Consultant Urologists Research Articles

A case of life-threatening hematuria.

A 66-year-old male with a past medical history of hypertension and benign prostatic hypertrophy, not on anticoagulation, presented with difficulty voiding and hematuria. He was seen at an outside hospital earlier in the day and received a straight catheterization for urinary retention, he was prescribed antibiotics for a urinary infection, and he was discharged home. Subsequently, after discharge, he developed hematuria with inability to void, prompting a visit to our emergency department (ED). On arrival, the patient was uncomfortable appearing, tachycardic with a heart rate of 116 beats per minute and a blood pressure of 114/67 mm Hg. His lower abdomen was tender to palpation. A point-of-care ultrasound (POCUS) of the bladder was performed. The ultrasound demonstrated a distended-appearing bladder containing a large area of layering mixed echogenicity with intrinsic turbulent Doppler signal (Video 1). The patient had a three-way Foley catheter placed in the ED for continuous bladder irrigation. He had a computerized tomography (CT) angiography of the abdomen and pelvis that did not reveal any active hemorrhage. He also had a CT urogram. Initially, the hematuria improved, however, following the abnormal ultrasound Doppler images, the patient was admitted to the urology service. Although he was admitted, his hemoglobin declined from 12 to 7.9 g/dL, and he suffered a cardiac arrest. The reason for the arrest was presumed to be from hemorrhagic shock. There was return of spontaneous circulation after initiation of massive transfusion protocol. He underwent cystoscopy showing an enlarged median prostate lobe with active extravasation, requiring embolization of the prostatic artery by interventional radiology (IR). Hematuria and urinary obstruction are common causes of ED visits with multiple underlying etiologies.1 Emergency physicians are tasked with the challenge of determining which patients can be managed as outpatients. In this case, gross hematuria from an actively bleeding prostate led to the hemorrhagic shock requiring multiple transfusions and need for IR embolization. The most common etiologies of prostatic hematuria are benign prostatic hyperplasia, iatrogenic urologic trauma, prostate cancer, and radiation therapy.2 In this patient, POCUS showed turbulent Doppler flow within the bladder (Figure 1A), which was concerning for active bleeding, and ultimately led to the patient's admission and emergent urologic consultation. Additionally, the POCUS also showed layering mixed echogenicities seen within the distended bladder, indicating a clot at various stages (Figure 1B). This case illustrates the importance of considering POCUS in patients with urinary retention and hematuria, especially in the setting of recent catheter placement.

The Metaverse for Healthcare: Trends, Applications, and Future Directions of Digital Therapeutics for Urology.

In recent years, the emergence of digital therapeutics as a novel approach to managing conditions has garnered significant attention. This approach involves using evidence-based therapeutic interventions that are facilitated by high-quality software programs to treat, manage, or prevent medical conditions. The incorporation of digital therapeutics into the Metaverse has increased the feasibility of their implementation and application in all areas of medical services. In urology, substantial digital therapeutics are being produced and researched, including mobile apps, bladder devices, pelvic floor muscle trainers, smart toilet systems, mixed reality-guided training and surgery, and training and telemedicine for urological consultations. The purpose of this review article is to provide a comprehensive overview of the current impact of the Metaverse on the field of digital therapeutics and identify its current trends, applications, and future perspectives in the field of urology.

(525) Challenges in Management of Sexual Disorders in Rwanda

Abstract Introduction In Rwanda, it is not common to talk about sexual issues but these days there are remarkable increase in sexual disorders consultations especially in men where most are complaining of erectile dysfunction followed by ejaculatory disorders which make about 10% in public and 20% in private urological consultations. Top causes are psychogenic while organic causes include Diabetes mellitus and post chemotherapy and radiotherapy in females. Most patients present late distressed and desperate hence poor quality of life. Objective Highlight the challenges in management of sexual disorders in Rwanda Methods Narrative opinion. I will discuss in details those challenges from a perspective of a urologist interested in sexual medicine. Results There are neither andrologists nor specialized sexual therapist in Rwanda, hence difficulty in treating these patients. Most of patients are exposed to highly mediatized wrong information from practitioners who use herbal medicines to treat them without success in most of them. Others consult general practitioners or gynecologists who refer them to urologists. With the scarcity of urologists in the country (only 10) and lack of psychosexual therapists, limited treatment options (only some PDEIs and antidepressants available) and cultural barriers, there is a big gap in proper management of sexual disorders. Conclusions There is high need for capacity building of health professionals, special training of urologists, research, access to evidence-based information and management options to bridge the big gap. Disclosure No

SHARING THE CARE: A project to enable prostate cancer care to be delivered in the community

AbstractProstate cancer has become the 2nd most common cancer in men worldwide. An ageing population and treatment improvements are increasing the number of men living with and beyond cancer. In 2013, there was both scant evidence to guide as to when, where or how men with prostate cancer should be followed up and neither, it appears, pointing to agreed pathways. Generally, follow up regimes are based on tradition and expert medical opinion rather than research or patient need. For men to have their follow up with their GP, several factors need to be in place such as a single system, an improved exchange of experiences, as well as information and knowledge sharing. A recent presentation of a randomized control trial has shown that there are no differences between secondary and primary care follow up. Understanding that the current model of follow up was not working and was unsustainable, a review of urological services was undertaken in 2011 in a large National Health Service (NHS) district general hospital in the north of England. The review evaluated current services, noting that some follow up pathways did not necessarily need to be undertaken within a secondary are setting. The process of relocating patients for primary care review, involved creating a shared care process for prostate cancer. A workstream consisting of consultant urologists, nurse specialists, GPs, service managers and clinical commissioners was convened. Protocols containing specific responsibilities for secondary and primary care were devised. The review and workstream, included a shared vision for improving and sustaining services. Whilst safely moving follow up from secondary to primary care, benefits were realized such as care closer to the home. In conclusion a radical approach to follow up was needed and undertaken. Shared care has yielded success for the patient, primary and secondary care.

