULD CT for patients with ureterolithiasis, measuring real-world radiation doses and stone detection performance. We reviewed all ULD CT scans performed at the Veterans Affairs Palo Alto Health Care System between 2016 and 2018. We included patients with ureteral stones and calculated the mean effective radiation dose per scan. We determined stone location and size, if the stone was visible on the associated KUB or CT scout film, and if hydronephrosis was present. We performed logistic regression to identify variables associated with visibility on KUB or CT scout film and hydronephrosis. One hundred eighteen ULD scans were reviewed, of which 50 detected ureteral stones. The mean effective radiation dose was 1.04 ± 0.41 mSv. Of the ULD CTs that detected ureterolithiasis, 38% lacked visibility on KUB/CT scout film and had no associated hydronephrosis, suggesting that they would be missed with a combination of KUB and ultrasound. Larger stones (odds ratio [OR]: 1.40, 95% confidence interval [CI]: 1.08, 1.96 for every 1 mm increase in stone size) were more likely to be detected by KUB/CT scout film or ultrasound, while stones in the distal ureter (OR: 0.18, 95% CI: 0.03, 0.81) were more likely to be missed by KUB/CT scout film or hydronephrosis. Based on our institutions' initial experience, ULD CT detects small and distal ureteral stones that would likely be missed by KUB or ultrasound, while maintaining a low effective radiation dose. An ULD CT protocol should be considered when reimaging for ureteral stones is necessary.
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http://dx.doi.org/10.1089/end.2019.0574DOI Listing
February 2020

Nonrenal Systemic Arterial Calcifications Predicts the Formation of Kidney Stones by Stern et al. (From: Stern KL, Ward RD, Li J, et al. J Endourol 2019;33:1032-1034; DOI: 10.1089/end.2019.0243).

J Endourol 2019 12 17;33(12):1035. Epub 2019 Oct 17.

Department of Urology, Stanford University School of Medicine, Stanford, California.

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http://dx.doi.org/10.1089/end.2019.0673DOI Listing
December 2019

Postoperative vacuum therapy following AMS™ LGX 700® inflatable penile prosthesis placement: penile dimension outcomes and overall satisfaction.

Int J Impot Res 2020 Jan 11;32(1):133-139. Epub 2019 Feb 11.

Department of Urology, Coral Gables Hospital, 3100 Douglas Rd, Coral Gables, FL, 33134, USA.

Penile shortening after inflatable penile prosthesis for erectile dysfunction is a common postoperative patient complaint and can reduce overall satisfaction with the procedure. In this prospective study we report our results regarding penile dimensions and patient satisfaction outcomes after 1 year of follow-up from AMS™LGX700® penile prosthesis implant with 6 months of vacuum erectile device therapy. Seventy-four selected patients with medically refractory erectile dysfunction underwent AMS™ LGX 700® IPP placement. Postoperatively, patients were assigned vacuum device therapy for 5 min twice daily. Follow-up continued for 1 year after surgery. Dimensional and functional results were assessed. Baseline median preoperative stretched penile length and girth were 14 cm (range 10-17) and 9 cm (range 7-12), respectively. At the end of the study penile median dimensional outcomes were 17 cm (range 13-23) for length and 11 cm (range 10-13) for girth while a median number of 24 pumps (range 18-29) to fully inflate the device was seen. Baseline median International Index of Erectile Function (IIEF-5) score was 9 (range 5-11), at 6 months 20 (range 18-26) and at 1 year was 25 (range 20-27) (p < 0.0001). Median Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score at the end of the follow-up was 74 (range 66-78). Our postoperative rehabilitation program is feasible and should be recommended after prothesis surgery in order to increase overall satisfaction with the procedure. Penile postoperative dimensional outcomes were statistically significant improved and complications were negligible.
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http://dx.doi.org/10.1038/s41443-019-0125-zDOI Listing
January 2020

Crowdsourced Assessment of Ureteroscopy with Laser Lithotripsy Video Feed Does Not Correlate with Trainee Experience.

J Endourol 2019 01 22;33(1):42-49. Epub 2018 Dec 22.

