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Abstract Objective To evaluate the ability to perform activities of daily living (ADLs) in patients who required nursing home (NH) care after radical cystectomy (RC), as this surgery can impair patients' ability to perform ADLs in the postoperative period. Methods Patients undergoing RC were identified in a novel database of patients with at least two NH assessments linked with Medicare inpatient claims. The NH assessment included the Minimum Data Set (MDS)-ADL Long Form (0-28; a higher score equals greater impairment), which quantifies ADLs. Paired t -tests and chi-squared analysis were used for comparisons. Results We identified 471 patients that underwent RC and had at least one MDS-ADL assessment. In total, 245 patients lived elsewhere prior to RC and went to an NH after RC, while 122 patients lived in an NH before and after RC. Mean age of the population was 80.7 years (standard deviation 5.7). Of the 245 patients who did not live in a facility before RC, 68% of patients were discharged directly to an NH and 31% were discharged to another location before NH. There was no difference in MDS-ADL score between these groups (16.4 vs 15.0, P =.09). Among the patients who lived in an NH before and after RC, the mean pre- and post-operative MDS-ADL scores were significantly different (12.1 vs 16.6, P <.0001). Conclusion ADLs, as measured by the MDS-ADL Long Form score, worsen after RC. This should be an important part of the risks and benefits conversation with patients, their families, and caregivers. [ABSTRACT FROM AUTHOR]

Objective: To report a case of pelvic angiosarcoma in a 27-year-old man with Li-Fraumeni Syndrome (LFS) and evaluate the presentation and timeline of genitourinary (GU) tract involvement in LFS patients.Methods: We retrospectively identified 39 LFS patients treated at our institution between 2000 and 2014; 7 (18%) had experienced a GU malignancy or an LFS-related malignancy involving the GU tract. Clinical characteristics, including dates of onset of first GU tract malignancies; pathologic findings; multimodal management; and familial history of LFS were reviewed.Results: Median age at first malignancy was 14.0 years (interquartile range [IQR] 5.5-24.0). There was a slight male predominance (4 of 7). Median time between first malignancy and the malignancy involving the GU tract was 10.1 years (IQR 8.0-19.5). Six of the 7 patients (86%) had a form of sarcoma involving the GU tract; 1 developed adrenocortical carcinoma. The cancer pedigree of all patients showed LFS-associated malignancies in family members. Multimodal management included surgical resection in 6 patients with adjuvant chemotherapy or radiotherapy in 1 patient each. One patient received chemotherapy only. Following diagnosis of malignancy involving the GU tract, 5 of the 7 patients developed additional primary malignancies. At a median follow-up of 4.7 years (IQR 3.0-12.1), 2 patients are alive, 3 died of disease, and 1 died of unknown cause. One patient was lost at follow-up.Conclusion: Continued follow-up of LFS cancer patients aimed at the determination of optimal screening, management, and surveillance protocols is recommended and may result in longer survival expectations. [ABSTRACT FROM AUTHOR]

Salvage treatment options after localized primary treatment failure of prostate cancer are limited and associated with risk for serious complications. We report on the management details of a 57-year-old African American man treated with partial-gland ablation using irreversible electroporation following local recurrence after brachytherapy and prior salvage cryoablation. Therapeutic and functional outcomes were assessed by conventional means, including serum prostate-specific antigen values and prostate biopsy results. [ABSTRACT FROM AUTHOR]