EARLY-STAGE TESTICULAR CANCER MANAGEMENT REFERRING TO EUROPEAN ASSOCIATION OF UROLOGY (EAU) GUIDELINES: A SURVEY IN INDONESIA

Objective: This study aimed to determine the management of early-stage testicular cancer among urologists in Indonesia by using a survey. Material & Methods: This research was a descriptive-analytic study using a survey method through a Google-forms questionnaire distributed to urologists throughout Indonesia who were willing to participate. Data were collected from September 1 to 30, 2021. Results: Of the total respondents, 15 (14.2%) respondents were consultant urologic oncologists, and 90 (85.71%) respondents were non-consultant urologists or consultant urologists non-oncology. There was no difference in the treatment given by consultant uro-oncologists and non-consultant urologists/consultant urologists non-oncology in the management of surveillance of stage IA-IB seminoma (66.7% vs. 55.6%, p-value = 0.207), chemotherapy of stage IIA-IIB seminoma (100.0% vs. 90.0%, p-value = 0.080), surveillance of stage I non-seminoma cancers (46.7% vs. 41.1%, p-value = 0.304), and chemotherapy of stage IIA and IIB non-seminoma cancers (80% vs. 91.1%, p-value = 0.193). Conclusion: In general, as many as 84.4% of oncology consultant urologists and 83.7% of non-consultant urologists/consultant urologists non-oncology have performed initial diagnostic examinations, treatment, and follow-up following testicular cancer management guidelines according to the European Association of Urology 2021.

Implementation of a clinical practice guideline for assessment and management of renal colic in the emergency department.

Renal colic is a common emergency department (ED) presentation. Variations in assessment and management of suspected renal colic may have significant implications on patient and hospital outcomes. We developed a clinical practice guideline to standardize the assessment and management of renal colic in the ED. We subsequently compared outcomes before and after guideline implementation. The guideline standardizes the analgesia regimen, urology consult criteria, imaging modality, patient education, and followup instructions. This is a single-center, observational cohort study of patients presenting to the ED with renal colic prospectively collected after guideline implementation (December 2018 to May 2019) compared to a control group retrospectively collected before guideline implementation (December 2017 to May 2018). A total of 528 patients (pre-guideline n=283, post-guideline n=245) were included. Statistical analysis was performed with SPSS using multivariate linear regression. ED length of stay (LOS) was significantly shorter after guideline implementation (pre-guideline 295.82±178.8 minutes vs. post-guideline 253.2±118.2 minutes, p=0.017). The number of computed tomography (CT) scans patients received was significantly less after guideline implementation (pre guideline 1.35±1.34 vs. post-guideline 1.00±0.68, p=0.034). Patients discharged for conservative management had a lower re-presentation rate in the post-guideline group (12.6%) than the pre-guideline group (17.2%); however, this did not reach statistical significance (p=0.18). Implementation of a clinical practice guideline for ureteric stones reduces the ED LOS and the total number of CT scan in patients who present with renal colic. Standardizing assessment and management of ureteric stones can potentially improve patient and hospital outcomes without compromising the quality of care.

MP02-10 UROLOGY DIRECTED MANAGEMENT OF HIGH GRADE RENAL TRAUMA IS ASSOCIATED WITH A LOW RATE OF EMERGENCY NEPHRECTOMY/RENORRHAPHY

You have accessJournal of UrologyCME1 Apr 2023MP02-10 UROLOGY DIRECTED MANAGEMENT OF HIGH GRADE RENAL TRAUMA IS ASSOCIATED WITH A LOW RATE OF EMERGENCY NEPHRECTOMY/RENORRHAPHY Aisling Fawaz, Robert Keenan, and Elaine Redmond Aisling FawazAisling Fawaz More articles by this author , Robert KeenanRobert Keenan More articles by this author , and Elaine RedmondElaine Redmond More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Major trauma care in Ireland is managed through a multidisciplinary collaborative approach between trauma surgeons and organ subspecialists e.g. urologists, cardiothoracic surgeons, neurosurgeons etc. Thus the urology service directs the management of all urological trauma irrespective of the grade of injury or other organ involvement. This is in contrast to the management of trauma care in other jurisdictions such as the United States where the majority of trauma cases are primarily managed by trauma surgeons with other specialities consulted as required. One recent study found that urology was consulted in only 15% of high grade renal trauma cases presenting to their institution even though urology consultation was associated with a lower nephrectomy rate (36.4% vs 78.8%).1 We hypothesised that the standardised urology directed care of renal injuries in Ireland would be associated with comparatively higher rates of renal preservation and reduced intervention/nephrectomy. The aim of our study was to evaluate the management of high grade renal trauma in Ireland using data derived from the Irish Major Trauma Audit which is stored on the Trauma Audit and Research Network (TARN) database. METHODS: The TARN database was used to identify all cases of significant renal trauma presenting to the 26 trauma receiving hospitals in Ireland between 2014 and 2020. Demographic data, mechanism of injury, injury characteristics, management and patient outcomes were analysed. RESULTS: There were a total of 426 renal trauma cases recorded during the study period, of which 305 patients had a high grade renal injury. The majority of patients in this group were male (241 (79%)). The median age was 28 years (range: 0.3-93.9 years). There were 276 cases of blunt renal trauma (90%) and 29 cases of penetrating trauma (10%). The most common cause for blunt renal trauma was road traffic accident. 65 patients (21%) required blood or blood products. Seven patients underwent emergency nephrectomy or renorraphy (2%). CONCLUSIONS: The need for emergency nephrectomy due to high grade renal trauma in Ireland is exceedingly rare. We conclude that an integrated multidisciplinary approach to trauma care results in a higher likelihood of avoiding intervention in this cohort of patients. 1Wang SL, Agrawal P, Rostom M, Gupta N, et al. Urology Consult: Association with Renal Trauma Imaging and Intervention. Urology 2022 (In press) Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e14 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aisling Fawaz More articles by this author Robert Keenan More articles by this author Elaine Redmond More articles by this author Expand All Advertisement PDF downloadLoading ...