1 Department of Urology, Stanford University School of Medicine , Stanford, California.

Objectives: We sought to validate the use of crowdsourced surgical video assessment in the evaluation of urology residents performing flexible ureteroscopic laser lithotripsy.

Methods: We collected video feeds from 30 intrarenal ureteroscopic laser lithotripsy cases where residents, postgraduate year (PGY) two through six, handled the ureteroscope. The video feeds were annotated to represent overall performance and to contain parts of the procedure being scored. Videos were submitted to a commercially available surgical video evaluation platform (Crowd-Sourced Assessment of Technical Skills). We used a validated ureteroscopic laser lithotripsy global assessment tool that was modified to include only those domains that could be evaluated on the captured video. Videos were evaluated by crowd workers recruited using Amazon's Mechanical Turk platform as well as five endourology-trained experts. Mean scores were calculated and intraclass correlation coefficients (ICCs) were computed for the expert domain and total scores. ICCs were estimated using a linear mixed-effects model. Spearman rank correlation coefficients were calculated as a measure of the strength of the relationships between the crowd mean and expert average scores.

Results: A total of 30 videos were reviewed 2488 times by 487 crowd workers and five expert endourologists. ICCs between expert raters were all below accepted levels of correlation (0.30), with the overall score having an ICC of <0.001. For individual domains, the crowd scores did not correlate with expert scores, except for the stone retrieval domain (0.60 p = 0.015). In addition, crowdsourced scores had a negative correlation with the PGY level (0.44, p = 0.019).

Conclusions: There is poor agreement between experts and poor correlation between expert and crowd scores when evaluating video feeds of ureteroscopic laser lithotripsy. The use of an intraoperative video of ureteroscopy with laser lithotripsy for assessment of resident trainee skills does not appear reliable. This is further supported by the lack of correlation between crowd scores and advancing PGY level.
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http://dx.doi.org/10.1089/end.2018.0534DOI Listing
January 2019

Payer Type, Race/Ethnicity, and the Timing of Surgical Management of Urinary Stone Disease.

J Endourol 2019 02 16;33(2):152-158. Epub 2018 Nov 16.

1 Department of Urology, Stanford University School of Medicine, Stanford, California.

Purpose: Surgery for upper tract urinary stone disease is often reserved for symptomatic patients and those whose stone does not spontaneously pass after a trial of passage. Our objective was to determine whether payer type or race/ethnicity is associated with the timeliness of kidney stone surgery.

Materials And Methods: A population-based cohort study was conducted using the California Office of Statewide Health Planning and Development dataset from 2010 to 2012. We identified patients who were discharged from an emergency department (ED) with a stone diagnosis and who subsequently underwent a stone surgery. Primary outcome was time from ED discharge to urinary stone surgery in days. Secondary outcomes included potential harms resulting from delayed stone surgery.

Results: Over the study period, 15,193 patients met the inclusion criteria. Median time from ED discharge to stone surgery was 28 days. On multivariable analysis patients with Medicaid, Medicare, and self-pay coverage experienced adjusted mean increases of 46%, 42%, and 60% in time to surgery, respectively, when compared with those with private insurance. In addition, patients of Black and Hispanic race/ethnicity, respectively, experienced adjusted mean increases of 36% and 20% in time to surgery relative to their White counterparts. Before a stone surgery, underinsured patients were more likely to revisit an ED three or more times, undergo two or more CT imaging studies, and receive upper urinary tract decompression.

Conclusions: Underinsured and minority patients are more likely to experience a longer time to stone surgery after presenting to an ED and experience potential harm from this delay.
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http://dx.doi.org/10.1089/end.2018.0614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388711PMC
February 2019

Non-ischemic priapism following recurrent idiopathic ischemic priapism treated successfully with selective arterial embolization and postoperative vacuum therapy before delayed inflatable penile prosthesis placement: A single case report.

IJU Case Rep 2018 Nov 20;1(1):13-15. Epub 2018 Sep 20.

Department of Urology "Sapienza" Rome University Policlinico Umberto I Rome Italy.