Objective To prospectively evaluate the effect of transrectal ultrasonography (TRUS)-guided prostate biopsy on erectile and voiding function at multiple time-points after biopsy. Patients and Methods All men who underwent TRUS-guided prostate biopsy completed a five-item version of the International Index of Erectile Function (IIEF-5) and the International Prostate Symptom Score (IPSS) before and at 1, 4 and 12 weeks after TRUS-guided biopsy. Statistical analyses used were a general descriptive analysis, continuous variables using a t-test and categorical data using chi-square analysis. A paired t-test was used to compare each patient's baseline score to their own follow-up survey scores. Results In all, 220 patients were enrolled with a mean age of 64.1 years and PSA level of 6.7 ng/dL. At initial presentation, 38.6% reported no erectile dysfunction (ED), 22.3% mild ED, 15.5% mild-to-moderate ED, 10% moderate ED, and 13.6% severe ED. On paired t-test there was a statistically significant reduction in IIEF-5 score at 1 week after biopsy compared with before biopsy (18.2 vs 15.5; P < 0.001). This remained significantly reduced at 4 (18.4 vs 17.3; P = 0.008) and 12 weeks (18.4 vs 16.9, P = 0.004) after biopsy. Conclusions The effects of TRUS-guided prostate biopsy on erectile function have probably been underestimated. It is important to be aware of these transient effects so patients can be appropriately counselled. The exact cause of this effect is yet to be determined. [ABSTRACT FROM AUTHOR]

Objective: To quantify the effect of the new 2010 World Health Organization (WHO) semen analysis reference values on reclassifying previous semen analysis parameters and definition of patients with male factor infertility. Design: A multi-institutional retrospective chart review. Setting: University and private male infertility clinics. Patient(s): Men referred for infertility evaluation. Intervention(s): Comparison of semen analysis values based on 2010 versus 1999 reference criteria. Main Outcome Measure(s): Quantification of the change based on individual sperm parameters and as a whole. Result(s): A total of 184 men had at least two semen analyses; 13 (7%), 17 (9.2%), 34 (18.4%), and 29 (15.7%) patients changed classification to being at or above the reference values by the 2010 criteria for semen volume, sperm concentration, motility, and morphology, respectively. A total of 501 men had one semen analysis on file; 40 (7.9%), 31 (6.2%), 50 (9.9%), and 74 (19.3%) would change classification for volume, concentration, motility, and morphology, respectively. Overall, 103 patients (15.1%) who had one or more parameter below the reference value on the original analysis were converted to having all parameters at or above the 2010 reference values. Conclusion(s): The 2010 reference values result in some infertile men being reclassified as fertile if status is based on semen analysis alone. This may lead to fewer men being referred for proper infertility evaluation or treatment. [ABSTRACT FROM AUTHOR]

The engraftment of human tumor tissues into immunodeficient host mice to generate patient-derived xenograft (PDX) models has become increasingly utilized for many types of cancers. By capturing the unique genomic and molecular properties of the parental tumor, PDX models enable analysis of patient-specific clinical responses. PDX models are an important platform to address the contribution of inter-tumoral heterogeneity to therapeutic sensitivity, tumor evolution, and the mechanisms of treatment resistance. With the increasingly important role played by targeted therapies in urological malignancies, the establishment of representative PDX models can contribute to improved facilitation and adoption of precision medicine. In this review of the evolving role of the PDX in urothelial cancer and kidney cancer, we discuss the essential elements of successful graft development, effective translational application, and future directions for clinical models. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the ability to perform activities of daily living (ADLs) in patients who required nursing home (NH) care after radical cystectomy (RC), as this surgery can impair patients' ability to perform ADLs in the postoperative period.Methods: Patients undergoing RC were identified in a novel database of patients with at least two NH assessments linked with Medicare inpatient claims. The NH assessment included the Minimum Data Set (MDS)-ADL Long Form (0-28; a higher score equals greater impairment), which quantifies ADLs. Paired t-tests and chi-squared analysis were used for comparisons.Results: We identified 471 patients that underwent RC and had at least one MDS-ADL assessment. In total, 245 patients lived elsewhere prior to RC and went to an NH after RC, while 122 patients lived in an NH before and after RC. Mean age of the population was 80.7 years (standard deviation 5.7). Of the 245 patients who did not live in a facility before RC, 68% of patients were discharged directly to an NH and 31% were discharged to another location before NH. There was no difference in MDS-ADL score between these groups (16.4 vs 15.0, P = .09). Among the patients who lived in an NH before and after RC, the mean pre- and post-operative MDS-ADL scores were significantly different (12.1 vs 16.6, P<.0001).Conclusion: ADLs, as measured by the MDS-ADL Long Form score, worsen after RC. This should be an important part of the risks and benefits conversation with patients, their families, and caregivers. [ABSTRACT FROM AUTHOR]

The article reports on chances of occurrence of Erectile Dysfunction after Prostate Biopsy surgery including side effects to patients such as hematospermia and fever, changes in International Index of Erectile Function (IIEF) scores and need of reducing these side effects by the urologists.