MP72-10 UROLITHIASIS IN THE EMERGENCY DEPARTMENT: RESULTS OF A COLLABORATIVE QUALITY IMPROVEMENT PROJECT

You have accessJournal of UrologyCME1 Apr 2023MP72-10 UROLITHIASIS IN THE EMERGENCY DEPARTMENT: RESULTS OF A COLLABORATIVE QUALITY IMPROVEMENT PROJECT Kimberly Kocour, Eliza Defroda, Elizabeth Malm-Buatsi, Mark Wakefield, Chase Schlesselman, Katie Murray, and Geoffrey Rosen Kimberly KocourKimberly Kocour More articles by this author , Eliza DefrodaEliza Defroda More articles by this author , Elizabeth Malm-BuatsiElizabeth Malm-Buatsi More articles by this author , Mark WakefieldMark Wakefield More articles by this author , Chase SchlesselmanChase Schlesselman More articles by this author , Katie MurrayKatie Murray More articles by this author , and Geoffrey RosenGeoffrey Rosen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003340.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urolithiasis is a frequent cause for emergency department (ED) visits. For some, urology consults are indicated, while for many, outpatient follow up is appropriate. We noted an opportunity to improve care for patients with newly diagnosed urolithiasis in our ED. We completed a quality improvement project to improve patient triage and decrease time to follow up, with the hypothesis that the protocol would lead to fewer ED revisits and improved patient management. METHODS: We created the MU Pathway for Particularly Expeditious Treatment of Stones (MUPPETS) which couples an ED stone triage protocol with early urologic follow up. The protocol helped identify patients who did not need a urology consult. For these patients, a new follow-up order was created which scheduled patients for a urology visit (typically by phone) within 72 hours. After creation of the protocol, educational sessions were given to Urology and ED at our institution. We retrospectively reviewed ED visits with kidney or renal stone diagnoses where the patient was discharged from the ED. Chi-squared tests were used to compare outcomes in the first 30 days after the ED visit. RESULTS: Protocol was initiated in March 2022. We identified 546 patients in the pre-intervention period (Dec 2020-Feb 2022), and 269 patients in the post-intervention period (Apr-Sep 2022). Narcotic prescribing decreased after our education sessions (38% vs 30%, p=0.02, figure 1a). 137 patients had the follow up order placed. These patients were more likely to have urology follow-up (62% vs 15%, p<0.0001) and urological surgery (15% vs 8%, p=0.008) in the first 30 days than those with no order. Patients who completed a follow up visit according to the protocol were less likely to have an ED visit in the first 30 days than those who did not (25% vs 49%, p=0.0004, figure 1b). CONCLUSIONS: We developed a quality improvement intervention aimed at improving triage of patients with urolithiasis and ensuring prompt follow up for those discharged from the ED. Implementation of this protocol at our institution significantly improved time to evaluation and treatment, and decreased repeat ED visits. This collaborative effort of urology and ED has the potential to improve patient care most importantly, but in turn could decrease unnecessary health care costs and narcotic use in urolithiasis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1028 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kimberly Kocour More articles by this author Eliza Defroda More articles by this author Elizabeth Malm-Buatsi More articles by this author Mark Wakefield More articles by this author Chase Schlesselman More articles by this author Katie Murray More articles by this author Geoffrey Rosen More articles by this author Expand All Advertisement PDF downloadLoading ...