Introduction: Priapism is defined as a persistent tumescence or erection of the penis not associated to sexual desire and/or stimulation. Idiopathic recurrent priapism may also occasionally follow treatment of veno-occlusive priapism and represents a diagnostic and therapeutic challenge.

Case Presentation: We report a single case of non-ischemic priapism that resulted after distal shunting procedure for severe and prolonged ischemic priapism and yet occurred without evidence of a cavernosal-sinusoidal fistula that was successfully treated with a bilateral selective arterial embolization. Our protocol of delayed inflatable penile prosthesis placement after a vacuum erectile device program was implemented.

Conclusions: The continuing use of a vacuum erectile device represented a bridge and an adjuvant therapy useful to facilitate later prosthesis placement. Anatomical and functional outcomes were optimal. No postoperative complaints or complications were reported.
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http://dx.doi.org/10.1002/iju5.12019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292072PMC
November 2018

Inflatable Penile Prosthesis Placement, Scratch Technique and Postoperative Vacuum Therapy as a Combined Approach to Definitive Treatment of Peyronie's Disease.

J Urol 2018 09 17;200(3):642-647. Epub 2018 Apr 17.

Department of Urology, Coral Gables Hospital, Coral Gables, Florida.

Purpose: Peyronie's disease is a devastating condition resulting in penile malformation, erectile dysfunction, pain and emotional distress. In this prospective, 2 institution study we evaluated a multimodal surgical and mechanical combined approach to the definitive treatment of Peyronie's disease and concomitant erectile dysfunction.

Materials And Methods: A total of 145 select patients underwent endocavernous disruption of Peyronie's disease plaques via the scratch technique, followed by inflatable penile prosthesis insertion. Postoperatively patients were assigned to vacuum device therapy for 3 minutes twice daily to continue penile curvature correction. Followup continued for 1 year after surgery. Anatomical and functional results were assessed.

Results: Patients with plaques in the proximal third, middle third and subcoronal areas of the penis had a mean ± SD postoperative residual curvature of 21.5 ± 4.5, 17.3 ± 4.8 and 14.1 ± 3.1 degrees, respectively. After 24 weeks of vacuum therapy the mean penile curvature deviation decreased to 8.7 ± 2.5, 9.1 ± 2.9 and 7.7 ± 0.9 degrees, respectively. The mean IIEF-5 (International Index of Erectile Function) score was 9.8 ± 2.3 preoperatively, 18.9 ± 3.1 at 6 months (p <0.001) and 24.1 ± 3.6 at 1 year (p <0.001). The mean EDITS (Erectile Dysfunction Inventory of Treatment Satisfaction) score at the end of followup was 64.6 ± 11.8. Operative and postoperative complications were minimal.

Conclusions: Our novel combination of intraoperative and postoperative therapies in the treatment of patients with Peyronie's disease and an inflatable penile prosthesis was safe and efficacious with excellent functional outcomes. Penile curvature corrections were statistically significant and complications were negligible.
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http://dx.doi.org/10.1016/j.juro.2018.04.060DOI Listing
September 2018

Unplanned Emergency Department Visits and Hospital Admissions Following Ureteroscopy: Do Ureteral Stents Make a Difference?

Urology 2018 Jul 27;117:44-49. Epub 2018 Mar 27.

Department of Urology, Stanford University School of Medicine, Stanford, CA; Division of Urology, Santa Clara Valley Medical Center, Santa Clara, CA.

Objective: To evaluate unplanned medical visits within the early postoperative period after ureteroscopy in patients with and without ureteral stent placement.

Materials And Methods: We identified all ureteroscopic procedures for urinary stone disease in the California Office of Statewide Health Planning and Development database from 2010 to 2012. The primary outcome was any emergency department visit or inpatient hospital admission in the first 7 days following ureteroscopy. Patients were subcategorized by type of ureteroscopy (ie, laser lithotripsy vs basket retrieval) and were analyzed for significant differences between stented and unstented patients. Multivariable logistic regression was performed to determine if ureteral stent placement was independently associated with unplanned visits.