Background Mannitol is currently used as a renal protective agent to mitigate the effects of renal ischemia during nephron-sparing surgery (NSS). This routine practice lacks rigorous methodological study. Objective To assess the effect on renal function outcomes after surgery of mannitol infusion prior to renal ischemia during NSS. Design, setting, participants This prospective, randomized, placebo-controlled, double-blind trial included 199 patients with a preoperative estimated glomerular filtration rate (eGFR) > 45 ml/min/1.73m 2 scheduled for NSS; the trial was conducted between July 2012 and July 2015. Intervention Patients undergoing NSS were randomized to receive mannitol (12.5 g) or placebo intravenously within 30 min prior to renal vascular clamping. Outcome measurements and statistical analysis The primary outcome was the difference in eGFR (renal function) between the two groups at 6 mo following surgery assessed with an analysis of covariance model using preoperative eGFR, treatment group, and surgical approach as covariates. Results and limitations At baseline, the median age of the patients was 58 yr, and the median eGFR was 88 ml/min/1.73m 2 . Comparing placebo with mannitol infusion, the adjusted difference of 0.2 eGFR units at 6 mo was not significant ( p = 0.9), with the upper bound of the 95% confidence interval (–3.1 to 3.5) excluding a clinically relevant effect of mannitol. Limitations include evaluation of a single mannitol dose and patients all had excellent preoperative renal function. Conclusions Intraoperative 12.5 g mannitol infusion during NSS has no demonstrable clinical benefit when compared with standardized fluid hydration in patients with normal preoperative renal function, and its use in this setting is not warranted. Patient summary In this randomized trial, patients with normal kidney function who received mannitol during surgery to remove part of their kidney had no better kidney function 6 mo after surgery than those who did not receive mannitol. We conclude that this routine practice should be discontinued. [ABSTRACT FROM AUTHOR]

To evaluate variability among hospitals in susceptibility of common uropathogens to antimicrobial agents frequently used in transurethral procedures in order to examine whether state-based guidelines might be more appropriate than national prophylactic guidelines. Hospital-level antibiograms were requested from all hospitals throughout the state of Missouri. We studied Escherichia coli, Klebsiella , and Proteus sensitivities to evaluate common guideline recommended antimicrobials including trimethoprim sulfamethoxazole (TMP-SMX), third-generation cephalosporins, cefazolin, penicillin combinations, gentamicin, and fluoroquinolones. We evaluated variability and association between hospital characteristics and antimicrobial sensitivities. Data was requested from 81 hospitals across the state and 38 provided the requested data (47% response rate). Susceptibility was highest for third-generation cephalosporins for E. coli (mean of 94%), Proteus (96%), and Klebsiella (96%). Gentamicin also had high susceptibility for the bacteria studied; 94% for E. coli and 96% for Klebsiella. Current first line recommended agents showed more modest coverage for E. coli (cefazolin 84%, TMP-SMX 78%), Proteus (cefazolin 82%, TMP-SMX 71%), and Klebsiella (cefazolin 90%, TMP-SMX 89%). Post transurethral procedure infections are common. Rates can be limited with appropriate prophylaxis. Deciding on empirical coverage must take into account local resistance patterns. There is substantial variability among and within states in antimicrobial susceptibility for common uropathogens. When selecting antimicrobial prophylaxis, urologists should consider local- rather than state- or nation-level antibiograms, given the considerable variability. Future studies should consider the merits of very-broad spectrum prophylaxis and the potential role of molecular urinary pathogen (and pathogen-resistance) testing when selecting an optimal regimen. [ABSTRACT FROM AUTHOR]

