SGSU/Kimbrough 2016

Many thanks to Dr. John Barry for his diligence in taking the time to provide SGSU members these insights.

• Yes, I timed all of the presentations. Most of the residents were within the allotted time. Some of the members and guest faculty seemed to lose track of time the moment that first slide appeared and the first word was spoken.
• The Westin Riverwalk was a good venue for the meeting.
• In the military, the lower utilization of active surveillance for clinical stage I testicular seminoma when compared to national studies is probably due to frequent deployments and transfers.
• Robot-assisted retroperitoneal lymph node dissection has come of age for the non-chemotherapy-treated, non-seminomatous testis cancer patient.
• Active surveillance is becoming more widely accepted as a management option by men with low risk prostate cancer.
• TMPRSS2-ERG may become a therapeutic target for the treatment of prostate cancer.
• The identification of biochemical recurrence-associated genes could provide personalized risk stratification for men with clinically localized prostate cancer (Basic Science Prize Winner).
• The collagenase injection protocol for Peyronie’s disease seems to work about a third of the time, is expensive, and is associated with adverse events, including penile fracture.
• There is an association between chronic testicular pain and mental health diagnoses.
• The DOD-approved 2% testosterone gel works.
• It doesn’t seem to matter if a testicular artery is injured during varicocele repair.
• Access to urologic care for many Medicaid patients is restricted and variable by state. (Is greed the cancer of American medicine?)
• Urology residents are assets to patient care and attending urologist job satisfaction at the cost of increased OR times. Health care systems should continue to support post-graduate medical education.
• Prostatic urethral lifts are effective and do not adversely affect sexual function.
• Percutaneous nerve stimulation is effective for overactive bladder symptoms.
• The pattern of colorectal, genitourinary and lower extremity injury of the current conflicts is devastating and lessened by protective leg, lower abdominal and genital protective garments.
• Is there an association of hypospadias with fertilized farmland?
• A robotic-assisted vasovasostomy can be done as rapidly as an open kidney transplant.
• PSA increases with bariatric surgery-induced weight loss. “Why” is to be determined.
• There is discordance between the AUA Cryptorchid Guideline and practice patterns by pediatric urologists.
• Do glanular and coronal hypospadias need to be repaired in childhood (or ever)?
• Re-do laparoscopic spiral flap pyeloplasty works and takes a lot of OR time.
• A reminder call to patients the day before an appointment is a waste of time.
• American health care doesn’t do well in value (outcome ÷ cost) calculations.
• The AUA Consensus Statement on Advanced Practitioner Providers is worth a read.
• Read the AHLTA coding tip handout. It’s applicable to any practice that’s RVU-monitored.
• In addition to the urologist (and his or her clinical pathways) and anesthesiology services, treatment plans for the management of invasive bladder cancer patients should include a nurse coordinator, social service, financial counseling, nutrition, pharmacy, and medical oncology.
• The risk of exstrophy is increased in IVF babies; 7X in the US and 14X in Europe.
• There is no shame in staged repairs of urethral strictures or hypospadias.
• Current pelvic/abdominal radiation therapy may allow small bowel and cecum to be used for urinary diversion/reconstruction.
• Make friends with orthopedic and plastic surgeons if you plan to take care of patients with complications of radiation therapy.
• A smooth transition of care to the VA health care system needs to be done for our wounded warriors.
• The principles of reconstructive genitourinary surgery following combat injuries are the same in the UK as in the US except that sperm may discreetly be retrieved without a wounded veteran’s permission in the UK.
• A tumor thrombus that extends into hepatic veins is a bad sign.
• In a rat model, sacral nerve stimulation can be delayed until the final 50% of bladder filling.
• Ureteroscopic operative time is increased for lower pole, large and uric acid stones.
• Sperm can be cryopreserved after ultrasound-guided aspiration from the seminal vesicles of dismounted IED-injured men.
• Mesothelioma of the tunica vaginalis of the testis is rare and has a poor prognosis.
• Radical cystectomy is a morbidity-prone procedure, perhaps less so as attending surgeon involvement is increased.
• External genital reconstructive surgery in women with adrenal hyperplasia is successful, and there is no shame in doing more than one operation to get it right.
• Desmoplastic small round cell tumor is a rare soft tissue sarcoma that requires multimodal therapy.
• Erythrocytosis is common in hypogonadal men treated with testosterone pellets.
• Obesity was not a risk factor for stone-free or complication rates after tubeless percutaneous nephrolithotomy. (With a stone-free rate of ~50%, perhaps a nephrostomy tube should be left in for access in case residual stone burden needs to be treated in the next day or two?)
• A modified clock-face Mohs technique can be applied to malignant external genital lesions.
• Urology rotations in Veterans Administration Medical Centers are important for residency training.
• Shockwave lithotripsy can be a successful treatment for pancreatic duct stones.
• Blue light cystoscopy may (or may not) make a bladder melanoma more visible.
• The management of metastatic extramammary Paget’s disease is a challenge and often unsuccessful.
• Renal cell carcinoma metastases can become apparent outside the 5-year surveillance window.
• Abdominoscrotal hydrocele is a rare condition that is successfully treated with surgery.
• It’s rare to have a uterus in the scrotum of a patient with an ovotesticular disorder of sexual development.
• Venous thromboembolism and pulmonary embolus are reported in 4% and 1.5%, respectively, of radical cystectomy patients, and the mortality rate for the pulmonary emboli patients is 50%. (Let’s do something about it.)
• Perhaps more neurovascular bundles could be preserved in patients undergoing radical prostatectomy for high risk prostate cancer.
• IL-6, IL-10, and C-reactive protein may be useful markers of surgical stress. (Will their measurement improve patient care?)
• “Stone-free” is a vague outcome measure when a variety of imaging techniques is used.
• The history of calyceal catheterization for stone manipulation was but one of General Ball’s significant contributions to urology, and the podium presentation coupled with the awards ceremony honoring Dr. Ball at the banquet was one of the highlights of the meeting.
• Vibrators seem to work as well in men as they do in women.
• The presentation by Dr. Ian Thompson, Jr. about a common sense approach to prostate cancer biomarkers was a classic. Use the PCPTRC 2.0; use the percent free PSA; PSA < 1? Get another one in 10 years. Seek out the high risk prostate cancers and the ones likely to bother a man during his lifetime – and treat them – and monitor the others.
• There’s no shame in getting an opinion from a medical oncologist about the timing and sequencing of androgen deprivation and chemotherapy for metastatic prostate cancer.
• Perhaps “condemn” shouldn’t be used in a slide…
• Get a nutrition consult before and after radical cystectomy.
• Do a DRE before a TRUS-guided prostate biopsy, and don’t do a biopsy through stool.
• For In-Service and Board Exams, memorize the algorithms for a metabolic stone work up and the medical management of stone-forming patients.
• For male stress urinary incontinence, the “4-Cough Test” with slings for “drippers” and sphincters for “streamers” seems reasonable.
• Voiding diaries are good.
• If possible, don’t use mesh for female pelvic surgery. If you must, monofilament polypropylene type 1 with large pores is preferred.
• The AUA Overactive Bladder Guidelines are worth a read; at least a look at the algorithm.
• Sacral neuromodulation works.
• Colonel Buckley’s personal account of USAF ParaRescue Operations at the banquet was outstanding.
• Let’s do this again next year.

John M. Barry, MD