Results: Our analytic cohort included 16,060 patients undergoing 17,716 ureteroscopy procedures. A ureteral stent was placed in 86.2% of patients undergoing laser lithotripsy and in 70.5% of patients receiving basket retrieval. In the 7 days following ureteroscopy, 6.6% of patients were seen in the emergency department and 2.2% of patients were admitted to a hospital. In a fully adjusted model, the utilization of a ureteral stent was not associated with emergency department visits or inpatient admissions.

Conclusion: Ureteral stent placement during ureteroscopy is not associated with an increased odds of emergency department visits and inpatient admissions in the early postoperative period.
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http://dx.doi.org/10.1016/j.urology.2018.03.019DOI Listing
July 2018

Distal Corporal Anchoring Stitch: A Technique to Address Distal Corporal Crossovers and Impending Lateral Extrusions of a Penile Prosthesis.

J Sex Med 2017 06;14(6):767-773

Miami Urology Specialists, FL, USA.

Background: Unidentified distal crossovers, delayed distal crossovers, and impending lateral extrusion are complications of penile prosthesis implant insertion but are not as common as prosthesis infection or mechanical failure.

Aim: To evaluate results of a surgical technique, the distal corporal anchoring stitch, that addresses fixation of the penile prosthesis in patients with these complications.

Methods: A lateral sub-coronal incision is used on the side where the crossover or laterally extruding cylinder should be positioned. Dissection is carried through the Buck fascia, followed by a transverse incision of the tunica albuginea, where the distal aspect of the affected cylinder is delivered. A 4-0 PDS suture is threaded through the distal cylinder ring of the implant. A new, properly positioned intracorporal channel is created and the suture is passed through the distal end of the channel. Once the suture is through the glans and the cylinder is in the correct position, a small cruciate incision is made on the glans at the location of the anchor stitch. The suture is tied with the knot buried in the glans tissue.

Outcomes: Fifty-three patients underwent treatment of their distal penile implant crossover with a distal corporoplasty using this method and their anatomic and functional outcomes and overall satisfaction were evaluated.

Results: This technique ensured that the cylinder remained in the newly created, appropriately positioned channel. No patients developed infections, wound-healing defect, glandular hypoesthesia, anesthesia, or altered sensation or pain in the glans related to the suture and only two reported recurrence of a lateral herniation that did not require further treatment.

Clinical Implications: Distal fixation of the penile prosthesis is a useful surgical adjunct to treating patients with prosthetic lateral extrusions or crossovers that can be applied in almost all cases.

Strengths And Limitations: Considering these rare complications, our experience is based on a relatively large number of patients and showed a low incidence of complications and a high satisfaction rate. The main limitation of this study is the retrospective nature of the data and the series included patients from two high-volume surgeons that might not be generalizable to all practices.

Conclusion: The distal corporal anchoring stitch is safe and effective in securing distal fixation of the extruding inflatable penile prosthesis. Antonini G, Busetto GM, Del Giudice F, et al. Distal Corporal Anchoring Stitch: A Technique to Address Distal Corporal Crossovers and Impending Lateral Extrusions of a Penile Prosthesis. J Sex Med 2017;14:767-773.
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http://dx.doi.org/10.1016/j.jsxm.2017.04.669DOI Listing
June 2017

Defining the Rate of Negative Ureteroscopy in the General Population Treated for Upper Tract Urinary Stone Disease.

J Endourol 2017 03 3;31(3):266-271. Epub 2017 Feb 3.

1 Department of Urology, Stanford University School of Medicine , Stanford, California.

Introduction: Ureteroscopy is increasingly used to treat upper tract urinary stone disease. A negative ureteroscopy is a ureteroscopy performed with the intent of removing a kidney or ureteral stone, but in which ultimately no stone is removed. Negative ureteroscopy may occur when the stone is found to have already passed, or the presumed stone is found to be outside of the collecting system. We sought to determine the rate of negative ureteroscopy in a large population-based sample as well as factors associated with its use.

Patients And Methods: We examined nonpublic data from the Office of Statewide Health Planning and Development (OSHPD) Database for all patients in California undergoing outpatient surgery from 2010 to 2012. We identified all patients with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for upper tract urinary stone disease, who underwent a ureteroscopic procedure. After excluding patients undergoing second look procedures or who had diagnosis codes for separate urologic pathology, the negative ureteroscopy rate was defined as the proportion of those ureteroscopy cases coded as a diagnostic ureteroscopy. We fit logistic regression models to evaluate patient factors associated with negative ureteroscopy.