PD03-04 A SIMPLE INTERVENTION TO INCREASE FUNCTIONAL EVALUATION OF THE ADRENAL INCIDENTALOMA

You have accessJournal of UrologyCME1 Apr 2023PD03-04 A SIMPLE INTERVENTION TO INCREASE FUNCTIONAL EVALUATION OF THE ADRENAL INCIDENTALOMA Jonathan Yu, David Barham, Alexandria Hertz, John Musser, and Frank Gould Jonathan YuJonathan Yu More articles by this author , David BarhamDavid Barham More articles by this author , Alexandria HertzAlexandria Hertz More articles by this author , John MusserJohn Musser More articles by this author , and Frank GouldFrank Gould More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003220.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons guidelines recommend adrenal incidentalomas undergo a biochemical workup. However, in a retrospective chart review at our institution performed in 2019, we found that only a quarter of adrenal incidentalomas underwent a complete workup. We sought to implement a simple intervention to improve clinician adherence to guidelines regarding evaluation of adrenal incidentalomas. METHODS: In 2019, all CT scans of the abdomen at our institution between April 2019 and September 2019 that included evaluation of the adrenal glands were reviewed. The final report was reviewed to identify adrenal incidentalomas diagnosed during this period. A retrospective chart review was performed to determine if patients with adrenal incidentalomas underwent a complete biochemical workup. In January 2020, we requested that radiologists at our institution include “Urology or endocrinology consultation recommended” in reports for identified adrenal incidentalomas. A second retrospective review was performed between February 2022 and August 2022. The main outcome measure was the number of adrenal incidentalomas that underwent a complete biochemical assessment. A paired t-test analysis was performed to compare the two groups. RESULTS: A total of 1,420 CT scans on 1,239 patients were reviewed between April 2019 and September 2019 and 1,542 CT scans on 1,408 patients between February 2022 and August 2022. 19 adrenal incidentalomas were identified in the pre-intervention group (2019). Of the 19 adrenal incidentalomas in the pre-intervention group, only 5 (26%) underwent a complete biochemical workup. In 2022, a total of 19 adrenal incidentalomas were identified. 11 of the 19 reports had recommendation for referral to Urology/Endocrinology or recommendation for further biochemical assessment. 8/11 (73%) of these patients underwent a full biochemical evaluation. Only 1 of 8 patients with adrenal incidentaloma that did not have the intervention included within the radiology report had a biochemical workup performed at follow up. We found that there were more patients that underwent a complete biochemical evaluation in the post-intervention group (p<0.001). CONCLUSIONS: More patients had the appropriate biochemical evaluation performed for an adrenal incidentaloma when the radiology report included “Urology or endocrinology consultation recommended”. This is a simple intervention that should be implemented at other treatment facilities to improve the quality of care for patients. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e75 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan Yu More articles by this author David Barham More articles by this author Alexandria Hertz More articles by this author John Musser More articles by this author Frank Gould More articles by this author Expand All Advertisement PDF downloadLoading ...

MP72-15 PREOPERATIVE MEDICAL CLEARANCE: UNVEILING PRIMARY CARE NEEDS AT A PUBLIC URBAN MEDICAL CENTER USING UROLOGIC CASE CANCELATION RATES

You have accessJournal of UrologyCME1 Apr 2023MP72-15 PREOPERATIVE MEDICAL CLEARANCE: UNVEILING PRIMARY CARE NEEDS AT A PUBLIC URBAN MEDICAL CENTER USING UROLOGIC CASE CANCELATION RATES Lauren Fink, Matthew Bruha, Frederick Okoye, Lauren Namkoong, Brian McNeil, and Llewellyn Hyacinthe Lauren FinkLauren Fink More articles by this author , Matthew BruhaMatthew Bruha More articles by this author , Frederick OkoyeFrederick Okoye More articles by this author , Lauren NamkoongLauren Namkoong More articles by this author , Brian McNeilBrian McNeil More articles by this author , and Llewellyn HyacintheLlewellyn Hyacinthe More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003340.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Elective surgical case cancelations are a common problem in healthcare, causing patient and staff dissatisfaction, and a financial burden on institutions. Underserved communities have unmet primary care needs, and case cancelations in these populations may reflect chronic disease burdens. We evaluate the role of urologic consultation in improving overall health by identifying undiagnosed or undermanaged conditions during preoperative evaluation METHODS: All canceled elective urologic procedures from two surgeons at one urban center were retrospectively analyzed from 1/2015-12/2019. Chart reviews were performed to obtain reason(s) for cancelation, demographics, medical interventions performed, and American Society of Anesthesiologists (ASA) score pre- and post-operatively. Age-adjusted odds ratio (OR) was calculated for the association between preoperative ASA and medical interventions RESULTS: 1780 total elective cases were scheduled in our review. 551 canceled elective cases were identified with a 30% overall cancelation rate. 250 of those canceled cases were due to >1 undiagnosed or under-managed medical condition(s), representing 14% of the overall cancelation rate. 91.2% of patients were over 60 years old and African American. Notes were available for 111 (44.4%) of the 250 total cases canceled due to undiagnosed or under-managed medical conditions. 83% of these patients received their intended procedures. 35.1% of cases received medication adjustments, most commonly for cardiology and diabetes. Preoperative ASA>3 was found to be significantly associated with medical interventions of any kind (OR 2.6923 [1.1188-6.4788] p=0.0271) CONCLUSIONS: Elective urologic case cancelations were frequent and often related to comorbid conditions. Most patients canceled for medical reasons received optimization and then underwent surgery. ASA scores>3 may assist urologists in underserved urban areas in identifying patients who require medical intervention before elective surgery. Urologic consultation and subsequent preoperative clearance seem to provide a safety net for patients to receive optimization of their medical conditions that otherwise might go unmanaged. Case cancellations can have economic effects, also. Procedure slots are difficult to fill in on short notice. This paired with a high cancelation rate prevents opportunities to generate revenue. Appropriate consultation can eliminate pitfalls by allowing patients to obtain preoperative clearance prior to scheduling their elective cases Source of Funding: SUNY Downstate Medical Center © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1030 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lauren Fink More articles by this author Matthew Bruha More articles by this author Frederick Okoye More articles by this author Lauren Namkoong More articles by this author Brian McNeil More articles by this author Llewellyn Hyacinthe More articles by this author Expand All Advertisement PDF downloadLoading ...

