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Objective: To perform a systematic review and a retrospective cohort analysis evaluating the rates of surgical downgrading of prostate cancer (PCa) from biopsy (PBx) to radical prostatectomy (RP), and their association with biochemical recurrence (BCR) in a multiethnic population., Methods: A systematic review of PubMed and other databases was performed. We included retrospective studies evaluating the relationship between surgical downgrading and BCR-free survival. Data regarding Gleason score (GL) downgrading were abstracted from the articles and categorized as follows: GL8-10 to GL7, GL7 to GL6, and GL 7(4 + 3) to GL7(3 + 4). We also performed a retrospective cohort review of patients who underwent RP at our institution from 2005 through 2020. Kaplan-Meier survival analysis and Cox proportional hazards models were used to compare BCR among downgraded versus non-downgraded men., Results: Systematic review yielded 137 abstracts; of these, 36 full-texts were reviewed, 8 of which were included in our systematic review. Despite substantial variability, all showed that GL at RP is one of the most important factors of BCR-free survival. A total of 1,484 men with PCa were analyzed from our institution. On multivariate analysis, GL7 to GL6 downgrading (HR = 0.50, p = 0.022) and GL8-10 to GL7 downgrading (HR = 0.42, p = 0.011) were associated with reduced risk of BCR when compared to men with GL7 and GL8-10 concordance, respectively. However, GL7(4 + 3) to GL7(3 + 4) downgrading was not significantly associated with reduced BCR (HR = 0.56, p = 0.12), when compared to GL7(4 + 3) concordance, although HR was similar., Conclusion: Surgical downgrading at RP was associated with a reduced risk of BCR compared to GL concordant disease, and these findings have been validated within our multiethnic population. Pathologic downgrading at the time of RP may be a more useful predictor of subsequent BCR in comparison to that associated with GL concordant pathology., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Postoperative delirium (POD) affects 10-70% of patients 60 years or older and has been linked to increasing length of hospitalization, mortality, and morbidity. Pre-existing cognitive impairment is a predictor of POD. COVID-19 restricted use of in-person cognitive screens. The Telephone Montreal Cognitive Assessment (T-MoCA) can screen for cognitive dysfunction remotely. We evaluated the feasibility of administering T-MoCA in a multiethnic population during pre-operative testing televisits., Methods: Patients scheduled for surgery between July 2020 and August 2020 were asked to participate in the T-MoCA at the end of their preadmission testing (PAT) televisit. A retrospective chart review was conducted to collect patient comorbidities and demographics. Patients were stratified by negative (T-MoCA≥19) or positive (T-MoCA<19) for mild cognitive impairment (MCI) and compared using 2-tailed χ 2 -tests. Univariate logistic regression was used to identify associations between patient characteristics and positive T-MoCA result., Results: Fifty out of 65 (77%) patients who consented to the T-MoCA completed the test. The average time to complete the assessment was 10.5 mins. Twenty two (44%) had a negative score and 28 (56%) had a positive score. Patients who had a positive T-MoCA were older (70.04±7.61 yrs) compared to those with a negative T-MoCA (67.68±4.69 yrs, p=0.007), although the distribution of patients above and below age 65 was not different (p=0.243). The two groups did not vary by gender, race/ethnicity, obesity, surgery type, or medical co-morbidities. When we examined our population for predictors of a positive T-MoCA, we found a trend toward men being less likely to score positive on T-MoCA (OR=0.33, 95% CI: 0.10-1.10, p=0.07) compared to women; and that patients with Hispanic race/ethnicity were more likely to test positive on the T-MoCA (OR=4.13, 95% CI: 0.84-20.28, p=0.08) compared to Non-Hispanic Whites., Conclusions: Implementation of the T-MoCA in a telemedicine-based PAT setting is feasible. In our cohort, most people who consented to the assessment completed it, and more than half scored positively, which may have important implications on the surgical plan and post-operative recovery. There may be limitations in using T-MoCA in certain populations, such as non-English preferred language, hearing difficulties, lack of focus, and use of external aids, which would need to be explored in a larger sample size., Competing Interests: The authors have no conflicts of interest, financial or otherwise, to declare., (© 2021 Elsevier Inc. All rights reserved.)

The prostate is a hormone-responsive organ where testicular androgens drive the proliferation and survival of prostatic cells, ensuring the development and functioning of this gland throughout life. Androgen deprivation therapy leads to apoptosis of prostatic cells and organ regression, and is a cornerstone of prostate cancer and benign prostatic hypertrophy treatment. For several decades, androgen deprivation has been used as an adjuvant to external beam radiotherapy, however, emerging data suggests that the low rates of epithelial proliferation in the castrated prostate imparts radio-resistance. As proliferating cells exhibit increased sensitivity to radiation, we hypothesized that short bursts of synchronized epithelial proliferation, which can be achieved by exogeneous testosterone supplementation prior to targeted high-dose radiation, would maximize sustained prostate ablation, while minimizing damage to surrounding tissues. To test this hypothesis, we designed a novel computed-tomography (CT)-guided stereotactic prostate radiation therapy (CT-SPRT) technique to deliver a single high-dose 25 Gy fraction of X-ray radiation. Sustained prostatic cell ablation was assessed post CT-SPRT by measuring prostate weight, epithelial cell number, and relative contributions of luminal and basal epithelial populations in control and testosterone-pretreated glands. CT-SPRT was safely delivered with no observed damage to surrounding rectal and bladder tissues. Importantly, castrated mice that received a pulse of testosterone to induce synchronous cell proliferation prior to CT-SPRT exhibited significant sustained gland ablation compared to control mice. These results provide new insights in stereotactic radiotherapy sensitivity to maximize prostatic cell ablation and improve our understanding of prostate gland regeneration that can potentially lead to improved non-invasive therapies for benign prostatic hypertrophy and prostate cancer.