Results: During the years 2010 to 2012, 20,236 eligible patients underwent ureteroscopic procedures for upper tract stone disease. Of these, 1287 patients underwent diagnostic ureteroscopy and 19,039 underwent ureteroscopy with stone removal accounting for a negative ureteroscopy rate of 6.3%. The odds of receipt of a negative ureteroscopy rate were higher in females compared to males (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.25, 1.58) and lower in self-pay patients compared with insured patients (OR = 0.55, 95% CI 0.33, 0.91).

Conclusions: Negative ureteroscopy is common, occurring in nearly 1 in 16 procedures to treat urinary stone disease.
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http://dx.doi.org/10.1089/end.2016.0751DOI Listing
March 2017

Paternal aging and increased risk of congenital disease, psychiatric disorders, and cancer.

Asian J Androl 2016 May-Jun;18(3):420-4

Male Reproductive Medicine and Surgery, Department of Urology and Department of Obstetrics and Gynecology, Stanford University School of Medicine, 300 Pasteur Drive, A259B, Stanford, California 94305-5118, USA.

As couples are increasingly delaying parenthood, the effect of the aging men and women on reproductive outcomes has been an area of increased interest. Advanced paternal age has been shown to independently affect the entire spectrum of male fertility as assessed by reductions in sperm quality and fertilization (both assisted and unassisted). Moreover, epidemiological data suggest that paternal age can lead to higher rates of adverse birth outcomes and congenital anomalies. Mounting evidence also suggests increased risk of specific pediatric and adult disease states ranging from cancer to behavioral traits. While disease states associated with advancing paternal age have been well described, consensus recommendations for neonatal screening have not been as widely implemented as have been with advanced maternal age.
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http://dx.doi.org/10.4103/1008-682X.175097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4854094PMC
January 2017

Hyperhomocysteinemia as an Early Predictor of Erectile Dysfunction: International Index of Erectile Function (IIEF) and Penile Doppler Ultrasound Correlation With Plasma Levels of Homocysteine.

Medicine (Baltimore) 2015 Sep;94(39):e1556

From the Department of Urology, Policlinico Umberto I Sapienza Rome University, Rome, Italy (RG, GMB, GA, ST, FDG, GR, VG, EDB); Department of Urology, European Oncology Institute (IEO), Milan, Italy (ODC, MF); Department of Urology, Stanford University of School of Medicine, Stanford, California, USA (SLC); and Department of Emergency and Organ Transplantation, Urology Unit, University of Bari, Bari, Italy (GL).

Erectile dysfunction (ED) is inability to achieve and maintain an erection to permit satisfactory sexual activity. Homocysteine (Hcys) is a sulfur-containing amino acid synthesized from the essential amino acid methionine. Experimental models have elucidated the role of hyperhomocysteinemia (HHcys) as a strong and independent predictor for atherosclerosis progression and impaired cavernosal perfusion. The aim of this study is to investigate the serum levels of Hcys in our cohort of patients with ED, to compare these values with these of control population and to examine Hcys as a predictive marker for those patients who are beginning to complain mild-moderate ED. A total of 431 patients were enrolled in the study. The whole cohort was asked to complete the International Index of Erectile Function (IIEF) questionnaire. The study population was divided in 3 main groups: Group A: 145 patients with no ED serving as a control group; Group B: 145 patients with mild or mild-moderate ED; Group C: 141 patients with moderate or severe ED. Each participant underwent blood analysis. All patients underwent baseline and dynamic penile Doppler ultrasonography. We found in our cohort mean Hcys plasma concentrations significantly higher than the cut-off point in both groups B and C (18.6 ± 4.7 and 28.38 ± 7.8, respectively). Mean IIEF score was 27.9 ± 1.39, 19.5 ± 2.6, and 11.1 ± 2.5 for groups A, B, and C, respectively (P < 0.0001). In the penile Doppler ultrasonography studies, a high significant inverse correlation was detected between the mean values of the 10th minute's peak-systolic velocity (PSV) and Hcys levels for the groups B and C. This establishes a dose-dependent association between Hcys and ED. Furthermore, we showed that Hcys was an earlier predictor of ED than Doppler studies, as the Hcys increase was present in patients with mild ED even before abnormal Doppler values.
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http://dx.doi.org/10.1097/MD.0000000000001556DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4616856PMC
September 2015

Alterations in DNA methylation may be the key to early detection and treatment of schistosomal bladder cancer.

