Globalization has impacted upon every aspect of our lives. The digital revolution sophisticated transportation systems, and cultural understanding, have all facilitated sharing ideas and improving lives. This maturation of our world has also caused positive changes in medicine. Initially, dissemination of thoughts and ideas were dominated by a few western focused publications. Over the past decade there has been a rapid evolution that has revealed the plethora of important ideas and practices from around the globe.

Objective: Late-onset hypogonadism, or androgen deficiency in the aging male, is a significant cause of morbidity in older men. Many men in the low normal or equivocal range for low testosterone level exhibit signs and symptoms of hypogonadism. Serum testosterone is an imperfect maker for hypogonadism as symptoms vary greatly within the low to low normal range in addition to variations among testosterone assays. Perineal ultrasound can be effectively used to examine the bulbocavernosus muscle (BCM), an androgenized tissue that may be impacted by androgen receptor activity.Methods: This study was a retrospective analysis of men who underwent perineal ultrasound for hypogonadism. The ultrasound data were used to calculate the area of the BCM and correlate it with indices of hypogonadismin symptomatic men including free and total testosterone and dual-energy X-ray absorptiometry (DEXA).Results: The results demonstrate that there is a significant correlation between total and free testosterone and BCM area in hypogonadal patients. Comparison between BCM area and total testosterone showed R²=0.061 and P=0.0187 and comparison between BCM area and free testosterone showed R²=0.0957 and P=0.0034. In addition, low BCM was also correlated with DEXA results showing osteoporosis and osteopenia (R²=0.2239, P=0.0027)..Conclusion: There has been recent controversy over the safety of testosterone replacement therapy. This might be particularly important in men with hypogonadal symptoms but a low normal testosterone level. Our study investigated the use of perineal ultrasound to measure BCM as a surrogate marker for poor androgenized men presenting with hypogonadism.

Objective: With today's modern imaging modalities, patients diagnosed with renal cell carcinoma (RCC) rarely present symptomatically. In some cases, however, they can develop paraneoplastic syndromes with associated symptoms. To date, only three cases of RCC presenting with chronic dry cough have been reported. We describe six patients who presented with cough that improved following radical nephrectomy.Methods: A retrospective review of patients undergoing partial or radical nephrectomy for renal masses between January 2015 and March 2016 was performed, and patients presenting with a cough were examined.Results: Six patients presented with chronic cough and were discovered to have a large renal mass. Postoperative spontaneous resolution of cough was noted in all but one patient, in whom coughing was reduced and limited to the mornings. Cough duration ranged from 3 months to just over a year. All patients were treated with radical nephrectomy, which was cytoreductive in four patients. Average tumor size was 10.9 cm (SD=2.2 cm). Five of the tumors had clear cell pathology, and every tumor was Fuhrman grade IV, unifocal, and demonstrated necrosis. Sarcomatoid features were reported in four of the tumors..Conclusion: Our study presents the largest series of patients with RCC who presented with a chronic cough that was significantly improved following radical nephrectomy. We believe the cause of cough is multifactorial and further investigation is needed to clearly elucidate the etiology.

Objective: The goal of hypospadias repair is to achieve normal voiding and good penile cosmesis with minimal complications. Some urethroplasties deteriorate from childhood to adolescence and late stage failures have been reported. We report our experience with adult patients who have had a previous repair during childhood and present with a late complication.Methods: We reviewed the records of 220 patients aged 15-39 years old with a history of hypospadias repair who presented to our clinic. Forty-five patients with chordee, 39 with urethral strictures, 11 urethral fistulae, five with hairy urethras, three with urethral diverticula, and 117 patients with an abnormal glans or subterminal meatus were repaired.Results: Median follow-up was 14 months. Two patients had persistent chordee. Island skin flap urethroplasty afforded one patient with a urethral fistula and another with a recurrent urethral stricture, while the buccal mucosa group had one fistula which healed spontaneously and two recurrent strictures. For the patients undergoing glanular repairs, seven had dehiscence or breakdown of the repair. All other operations were successful..Conclusion: Complications of childhood hypospadias repair may present later in life as some urethroplasties deteriorate with time. We now recommend to parents of children with repaired proximal hypospadias to come for follow-up as their child transitions to adolescence.

Over 1%-15% of the population worldwide is affected by nephrolithiasis, which remains the most common and costly disease that urologists manage today. Identification of atrisk individuals remains a theoretical and technological challenge. The search for monogenic causes of stone disease has been largely unfruitful and a technological challenge; however, several candidate genes have been implicated in the development of nephrolithiasis. In this review, we will review current data on the genetic inheritance of stone disease, as well as investigate the evolving role of genetic analysis and counseling in the management of nephrolithiasis.