MP70-17 IMPLEMENTATION OF AN ED NEPHROLITHIASIS PROTOCOL INCREASES USE OF MEDICAL EXPULSIVE THERAPY IN THE PEDIATRIC POPULATION

You have accessJournal of UrologyCME1 Apr 2023MP70-17 IMPLEMENTATION OF AN ED NEPHROLITHIASIS PROTOCOL INCREASES USE OF MEDICAL EXPULSIVE THERAPY IN THE PEDIATRIC POPULATION Daniel Salevitz, Chung-Yon Lin, Bernice Alcanzo, Abhijeet Namjoshi, Philip Lee, Cecilia Monteilh, and Gwen Grimsby Daniel SalevitzDaniel Salevitz More articles by this author , Chung-Yon LinChung-Yon Lin More articles by this author , Bernice AlcanzoBernice Alcanzo More articles by this author , Abhijeet NamjoshiAbhijeet Namjoshi More articles by this author , Philip LeePhilip Lee More articles by this author , Cecilia MonteilhCecilia Monteilh More articles by this author , and Gwen GrimsbyGwen Grimsby More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A review of children presenting to our emergency department (ED) from 2011 to 2017 found that ureteral stone passage was significantly higher for those prescribed medical expulsive therapy (MET), versus analgesics alone (45% vs 20%, p<0.0001). Urology consultation was also associated with increased MET use (p<0.0001). As a result, a new nephrolithiasis management protocol was implemented at our ED in August 2017 with the goal of increasing MET usage, decreasing use of CT scans, and increasing outpatient referrals to Urology and Nephrology. METHODS: This is a retrospective study of children aged 2 months to 18 years old who presented to a quaternary children’s hospital ED with an ICD-9 or ICD-10 diagnosis of urolithiasis from August 2017 to April 2022. Basic demographics, MET prescribing, use of CT for stone diagnosis, opioid prescription rate, and referral to Urology and Nephrology were compared before and after implementation of the ED nephrolithiasis protocol. Statistical analysis was performed using two sample t-test analysis and Fisher’s exact test. RESULTS: A total of 124 patients met inclusion criteria. Mean age was 14 years (SD 3.64), 47 (38%) male. Comparing pre and post-protocol implementation, there was no difference in mean age, gender, or stone size between groups (Table 1). Post-protocol, 99 patients (80%) were prescribed MET, which was significantly higher compared with 54% prior to the protocol (p<0.0001). Patients prescribed MET were older (mean 16 vs 15, p=0.014), and a higher proportion were discharged from the ED (71% vs 48%, p=0.033). Post protocol significantly less patients were prescribed opioids (27% vs 44%, p=0.0069). There was no difference in use of CT scans (79% vs 70%, p=0.1169), return to the ED (14% vs 14%, p=0.8681), outpatient urology (89% vs 89%, p=1.0) or nephrology referrals (23% vs 22%, p=1.0) pre and post protocol implementation, Table 1. CONCLUSIONS: After implementation of an ED nephrolithiasis protocol, use of MET for ureteral stones increased and prescription of opioids decreased. There was no difference in use of CT scans or outpatient referral to Urology and Nephrology pre versus post-protocol. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1010 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Salevitz More articles by this author Chung-Yon Lin More articles by this author Bernice Alcanzo More articles by this author Abhijeet Namjoshi More articles by this author Philip Lee More articles by this author Cecilia Monteilh More articles by this author Gwen Grimsby More articles by this author Expand All Advertisement PDF downloadLoading ...

MP54-17 FERTILITY PRESERVATION RATES AMONG TRANSGENDER GIRLS IN A MULTIDISCIPLINARY TRANSGENDER PROGRAM

You have accessJournal of UrologyCME1 Apr 2023MP54-17 FERTILITY PRESERVATION RATES AMONG TRANSGENDER GIRLS IN A MULTIDISCIPLINARY TRANSGENDER PROGRAM Nir Tomer, Eva Baldisserotto, Alexandra Siegal, Benjamin Eilender, Erin Miller, Mabel Yau, Matthew Oransky, Joshua Safer, and Neha Malhotra Nir TomerNir Tomer More articles by this author , Eva BaldisserottoEva Baldisserotto More articles by this author , Alexandra SiegalAlexandra Siegal More articles by this author , Benjamin EilenderBenjamin Eilender More articles by this author , Erin MillerErin Miller More articles by this author , Mabel YauMabel Yau More articles by this author , Matthew OranskyMatthew Oransky More articles by this author , Joshua SaferJoshua Safer More articles by this author , and Neha MalhotraNeha Malhotra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003307.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Fertility preservation (FP) should be an important step in health care prior to initiating gender affirming hormonal therapy (GAHT) or puberty blockade in transgender and gender diverse (TGD) people. However, FP is often not integrated into comprehensive gender affirming care. Prior studies show low rates of FP in transgender youth. The aim of this study was to understand how the integration of a pediatric urology team into our Center for Transgender Medicine and Surgery program would impact the overall number of transgender girls who pursue fertility preservation. METHODS: To assess the success of fertility preservation, we performed a retrospective review of a database of all TGD patients who were 18 years or younger with testes, and sought GAHT. Patients were evaluated and followed in our Center for Transgender Medicine and Surgery from 4/2022 through 10/2022. Demographics, age, hormonal treatment, Tanner stages, and FP use were recorded from the medical record. Successful sperm banking was defined as freezing >1 vial of sperm. RESULTS: Twenty seven patients ranging from ages 10-17 years old were referred to pediatric urology for FP. Of patients referred to the clinic, 20 (74.1%) were interested in pursuing/are in the process of sperm banking. Of the patients who didn’t pursue FP, 1 (3.7%) of the patients were prepubertal (Tanner I), 4 (14.8 %) patients declined to attempt FP because they wanted to avoid masturbation, and 2 (7.4%) patients declined referral altogether. Twelve patients began the process of FP with sperm banking - ten of whom successfully froze sperm within WHO reference ranges of semen parameters and 2 children were azoospermic. Upon review, these 2 patients with azoospermia were found to already have started hormonal suppression. CONCLUSIONS: Our data suggest that a large percentage of patients may be interested in fertility preservation. The integration of a pediatric urology team can help to increase access to this service. Importantly, that the children who already started pubertal suppression were azoospermic highlights the importance of the integration of pediatric urology and FP into the health care process prior to pubertal suppression therapy. In our program, counseling on GAHT and puberty blockers’ impact on fertility is introduced early and pediatric urology consultation is offered concurrently or even prior to endocrinology consultation. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e760 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nir Tomer More articles by this author Eva Baldisserotto More articles by this author Alexandra Siegal More articles by this author Benjamin Eilender More articles by this author Erin Miller More articles by this author Mabel Yau More articles by this author Matthew Oransky More articles by this author Joshua Safer More articles by this author Neha Malhotra More articles by this author Expand All Advertisement PDF downloadLoading ...