PLoS Negl Trop Dis 2015 Jun 4;9(6):e0003696. Epub 2015 Jun 4.

Biomedical Research Institute, Rockville, Maryland, United States of America; Division of Urology, Children's National Health System, Washington, D.C., United States of America; Department of Urology, The George Washington University, Washington, D.C., United States of America.

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http://dx.doi.org/10.1371/journal.pntd.0003696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4456143PMC
June 2015

A new mouse model for female genital schistosomiasis.

PLoS Negl Trop Dis 2014 May 1;8(5):e2825. Epub 2014 May 1.

Department of Urology, Stanford University School of Medicine, Palo Alto, California, United States of America.

Background: Over 112 million people worldwide are infected with Schistosoma haematobium, one of the most prevalent schistosome species affecting humans. Female genital schistosomiasis (FGS) occurs when S. haematobium eggs are deposited into the female reproductive tract by adult worms, which can lead to pelvic pain, vaginal bleeding, genital disfigurement and infertility. Recent evidence suggests co-infection with S. haematobium increases the risks of contracting sexually transmitted diseases such as HIV. The associated mechanisms remain unclear due to the lack of a tractable animal model. We sought to create a mouse model conducive to the study of immune modulation and genitourinary changes that occur with FGS.

Methods: To model FGS in mice, we injected S. haematobium eggs into the posterior vaginal walls of 30 female BALB/c mice. A control group of 20 female BALB/c mice were injected with uninfected LVG hamster tissue extract. Histology, flow cytometry and serum cytokine levels were assessed at 2, 4, 6, and 8 weeks post egg injection. Voiding studies were performed at 1 week post egg injection.

Results: Vaginal wall injection with S. haematobium eggs resulted in synchronous vaginal granuloma development within 2 weeks post-egg injection that persisted for at least 6 additional weeks. Flow cytometric analysis of vaginal granulomata revealed infiltration by CD4+ T cells with variable expression of the HIV co-receptors CXCR4 and CCR5. Granulomata also contained CD11b+F4/80+ cells (macrophages and eosinophils) as well as CXCR4+MerTK+ macrophages. Strikingly, vaginal wall-injected mice featured significant urinary frequency despite the posterior vagina being anatomically distant from the bladder. This may represent a previously unrecognized overactive bladder response to deposition of schistosome eggs in the vagina.

Conclusion: We have established a new mouse model that could potentially enable novel studies of genital schistosomiasis in females. Ongoing studies will further explore the mechanisms by which HIV target cells may be drawn into FGS-associated vaginal granulomata.
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http://dx.doi.org/10.1371/journal.pntd.0002825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006711PMC
May 2014

Procedures needed to maintain functionality of adult continent catheterizable channels: a comparison of continent cutaneous ileal cecocystoplasty with tunneled catheterizable channels.

J Urol 2014 Sep 21;192(3):821-6. Epub 2014 Mar 21.

Department of Surgery, Center for Reconstructive Urology and Men's Health, University of Utah School of Medicine, Salt Lake City, Utah.

Purpose: We compared the outcomes of various adult continent catheterizable channels in a multi-institutional setting.

Materials And Methods: We retrospectively reviewed the records of all adults who underwent construction of a continent catheterizable channel at our 4 institutions from 2004 to 2013 and who had at least 6 months of followup. Patients were stratified by channel type, including continent cutaneous ileal cecocystoplasty or tunneled cutaneous channel, eg appendicovesicostomy, Monti channel, etc. The primary study outcome was the need for a secondary procedure to correct stomal leakage, catheterizable channel obstruction or stomal stenosis. Secondary outcomes were patient reported leakage and 30-day postoperative complications. We used Firth logistic regression to control for the heterogeneity induced by multiple institutions.