Objective: Selective angioembolization (SAE) effectively diagnoses and treats iatrogenic vascular complications following percutaneous nephrolithotomy (PCNL).Methods: We retrospectively reviewed 1329 consecutive PCNLs and identified patients who underwent SAE following PCNL with at least 12-month follow-up. Estimated glomerular filtration rate (eGFR) was calculated for all patients preoperatively, postoperatively and at last followup. A 1:2 matched cohort analysis was performed.Results: Twenty-three patients underwent SAE and matched to 46 controls. There was no statistically significant difference in preoperative, postoperative, and follow-up eGFR when comparing patients who underwent SAE and those with an uneventful course..Conclusion: Long-term eGFR is comparable in patients who undergo uncomplicated PCNL and those requiring SAE.

Objective: Extracapsular extension (ECE) of prostate cancer is a poor prognostic factor associated with progression, recurrence after treatment, and increased prostate cancer-related mortality. Accurate staging prior to radical prostatectomy is crucial in avoidance of positive margins and when planning nerve-sparing procedures. Multi-parametric magnetic resonance imaging (mpMRI) of the prostate has shown promise in this regard, but is hampered by poor sensitivity. We sought to identify additional clinical variables associated with pathologic ECE and determine our institutional accuracy in the detection of ECE amongst patients who went on to radical prostatectomy.Methods: mpMRI studies performed between the years 2012 and 2014 were cross-referenced with radical prostatectomy specimens. Predictive properties of ECE as well as additional clinical and biochemical variables to identify pathology-proven prostate cancer ECE were analyzed.Results: The prevalence of ECE was 32.4%, and the overall accuracy of mpMRI for ECE was 84.1%. Overall mpMRI sensitivity, specificity, positive predictive value, and negative predictive value for detection of ECE were 58.3%, 97.8%, 93.3%, and 81.5%, respectively. Specific mpMRI characteristics predictive of pathologic ECE included primary lesion size ((20.73±9.09) mm, mean±SD, P<0.001), T2 PIRADS score (P=0.009), overall primary lesion score (P<0.001), overall study suspicion score (P=0.003), and MRI evidence of seminal vesicle invasion (SVI) (P=0.001)..Conclusion: While mpMRI is an accurate preoperative assessment tool for the detection of ECE, its overall sensitivity is poor, likely related to the low detection rate of standard protocol MRI for microscopic extraprostatic disease. The additional mpMRI findings described may also be considered in surgical margin planning prior to radical prostatectomy.

Objective: Treatment options for metastatic castration resistant prostate cancer (mCRPC) have expanded rapidly in recent years. Given the significant economic burden, we sought perform a cost-effectiveness analysis (CEA) of the contemporary treatment paradigm for mCRPC.Methods: We devised a treatment protocol consisting of sipuleucel-T, enzalutamide, abiraterone, docetaxel, radium-223, and cabazitaxel. We estimated number and length of treatments for each therapy using dosing schedules or progression free survival data from published clinical trials. We estimated treatment cost using billing data and Medicare reimbursement values and performed a CEA. Our analysis assumed US$100,000 per life year saved (LYS) as the threshold societal willingness to pay.Results: Incremental cost-effectiveness ratios (ICER) for strategies incorporating sipuleucel-T that were not eliminated by extended dominance exceeded the societal threshold willingnessto-pay of US$100,000 per LYS, the lowest of which was sipuleucel-T+enzalutamide+abiraterone+docetaxel at US$207,714 per LYS. Enzalutamide+abiraterone+docetaxel exhibited the most favorable ICER among strategies without sipuleucel-T at US$165,460 per LYS..Conclusion: Based on the available survival data and current costs of treatment, all treatment strategies greatly exceed a commonly assumed societal willingness-to-pay threshold of US$100,000 per LYS. Improvements in this regard can only come with a reduction in pricing, better tailoring of treatment or significant enhancements in survival with clinical use of treatment combinations or sequences.