Objectives: To assess the safety profile of antegrade mitomycin gel instillation through a percutaneous nephrostomy tube (PCNT) for upper tract urothelial carcinoma (UTUC) with the aim of decreasing morbidity associated with therapy. Patients and Methods: Patients undergoing antegrade administration of mitomycin gel via PCNT were retrospectively included for analysis from four tertiary referral centres between 2020 and 2022. The primary outcome was safety profile, as graded by Common Terminology Criteria for Adverse Events (v5.0). Post‐therapy disease burden was assessed by primary disease evaluation (PDE) via ureteroscopy. Results: Thirty‐two patients received at least one dose of mitomycin gel via PCNT for UTUC, 29 of whom completed induction and underwent PDE. Thirteen patients (41%) had residual tumour present prior to induction therapy. At a median of 15.0 months following first dose of induction therapy, ureteric stenosis occurred in three patients (9%), all of whom were treated without later recurrence or chronic stenosis. Other adverse events included fatigue (27%), flank pain (19%), urinary tract infection (12%), sepsis (8%) and haematuria (8%). No patients had impaired renal function during follow‐up and there were no treatment‐related deaths. Seventeen patients (59%) had no evidence of disease at PDE and have not experienced recurrence at a median follow‐up of 13.0 months post induction. Conclusions: Administration of mitomycin gel via a PCNT offers a low rate of ureteric stenosis, demonstrates a favourable safety profile, and is administered without general anaesthesia. [ABSTRACT FROM AUTHOR]

To determine if clustering methods can use a holistic assessment of health-related quality-of-life after bladder cancer diagnosis to predict survival outcomes independent of clinical characteristics. In the United States, an estimated 81,180 cases of bladder cancer will be diagnosed in 2022. We aim to help address the knowledge gap concerning the impact of patient functional status on outcomes. This is a cross-sectional, retrospective cohort study of patients in the End Results-Medicare Health Outcomes Survey Registry. Age and 36-Item Short Form Survey (SF-36) responses were used as K-means inputs to identify homogenous clusters of older patients with bladder cancer. We analyzed the association between the identified clusters, patient and disease characteristics, and outcomes. We used Cox proportional hazard regression to compare overall survival. We identified 5 homogenous clusters that exhibited differences in patient characteristics and survival. There was no significant difference in cancer stage or surgery type among the clusters. The Cox proportional hazard regression demonstrated significant associations of cluster with gender, age, education, marital status, smoking status, type of surgery, and cancer stage on overall survival. Cluster independently predicted overall survival. Using unsupervised machine learning, we identified clusters of patients with bladder cancer who had similar mental and physical function scores. Cluster grouping suggests that patients' mental and physical function may not be based on disease or treatment. There are significant survival differences between all clusters, demonstrating that a holistic assessment of patient-reported health-related quality-of-life has the potential to predict survival and possible modifiable risk factors in older patients with bladder cancer. [ABSTRACT FROM AUTHOR]

Background: UGN-101 is a novel delivery system for intracavitary treatment of upper tract urothelial cancer (UTUC). UGN-101 was approved based on a pivotal trial for small volume residual low-grade UTUC. Our aim was to report our experience with UGN-101 in a more heterogenous and real-world setting.Methods: We performed a retrospective review of all UGN-101 cases from 15 institutions with a focus on practice patterns, efficacy, and adverse effects. We include UGN-101 utilization in both the chemoablative and adjuvant setting.Results: There were a total 136 renal units treated from 132 patients. The majority of cases were biopsy proven low-grade UTUC. Practice patterns varied considerably - the most common administration technique was antegrade instillation via a percutaneous nephrostomy. When utilized in the adjuvant setting, 69% of patients were disease free at the time of their first endoscopic evaluation, while in the chemoablative setting, 37% were endoscopically clear on the first evaluation (P < 0.001). Complete response was higher in patients with smaller tumor size prior to UGN-101 induction; low volume (<1 cm) residual disease was associated with a 70% complete response, similar to disease free rate at first endoscopic evaluation when UGN-101 was used in the adjuvant setting. The use of maintenance doses of UGN-101 was reported in 27% of cases. The overall incidence of new onset, clinically significant ureteral stenosis was 23%.Conclusions: This study represents the largest review of patients treated with UGN-101 and can serve as a basis of ongoing hypotheses regarding treatment with UGN-101 for UTUC. [ABSTRACT FROM AUTHOR]