Results: A total of 61 patients were included in study, of whom 31 underwent continent cutaneous ileal cecocystoplasty. Mean age was 41.4 years (range 22 to 76). Median followup was 16 months. More patients with a tunneled channel required a secondary procedure than those with cecocystoplasty (15 of 30 or 50% vs 4 of 31 or 13%, OR 6.4, 95% CI 1.8-28). The total number of required secondary procedures was also greater for tunneled channels than for cecocystoplasty (27 vs 4). Of patients with cecocystoplasty 29% reported stomal leakage compared with 43% of those with a tunneled channel (p = 0.12). A high rate of postoperative complications was observed regardless of technique, including 40% for channels and 51.7% for cecocystoplasty.

Conclusions: Patients with continent cutaneous ileal cecocystoplasty undergo fewer interventions to maintain the catheterizable channel than patients with a tunneled continent catheterizable channel.
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http://dx.doi.org/10.1016/j.juro.2014.03.088DOI Listing
September 2014

Utilization of cytoreductive nephrectomy and patient survival in the targeted therapy era.

Int J Cancer 2014 May;134(9):2245-52

We sought to analyze utilization and survival outcomes of cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (RCC) before and after introduction of targeted therapy. We identified patients with metastatic RCC between 1993 and 2010 in the SEER registry and examined temporal trends in utilization. We performed a joinpoint regression to determine when changes in utilization of CN occurred. We fitted multivariable proportional hazard models in full and propensity score-matched cohorts. We performed a difference-in-difference analysis to compare survival outcomes before and after introduction of targeted therapy. The proportion of patients undergoing CN increased from 1993 to 2004, from 29% to 39%. We identified a primary joinpoint of 2004, just prior to the introduction of targeted therapy. Beginning in 2005, there was a modest decrease in utilization of CN. CN was associated with a lower adjusted relative hazard (0.41, 95% confidence interval 0.34–0.43). Median survival among patients receiving CN increased in the targeted therapy era (19 vs. 13 months), while median survival among patients not receiving CN increased only slightly (4 vs. 3 months). Difference-in-difference analysis showed a significant decrease in hazard of death among patients who received CN in the targeted therapy era. Despite decreased utilization in the targeted therapy era, CN remains associated with improved survival. Prospective randomized trials are needed to confirm the benefit of CN among patients with metastatic RCC treated with novel targeted therapies.
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http://dx.doi.org/10.1002/ijc.28553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3969398PMC
May 2014

Prostate size does not predict high grade cancer.

J Urol 2012 Feb 15;187(2):477-80. Epub 2011 Dec 15.

Department of Urology, Stanford University School of Medicine, Stanford, CA, USA.

Purpose: Several radical prostatectomy series have linked small prostates with high grade cancer based on the hypothesis that a small prostate results from a low androgen milieu that selects for less hormone dependent, more aggressive tumors. We previously reported that this association resulted from ascertainment bias from the performance characteristics of prostate specific antigen rather than from tumor biology in our radical prostatectomy cohort. In this study we analyzed this association in a more generalized population of men who underwent prostate needle biopsy.

Materials And Methods: The prostate needle biopsy database at our institution was queried for all initial biopsies. Included patient characteristics were age, race, family history of prostate cancer, prostate specific antigen, abnormal digital rectal examination and prostate volume in ml on transrectal ultrasound. Multivariate logistic regression was used to determine the influence of prostate volume on the odds of high grade cancer.

Results: The study population included 1,295 patients during 2000 to 2010, of whom 582 (44.9%) had prostate cancer and 398 (30.7%) had high grade cancer. When all patients were pooled, the OR for high grade cancer was 0.85 (95% CI 0.78-0.92) for each 10 ml increase in prostate volume. When patients were divided by clinical T stage, the corresponding ORs for those with T1c disease was 0.83 (95% CI 0.74-0.93) and for those with T2 or greater disease it was 0.99 (0.98-1.00).