MP16-05 A NOVEL EMR-BASED CARE PATHWAY FOR NEPHROLITHIASIS: DEVELOPMENT AND 1 YEAR UTILIZATION

You have accessJournal of UrologyCME1 Apr 2023MP16-05 A NOVEL EMR-BASED CARE PATHWAY FOR NEPHROLITHIASIS: DEVELOPMENT AND 1 YEAR UTILIZATION Soum Lokeshwar, Daniel Heacock, Ankur Choksi, Devin Shaheen, Dylan Heckscher, Syed Rahman, Dinesh Singh, and Piruz Motamedinia Soum LokeshwarSoum Lokeshwar More articles by this author , Daniel HeacockDaniel Heacock More articles by this author , Ankur ChoksiAnkur Choksi More articles by this author , Devin ShaheenDevin Shaheen More articles by this author , Dylan HeckscherDylan Heckscher More articles by this author , Syed RahmanSyed Rahman More articles by this author , Dinesh SinghDinesh Singh More articles by this author , and Piruz MotamediniaPiruz Motamedinia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003236.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with acute renal colic due to stones frequently visit the ED. With limited ED resources due to the COVID-19 pandemic, we developed a best practice management pathway within our electronic medical records (EMR) to provide consistent, expeditious and appropriate care for patients with nephrolithiasis. The objective of this study is to describe the development and 1 year outcomes of our EMR Care Pathway for nephrolithiasis. METHODS: Our hospital system is composed of many centers. To standardize best practice care, we convened a clinical consensus group, with key stakeholders in emergency medicine, urology, interventional and diagnostic radiology to develop a pathway for the initial work up and management of acute renal colic. AUA guidelines, current literature, and expert consensus across specialties were used to develop the pathway to guide work up and management. Risk assessment tools, and criteria for specific imaging modalities, lab work, and pain protocols were outlined. Criteria for routine discharge with follow-up, including pre-populated links for referrals, indications for urology consult, hospital admission and urgent decompression (stent versus nephrostomy tube) were provided. Data was gathered through the EMR analytics team and descriptive statistics were performed. RESULTS: The Care Pathway was utilized 944 times from August 3, 2021 – September 17, 2022 at 11 different hospitals or care centers (Table 1). Usage increased overtime (r2=0.77). The majority of usage was in the ED (892, 94.4%). A total of 194 providers utilized the Pathway with the majority being residents (64, 33.0%). The pathway included care of 505 unique patients, with 106 primary diagnosis key words triggering pathway use. 139 Urology referrals were placed through the pathway with 124 new 28 day prescriptions of tamsulosin. CONCLUSIONS: An EMR-integrated care pathway has been readily utilized in our system and may augment triage and best practice management of patients presenting with stone disease. Further studies are needed to understand the full impact on outcomes. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e203 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Soum Lokeshwar More articles by this author Daniel Heacock More articles by this author Ankur Choksi More articles by this author Devin Shaheen More articles by this author Dylan Heckscher More articles by this author Syed Rahman More articles by this author Dinesh Singh More articles by this author Piruz Motamedinia More articles by this author Expand All Advertisement PDF downloadLoading ...

MP34-06 THE ROLE OF MICROGENDX TESTING IN PATIENTS WITH LOWER URINARY TRACT SYMPTOMS AND NEGATIVE STANDARD URINE CULTURES