Objective: To evaluate optimal regimens for perioperative antimicrobial prophylaxis in transurethral procedures by examining antimicrobial susceptibility patterns in the United States.Materials and Methods: Through several methods, we attempted to attain an antibiogram for each state. We focused on microbes known to cause infections after transurethral surgeries and antibiotics referred to in current or prior recommendations and compared susceptibility rates across states using Kruskal Walis tests and the Dwass, Steel, Critchlow-Fligner tests. We also examined susceptibility to (non-ceftazidime) third generation cephalosporins.Results: Data is included from 40 states. For each microbe studied, there was significant variability in sensitivity to antibiotics studied. Current first line recommendations for antimicrobial prophylaxis include first generation cephalosporins with 82%, 80%, and 87% mean coverage for E coli, Proteus, and Klebsiella respectively and trimethoprim-sulfamethoxazole with 74%, 80%, and 93% coverage, respectively. Susceptibility to aminoglycosides is 91%, 92%, and 96%, respectively and to third generation cephalosporin, it is 92%, 99%, and 94%.Conclusion: Current first line recommended antimicrobials for prophylaxis in transurethral procedures provide overall poor predicted coverage based on our database of antibiograms. Alternatives exist that have higher predicted susceptibility, though clinical significance of this and risk of resultant antimicrobial resistance is unknown. Urologists should consider local patterns when selecting antimicrobial prophylaxis for their patients. [ABSTRACT FROM AUTHOR]

Objective: To demonstrate placement of bedside double-j ureteral stents in an Emergency Department or hospital floor setting.Background: Ureteral stent placement is a potentially lifesaving intervention and is one of the most common procedures performed by urologists. Although this procedure is typically performed in the operating room, studies have shown placing ureteral stents at the bedside could potentially decrease delay in stent placement, alleviate financial burdens of operating room use, decrease radiation exposure, and avoid general anesthesia risks1-5. We demonstrate a safe and efficacious method for bedside ureteral stent placement without fluoroscopic guidance.Materials and Methods: In the setting of the Emergency Department we use ketamine for conscious sedation and local anesthesia while on the wards, we utilize just local anesthesia. After the patient has been sterilely prepped and draped, the operator passes the flexible cystoscope into the bladder in the standard fashion. The obstructed ureteral orifice is identified, and an extra-long guidewire is used to place a 4.8-French ureteral stent through the scope and beyond the obstruction. A post-operative plain film x-ray of the abdomen confirms proper placement. If significant issues are encountered, the procedure is abandoned, and standard operating room stent placement is undertaken.Results: The technique is simple and reproducible for placing double-j ureteral stents outside of the operating room environment without general anesthesia.Conclusion: In select patients, bedside double-j ureteral stent placement using our method is a safe and reproducible way to avoid the costs and risks associated with general anesthesia and to optimize utilization of scarce operating room resources. [ABSTRACT FROM AUTHOR]