Conclusions: The association between small prostates and high grade cancer exists only in men with clinical T1c (normal digital rectal examination) prostate cancer. It likely resulted from ascertainment bias due to the performance characteristics of prostate specific antigen rather than tumor biology.
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http://dx.doi.org/10.1016/j.juro.2011.10.042DOI Listing
February 2012

Pathological outcomes of candidates for active surveillance of prostate cancer.

J Urol 2009 Apr 23;181(4):1628-33; discussion 1633-4. Epub 2009 Feb 23.

Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California, USA.

Purpose: Active surveillance of prostate cancer has emerged as a viable treatment option for men with features of low risk disease. Five prospective studies have enrolled patients for active surveillance with varying inclusion criteria. We evaluated the pathological outcomes of men meeting published criteria for active surveillance who elected immediate radical prostatectomy to assess the risk of under grading and under staging in candidates for active surveillance.

Materials And Methods: Data were extracted from our institutional urological oncology database for all men who underwent radical prostatectomy between 1996 and 2007. The primary outcome was pathological up staging, defined as the occurrence of extracapsular extension or seminal vesicle involvement. Pathological upgrading was identified as a secondary outcome. We determined the proportion of men who would have qualified for each published active surveillance study and the respective rates of upgrading and up staging in each group.

Results: We identified 1,097 men who underwent radical prostatectomy with a mean age of 59 years. Overall 28% of the men experienced a Gleason upgrade, 21% had extracapsular extension and 11% had seminal vesicle involvement. In men qualifying based on published active surveillance inclusion criteria, rates of upgrading varied between 23% and 35%, the incidence of extracapsular extension ranged from 7% to 19% and seminal vesicle involvement ranged from 2% to 9%.

Conclusions: Varying entry criteria for active surveillance show different rates of adverse pathological features at radical prostatectomy. Predictably fewer men met the more stringent criteria but these men had a lower incidence of seminal vesicle involvement and extracapsular extension. Such data can be used to advise men of the risks of active surveillance.
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http://dx.doi.org/10.1016/j.juro.2008.11.107DOI Listing
April 2009

Risk factors for emotional and relationship problems in Peyronie's disease.

J Sex Med 2008 Sep 14;5(9):2179-84. Epub 2008 Jul 14.

University of California, San Francisco-Urology, San Francisco, CA, USA.

Introduction: Peyronie's disease (PD) occurs in 3-9% of all men. Little is known regarding the specific psychological or emotional disruptions to sexuality associated with PD.

Aim: Our primary aim was to identify risk factors associated with psychosocial difficulties in men with PD.

Methods: This cross-sectional study enrolled patients from a single clinical practice. Detailed medical histories, physical examinations, and a PD-specific questionnaire were used to define clinical characteristics. Odds ratios (ORs) were used as a measure of association.

Main Outcome Measures: Emotional and relationship problems were determined by "yes" or "no" answers to two specific questions.

Results: The mean age of all PD patients (N = 245) was 54.4 years (range 19.4-75.6); 62% were married, and 59% presented within 2 years of disease onset. The overall prevalence of emotional and relationship problems attributable to PD was 81% and 54%, respectively. Among men who had relationship problems, the prevalence of emotional problems was 93%. In men with emotional problems due to PD, relationship issues were observed in 62%. Multivariable analysis revealed that emotional difficulties (OR 6.9, P < 0.001) and ability to have intercourse (OR 0.4, P = 0.004) were independently associated with relationship problems. Relationship problems (OR 8.0, P < 0.001) and loss of penile length (OR 2.7, P = 0.02) were significant independent predictors of emotional problems after adjustment for the ability to maintain erections, low libido, and penile pain.

Conclusions: Among men with PD, there is a very high prevalence of emotional and relationship problems. Loss of penile length and inability to have intercourse are strong predictors of these problems and as such make ideal targets for intervention. Medical and surgical therapies may enhance quality of life through their ability to improve sexual function. Further research will characterize the ways in which individual symptoms affect emotional and psychological well-being.
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http://dx.doi.org/10.1111/j.1743-6109.2008.00949.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881678PMC
September 2008