As the number of Americans aged 65 years and older continues to rise, there is projected to be a corresponding increase in demand for major surgeries within this population. Consequently, it is important to utilize accurate preoperative risk stratification techniques that are applicable to elderly individuals. Currently, commonly used preoperative risk assessments are subjective and often do not account for elderly-specific syndromes that may pose a hazard for geriatric patients if not addressed. Failure to accurately risk-stratify these patients may increase the risk of postoperative complications, morbidity, and mortality. Therefore, we aimed to identify and discuss the more objective and better-validated measurements indicative of poor surgical outcomes in the elderly with special focus on frailty, patient optimization, functional status, and cognitive ability.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating, chronic condition characterized by chronic pelvic pain, urinary urgency, and frequency and is well-known to be associated with a decrease in work productivity, emotional changes, sleep, sexual dysfunction, and mobility. Many metrics of quality of life (QoL) in this patient population have been developed; however, a unified, standardized approach to QoL in these patients has not been determined. The effects of IC/BPS and co-morbid conditions on QoL are described using current validated metrics. Next, data regarding successful treatment of IC/BPS in terms of QoL improvement are reviewed. While QoL is the single most important clinical measure of success in the treatment of patients suffering from IC/BPS, addressing QoL in this patient population remains a significant challenge, as its effects on QoL are highly variable and unable to be differentiated from the effects of comorbid conditions on QoL, including depression, poor sleep, and inability to work. Future studies will need to address treatment efficacy on the basis of IC/BPS specific QoL metrics, and multi-modal assessment and therapy to address comorbid disease will also play an important role in the future to ensure comprehensive management of these patients.

While robotic surgery has shown clear utility and advantages in the adult population, its role in pediatrics remains controversial. Pediatric-sized robotic instruments and equipment are not readily available yet, so certain modifications can be made in order to make robotic surgery successful in children. While the cost of robotic surgery remains high compared to open procedures, patients experience greater satisfaction and quality of life with robotic surgery. Robotic pyeloplasty is a standard of care in older children, and has even been performed in infants and re-do surgery. Other robotic procedures performed in children include heminephroureterectomy, ureteroureterostomy, ureteral reimplantation, urachal cyst excision, bladder diverticulectomy, and bladder reconstructive procedures such as augmentation, appendicovesicostomy, antegrade continence enema, bladder neck reconstruction and sling, as well as other procedures. Robotic surgery has also been used in oncologic cases such as partial nephrectomy and retroperitoneal lymph node dissection. Future improvements in technology with production of pediatric-sized robotic instruments, along with increases in robotictrained pediatric urologists and surgeon experience along each's learning curve, will help to further advance the field of robotic surgery in pediatric urology.

Objective: Contemporary prostate cancer (PCa) screening modalities such as prostate specific antigen (PSA) and digital rectal examination (DRE) are limited in their ability to predict the detection of clinically significant disease. Multi-parametric magnetic resonance imaging (mpMRI) of the prostate has been explored as a staging modality for PCa. Less is known regarding its utility as a primary screening modality. We examined our experience with mpMRI as both a screening and staging instrument.Methods: mpMRI studies performed between 2012 and 2014 in patients without PCa were cross-referenced with transrectal ultrasonography (TRUS) biopsy findings. Statistical analyses were performed to determine association of mpMRI findings with overall cancer diagnoses and clinically significant (Gleason score≥7) disease. Subgroup analyses were then performed on patients with a history of prior negative biopsy and those without a history of TRUS biopsy. mpMRI studies were also cross-referenced with RP specimens. Statistical analyses determined predictive ability of extracapsular extension (ECE), seminal vesicle involvement (SVI), and pathologic evidence of clinically significant disease (Gleason score≥7).Results: Four hundred biopsy naïve or prior negative biopsy patients had positive mpMRI studies. Overall sensitivity, specificity, positive and negative predictive values were 94%, 37%, 58%, and 87%, respectively and 95%, 31%, 42%, and 93%, respectively for overall cancer detection and Gleason score≥7 disease. In patients with no prior biopsy history, mpMRI sensitivity, specificity, positive and negative predictive values were 94%, 36%, 65%, and 82%, for all cancers, and 95%, 30%, 50%, and 89% for Gleason score≥7 lesions, respectively. In those with prior negative biopsy sensitivity, specificity, positive and negative predictive values were 94%, 37%, 52%, and 90% for all cancers, and 96%, 32%, 36%, and 96% for Gleason score≥7 lesions, respectively. Seventy-four patients underwent radical prostatectomy (RP) after mpMRI. Lesion size on mpMRI correlated with the presence of Gleason score≥7 cancers (P=0.005). mpMRI sensitivity, specificity, positive and negative predictive values were 84%, 39%, 81%, and 44% respectively, for Gleason≥7 cancer. For ECE and SVI, sensitivity and specificity were 58% and 98% and 44% and 97%, respectively..Conclusion: mpMRI is an accurate predictor of TRUS biopsy and RP outcomes. mpMRI has significant potential to change PCa management, particularly in the screening population, in whom a significant proportion may avoid TRUS biopsy. Further studies are necessary to determine how mpMRI should be incorporated into the current PCa screening and staging paradigms.