You have accessJournal of UrologyCME1 Apr 2023MP34-06 THE ROLE OF MICROGENDX TESTING IN PATIENTS WITH LOWER URINARY TRACT SYMPTOMS AND NEGATIVE STANDARD URINE CULTURES Rahul Dutta, Wyatt Whitman, Maxwell Sandberg, Stephen Walker, and Catherine Matthews Rahul DuttaRahul Dutta More articles by this author , Wyatt WhitmanWyatt Whitman More articles by this author , Maxwell SandbergMaxwell Sandberg More articles by this author , Stephen WalkerStephen Walker More articles by this author , and Catherine MatthewsCatherine Matthews More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003268.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with acute lower urinary tract symptoms (LUTS) and a negative standard urinary culture are challenging to manage. Some may have identifiable organisms on urinary polymerase-chain reaction (PCR) testing or next-generation DNA sequencing (NGS). We sought to better understand the relationship between patients with negative UC and positive (with an identifiable microbe) PCR/NGS that had treatment for LUTS directed towards the organism(s) on PCR/NGS. METHODS: Patients from a single academic center for which a MicroGenDX PCR/NGS sample was analyzed were retrospectively reviewed. Relationships between demographics, UC and urinalysis data, symptomatology, treatment data, and comorbidities were analyzed. RESULTS: A total of 122 patients were reviewed, of which 116 (95%) had identifiable bacteria and 17 (14%) had identifiable fungi on urinary PCR/NGS. Of these, 95 (81% female) had both negative UC and identifiable microbes on PCR/NGS and were therefore included in the following analysis. The most common reasons for urologic consultation were recurrent urinary tract infection (UTI, 27%), stone disease (21%), and LUTS (18%). Leukocytes were identified on 44% of patients who had a urinalysis at the time of PCR/NGS with negative UC. Forty-seven (54%) patients were treated with antimicrobials following PCR/NGS and 25 of them (53%) had resolution or improvement in their symptoms. There was no association between treatment success and gender, interstitial cystitis, stone disease, diabetes mellitus, vaginal prolapse beyond the hymen, menopausal status, vaginal estrogen use, or overactive bladder syndrome (p>0.05). There was no association between the presence of moderate or greater leukocytes on urinary dipstick and likelihood of symptomatic resolution with treatment (p>0.05). There was a trend to increased likelihood of symptomatic resolution in patients with identifiable fungi on UPCR (p=0.1131). CONCLUSIONS: In the small present study, most patients with lower urinary tract symptoms and a negative standard urine culture have identifiable pathologic microbes on urinary PCR/NGS testing. The clinical utility of PCR/NGS testing, however, is unclear as symptomatic improvement with targeted antimicrobial treatment occurred in only approximately half of these patients. No relationships with treatment success, urinalysis findings, or common medical comorbidities were found. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e461 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rahul Dutta More articles by this author Wyatt Whitman More articles by this author Maxwell Sandberg More articles by this author Stephen Walker More articles by this author Catherine Matthews More articles by this author Expand All Advertisement PDF downloadLoading ...

Anxiety and depression in association with lower urinary tract symptoms: results from the COBaLT study.

Depression and anxiety have been associated with lower urinary tract symptoms (LUTS) in several studies. In our population, the prevalence of LUTS is high, consequently, it is essential and an objective of this study, to determine the association between anxiety, depression, and LUTS in a large Hispanic population. A sub-analysis of a cross-sectional population-based study to estimate LUTS prevalence in the Colombian population was performed (COBaLT study) (Plata et al. in Neurourol Urodyn 38:200-207, 2018). The Hospital Anxiety and Depression Scale (HADS) was used to evaluate mental health. Logistic regression was carried out to estimate the association of depression and anxiety with different LUTS. Variables that proved statistically significant (p < 0.05) were included in a multivariate model. A total of 1060 individuals were assessed. The prevalence of anxiety in women and men was 17.1% and 6.7%, respectively. Depression in women and men was 20.1% and 9.4%, respectively. An association was found between anxiety and overactive bladder (OAB) without urinary incontinence (OR = 3.7) and moderate or severe LUTS in men (OR = 3.8). In women, anxiety was associated with nocturia (OR = 4.2) and stress urinary incontinence (OR = 2.4). For depression, an association was found between sexual dysfunction (OR = 4.3) and moderate or severe LUTS (OR = 4.0) in men; while in women it was associated with stress urinary incontinence (OR = 2.3), the sensation of incomplete emptying (OR = 1.7) and decreased frequency of sexual activity (OR = 1.8). The associations found are consistent with other reports. It is essential to inquire about possible symptoms related to the mental sphere in the urology consultation to make appropriate referrals and subsequent management.

The need for a course to complete urological education for consultant practice using a simulated ‘boot camp’ structure at the end of specialist training: A survey-based study

To obtain opinions from urology trainees and consultants regarding the need for, and structure of, a post-specialty training Urology Simulation Boot Camp (USBC) for consultant practice. A survey-based study was conducted, and 'Google Forms' were distributed electronically via social media. Urology specialist trainees (ST) in years 5-7 (ST5-ST7), post-certification of completion of training (CCT) fellows and ST3 boot camp faculty consultants in practice for ≤5 years and >5 years were included. One hundred and seven responses were received. 97.2% of responders thought a pre-consultant USBC was worthwhile; 55.1% selected the course duration to be 2 days. 47.7% felt that the USBC should be delivered post-exam in ST7. 91.6%, 43.9%, 73.8%, 87.9% and 74.8% considered that modules in emergency operative procedures, novel uro-technologies, delivering multidisciplinary team (MDT) meetings, non-clinical consultant roles and responsibilities, stress and burnout to be important, respectively. 62.6% and 31.8% felt that the course should be wholly or part-funded by Health Education England (HEE). A post-specialty training, pre-consultant, USBC delivered post-exam in ST7, is worthwhile and should include modules on emergency operative procedures, leading MDTs, non-clinical roles and responsibilities and managing stress and burnout in consultant careers. Ideally, it should be fully/part-funded by HEE.