Background: The first wave of the COVID-19 pandemic in March 2020 forced our healthcare system in the Bronx, New York to cancel nearly all scheduled surgeries. We developed a framework for prioritizing postponed urologic surgeries that was utilized once cases were permitted to be rescheduled. As many parts of our country experience first and second waves of this pandemic, our framework may serve as a resource for other centers experiencing restrictions on the scheduling of elective urologic surgeries., Methods: As the COVID-19 pandemic started and peaked in New York, almost all of our scheduled urologic surgeries were cancelled. Each Urologist was asked to rank his/her cancelled surgeries by priority (Level 1-least urgent; Level 2-moderately urgent; Level 3-most urgent). A committee of Urologists assigned a subclass to Level 3 and 2 cases (3a-least urgent; 3b-moderately urgent; 3c-most urgent; 2a-lower priority; 2b-higher priority). The committee then reviewed cases by urgency to derive a final priority ranking., Results: A total of 478 total urologic surgeries were canceled and categorized: 250 Level 1, 130 Level 2, 98 Level 3 (73 adult, 25 pediatric). Level 3c involved renal cell carcinoma ≥ T2b, high-grade bladder urothelial carcinoma, adrenal mass/cancer > 6 cm, testicular cancer requiring radical orchiectomy, and penile cancer. Level 3b involved T2a renal masses requiring nephrectomy, while high-risk prostate cancer and symptomatic nephrolithiasis were classified as 3a. Level 2 included testicular cancer requiring retroperitoneal lymph node dissection and complicated benign prostatic hyperplasia. Surgeries for urologic reconstruction, non-complicated nephrolithiasis, erectile dysfunction, and urinary incontinence were considered Level 1., Conclusions: Our disease-specific approach to surgical rescheduling offers appropriate guidance for triaging urologic surgeries. Our system can provide guidance to other institutions as COVID-19 cases surge in different regions and with the growing second wave.

To compare renal functional outcomes in patients with and without chronic kidney disease (CKD) to identify predictors of change in renal function after percutaneous nephrolithotomy (PCNL). We reviewed patients who underwent PCNL by a single surgeon over 3.5 years. Patients' pre- and post-operative Glomerular Filtration Rate (GFR) was calculated. Baseline GFR < 60 ml/min/1.73 m 2 (stage ≥ 3 CKD) defined our CKD cohort. Patients' baseline renal function, comorbidities, stone parameters, and intra-operative variables were analyzed to determine the relationship with post-operative renal function after PCNL by multivariate analysis. 202 patients were analyzed. Mean follow-up time was 16 months. At baseline, 163 (80.7%) patients were free of CKD and 39 (19.3%) had CKD. Patients without CKD had an overall decrease in GFR from 105.6 to 103.3 ml/min/1.73 m 2 (p = 0.494). 14/163 (8.6%) non-CKD patients experienced a significant decline in renal function after PCNL; 7/163 (4.3%) developed de novo CKD and 7 had a ≥ 30% decline in GFR. Patients with CKD had an overall increase in mean GFR post-operatively, from 47.3 to 54.0 ml/min/m 2 (p = 0.067). Two in this cohort (5.1%) experienced a > 30% decline in renal function post-operatively. Age, gender, African American race, presence of comorbidities and pre-operative CKD were not significant predictors of renal function post-operatively on multivariate analysis. PCNL in this cohort appears GFR neutral in the setting of baseline CKD. CKD was not predictive of renal functional decline after PCNL. Given that stone disease carries a high recurrence rate and that CKD is associated with stone formers, further investigation into predictors of renal function change after PCNL is warranted.

Principles of abdominal vesicovaginal fistula (VVF) repair include good exposure of the fistulous tract, double-layer bladder closure, retrograde fill of the bladder to ensure a water-tight seal, tension-free closure and continuous postoperative bladder drainage. Minimally invasive approaches, particularly robot-assisted laparoscopy, have demonstrated shorter operative times, decreased blood loss, improved visibility, and similar cure rates without increased adverse events. These techniques are therefore rising in popularity among surgeons. Ultimately, surgical approach to VVF repair depends upon the individual characteristics of the patient and fistula, as well as the preference and experience of the surgeon., (Copyright © 2018 Elsevier Inc. All rights reserved.)

To examine how a low-carbohydrate diet affects cognitive performance, women participated in one of two weight-loss diet regimens. Participants self-selected a low-carbohydrate (n=9) or a reduced-calorie balanced diet similar to that recommended by the American Dietetic Association (ADA diet) (n=10). Seventy-two hours before beginning their diets and then 48 h, 1, 2, and 3 weeks after starting, participants completed a battery of cognitive tasks assessing visuospatial memory, vigilance attention, memory span, a food-related paired-associates a food Stroop, and the Profile of Moods Scale (POMS) to assess subjective mood. Results showed that during complete withdrawal of dietary carbohydrate, low-carbohydrate dieters performed worse on memory-based tasks than ADA dieters. These impairments were ameliorated after reintroduction of carbohydrates. Low-carbohydrate dieters reported less confusion (POMS) and responded faster during an attention vigilance task (CPT) than ADA dieters. Hunger ratings did not differ between the two diet conditions. The present data show memory impairments during low-carbohydrate diets at a point when available glycogen stores would be at their lowest. A commonly held explanation based on preoccupation with food would not account for these findings. The results also suggest better vigilance attention and reduced self-reported confusion while on the low-carbohydrate diet, although not tied to a specific time point during the diet. Taken together the results suggest that weight-loss diet regimens differentially impact cognitive behavior.