• UGN-101 has been approved for the use based on data showing efficacy in the chemo-ablation of small upper tract tumors of pyelocaliceal system – but there is no data on potential efficacy in the setting of ureteral tumors. • This study aims to explore this for the first time and review outcomes in 47 ureteral tumors treated with UGN-101. • The complete response rate in patients treated with chemo-ablative intent (n = 23) was 47.8%. UGN-101 has been approved for the chemoablation of low-grade upper tract urothelial cancer (UTUC) involving the renal pelvis and calyces. Herein is the first reported cohort of patients with ureteral tumors treated with UGN-101. We performed a retrospective review of patients treated with UGN-101 for UTUC at 15 high-volume academic and community centers focusing on outcomes of patients treated for ureteral disease. Patients received UGN-101 with either adjuvant or chemo-ablative intent. Response rates are reported for patients receiving chemo-ablative intent. Adverse outcomes were characterized with a focus on the rate of ureteral stenosis. In a cohort of 132 patients and 136 renal units, 47 cases had tumor involvement of the ureter, with 12 cases of ureteral tumor only (8.8%) and 35 cases of ureteral plus renal pelvic tumors (25.7%). Of the 23 patients with ureteral involvement who received UGN-101 induction with chemo-ablative intent, the complete response was 47.8%, which did not differ significantly from outcomes in patients without ureteral involvement. Fourteen patients (37.8%) with ureteral tumors had significant ureteral stenosis at first post-treatment evaluation, however, when excluding those with pre-existing hydronephrosis or ureteral stenosis, only 5.4% of patients developed new clinically significant stenosis. UGN-101 appears to be safe and may have similar efficacy in treating low-grade urothelial carcinoma of the ureter as compared to renal pelvic tumors. [ABSTRACT FROM AUTHOR]

Context: Age-adjusted death rates for heart disease are higher in rural areas than in urban areas. Lay advisors could potentially facilitate improvement in cardiovascular health outcomes. The aim of this systematic review and meta-analysis is to estimate lay advisor intervention effects on cardiovascular health metrics in rural populations.Evidence Acquisition: Searches of databases including MEDLINE, CINAHL, and Scopus from 1975 through October 2017 retrieved 323 citations, of which 272 abstracts were reviewed. Two authors independently abstracted data from eligible studies. Analysis was conducted in March 2018.Evidence Synthesis: Of 21 articles included in the systematic review, eight were RCTs and 13 were pre- and post-intervention studies. Of the RCTs, three took place in the U.S. Only two studies had low risk of bias. Using a random effects model, meta-analysis of six RCTs (1,641 participants) showed that lay advisor interventions in rural residents were associated with improvement in HbA1c of 0.4% (95% CI=0.13, 0.66, p=0.004, I2=60.65%). From four RCTs (873 participants), lay advisor interventions significantly improved BMI with pooled effect of 2.18 (95% CI=1.13, 3.24, p<0.001, I2=0.00%). Most studies had normal baseline blood pressure and cholesterol levels before intervention, and no significant effects were noted for these outcomes. Diverse types of measures used for diet, physical activity, and smoking precluded statistical synthesis.Conclusions: Lay advisor interventions had significant positive effects on glycemic control and BMI for rural residents; however, further rigorous studies are needed in U.S. rural populations, and elements of effective lay advisor interventions require further investigation. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effectiveness of combination treatment of vascular targeted photodynamic therapy and anti‐cytotoxic T‐lymphocyte‐associated antigen 4 immunotherapy in a mouse model of urothelial carcinoma. Methods: We used C57BL/6 mice injected with murine bladder 49 cell line. Mice were randomly allocated into four treatment groups: vascular targeted photodynamic therapy only, anti‐cytotoxic T‐lymphocyte‐associated antigen 4 only, combination therapy and control. We carried out three separate experiments that used distinct cohorts of mice: tumor growth and development of lung metastases monitored with bioluminescent imaging (n = 91); survival evaluated with Kaplan–Meier curves (n = 111); and tumor cell population studied with flow cytometry (n = 20). In a fourth experiment, we re‐challenged tumors in previously treated mice and compared tumor growth with that of naïve mice. Results: Combination therapy provided significant benefits over the other three treatment groups: prolonged survival (P < 0.0001), lower tumor signal (P < 0.0001) and decreased lung signal uptake (P ≤ 0.002). We also observed that mice previously treated with vascular targeted photodynamic therapy only or combination therapy did not present tumor growth after re‐challenged tumors. Conclusions: Combination of vascular targeted photodynamic therapy with anti‐cytotoxic T‐lymphocyte‐associated antigen 4 is an effective therapy in a urothelial carcinoma syngeneic mouse model. The present results suggest this therapy as a potential treatment option for both bladder and upper tract tumors in future clinical trials. [ABSTRACT FROM AUTHOR]