Genitourinary management and follow-up for patients with Stevens-Johnson syndrome/toxic epidermal necrolysis

ObjectiveTo review the cases of Stevens-Johnson syndrome and/or toxic epidermal necrolysis in adult male patients to determine the incidence of genitourinary manifestations, the indication for urethral catheters, and to provide recommendations for management. Materials and methodsThis is a retrospective observational study of adult male patients over a ten year period. The study group is divided into patients with and without genitourinary manifestations. ResultsWe identified 57 patients who met the study inclusion criteria, of whom 39 had genitourinary involvement. The most common location of lesions was the phallus although many patients had multiple sites of involvement. These lesions were treated similarly compared to other nongenitourinary cutaneous lesions. Four patients presented with dysuria, one with frequency, and one with hesitancy and intermittency. A urethral catheter was placed in 25 of the 39 patients. None of the patients who were not catheterized and did not have lower urinary tract symptoms at the time of presentation developed voiding symptoms during their hospital stay. Apart from a one-time episode of incontinence in one patient that resolved spontaneously, none of the patients who were catheterized developed voiding issues after their catheters were removed. No patients required follow-up with urology after discharge. ConclusionsNo patients developed a symptomatic urethral stricture. Many patients had multiple sites of involvement. Despite no standardized treatment being used, all cutaneous lesions were successfully treated in patients who survived their illness, with documented resolution of genitourinary lesions on physical examination. Routine urethral catheterization and urologic consultation are not necessary in these patients.

The Impact of Within-Consultation and Preconsultation Decision Aids for Localized Prostate Cancer on Patient Knowledge: Results of a Patient-Level Randomized Trial

To evaluate the role of timing (either before or during initial consultation) on the effectiveness of decision aids (DAs) to support shared-decision-making in a minority-enriched sample of patients with localized prostate cancer using a patient-level randomized controlled trial design. We conducted a 3-arm, patient-level-randomized trial in urology and radiation oncology practices in Ohio, South Dakota, and Alaska, testing the effect of preconsultation and within-consultation DAs on patient knowledge elements deemed essential to make treatment decisions about localized prostate cancer, all measured immediately following the initial urology consultation using a 12-item Prostate Cancer Treatment Questionnaire (score range 0 [no questions correct] to 1 [all questions correct]), compared to usual care (no DAs). Between 2017 and 2018, 103 patients-including 16 Black/African American and 17 American Indian or Alaska Native men-were enrolled and randomly assigned to receive usual care (n=33) or usual care and a DA before (n=37) or during (n=33) the consultation. After adjusting for baseline characteristics, there were no statistically significant proportional score differences in patient knowledge between the preconsultation DA arm (0.06 knowledge change, 95% CI -0.02 to 0.12, P=.1) or the within-consultation DA arm (0.04 knowledge change, 95% CI -0.03 to 0.11, P=.3) and usual care. In this trial oversampling minority men with localized prostate cancer, DAs presented at different times relative to the specialist consultation showed no improvement in patient knowledge above usual care.

A High-Efficiency Consultation Improves Urological Diagnosis in Patients with Complex LUTS-A Pilot Study.

(1) Background: The diagnosis of moderate-severe lower urinary tract symptoms (LUTS) is not easy due to the complexity of the micturition act. Sequential diagnostic tests can be time consuming due to waiting lists. Thus, we developed a diagnostic model combining all the tests in a single one-stop consultation. (2) Methods: In a prospective pilot study in patients with complex LUTS, they received all diagnostic tests (ultrasound, uroflowmetry, cystoscopy, pressure-flow study) in a single consultation and by the same doctor. Patients' results were compared with those from a 2021 paired cohort that underwent the classical sequential diagnostic pathway. (3) Results: Per patient, the high-efficiency consultation saved: 175 days of waiting, 60 min doctor time and 120 nursing assistant time and over 300 euros on average. The intervention also saved 120 patient journeys to the hospital, lowering the total carbon footprint by 145.86 kg CO2. In one-third of the patients, performing all the tests within the same consultation contributed to reaching a more appropriate diagnosis and thus more effective treatment. Patients' satisfaction was high, with good tolerability. (4) Conclusions: The high-efficiency urology consultation improves waiting times, therapeutic decisions and the degree of patient satisfaction while optimizing the use of resources and generating savings for the health system.

Do PHI and PHI density improve detection of clinically significant prostate cancer only in the PSA gray zone?

Prostate health index (PHI) is a predictive biomarker of positive prostate biopsy. The majority of evidence refers to its use in the PSA gray zone (4-10ng/mL) and negative digital rectal exam (DRE). We aim to evaluate and compare the predictive accuracy of PHI and PHI density (PHId) with PSA, percentage of free PSA and PSA density, in a wider range of patients for the detection of clinically significant prostate cancer (csPCa). Multicenter prospective study that included patients suspicious of harboring prostate cancer. Non-probabilistic convenience sampling, where men who attended the urology consultation were tested for PHI before prostate biopsy. To evaluate and compare diagnostic accuracy AUC and decision curve analysis (DCA) were calculated. All these procedures were performed for the overall sample and the following subsamples: PSA<4ng/ml; PSA 4-10ng/ml; PSA 4-10ng/ml plus negative DRE and PSA>10ng/ml. Among the 559 men included, 194 (34.7%) were diagnosed of csPCa. PHI and PHId outperfomed PSA in all subgroups. PHI best diagnostic performance was found in PSA 4-10ng/ml with negative DRE (sensitivity 93.33, NPV 96.04). Regarding AUC, significant differences were found between PHId and PSA in the subgroup of PSA 4-10ng/ml, whatever DRE status. In DCA, PHI density shows the highest net benefit. PHI and PHId outperfom PSA in csPCa detection, not only in the PSA grey zone with negative DRE, but also in a wider range of PSA values. There is an urgent need of prospective studies to established a validated threshold and its incorporation in risk calculators.