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The article focuses on the growing global challenge of kidney stone disease, emphasizing its increased prevalence, association with systemic illnesses, and substantial economic impact. Topics discussed include key risk factors such as hypercalciuria and hyperoxaluria, the imperative of early diagnosis using imaging techniques, and the role of dietary modifications and diverse surgical interventions in managing kidney stones clinically.

Objectives: To characterize the perioperative morbidity of transurethral resection of bladder tumor (TURBT) in order to identify important determinants of both quality and cost in the delivery bladder cancer care.Methods: We identified 24,100 patients aged 18-89 years who underwent TURBT from 2010 to 2015 in the National Surgical Quality Improvement Program database. Multivariable logistic regression was performed to evaluate the associations of patient features and tumor size (<2 cm, 2-5 cm, or >5 cm) with 30-day perioperative outcomes.Results: Thirty-day postoperative complications occurred in 5.1% of patients, perioperative blood transfusion in 1.5% of patients, hospital readmission in 3.7% of patients, reoperation in 1.5% of patients, and mortality in 0.8% of patients. The most common reasons for readmission were bleeding (29%) and infectious (21%) complications. Although several patient features were associated with increased perioperative morbidity on multivariable analysis, including congestive heart failure, renal failure, higher American Society of Anesthesiology class, and dependent functional status, only larger tumor size was independently associated with increased risks of all perioperative endpoints.Conclusion: Perioperative morbidity following TURBT is substantial and represents an important target for quality improvement. Extent of resection, patient functional status, and specific comorbidities are independently associated with increased risks of perioperative morbidity and mortality. These results have implications for patient counseling, perioperative management, and quality improvement programs. [ABSTRACT FROM AUTHOR]

Objective: To determine if the histopathology of the ureteropelvic junction differs between those with and without crossing vessels who present with a ureteropelvic junction obstruction (UPJO).Materials and Methods: Our database was queried for patients undergoing pyeloplasty (Current procedural terminology 50400, 50405, and 50544) between June 1, 2002, and March 10, 2016. We excluded patients with other renal anatomic abnormalities and patients undergoing surgery for upper tract tumor. One genitourinary pathologist reviewed all slides for muscle hypertrophy, fibrosis, edema, and inflammation. Statistics were modeled in SAS 9.4 (SAS, Cary, NC) using logistic regression with maximum likelihood.Results: A total of 178 patients met the inclusion criteria, and pathology slides were available for 136 patients. Thirty-three patients had crossing vessels in association with a UPJO. The degrees of muscle hypertrophy (P = .89) and fibrosis (P = .17) were not predictive of etiology. The odds of a crossing vessel increased by 4.3 times (95% confidence interval 1.8-9.9) when edema was present (P = .009) and by 4.4 (95% confidence interval 1.4-13.7) times when inflammation was present (P = .0103).Conclusion: In the largest pathology series to date, histopathology showed increased inflammation in the presence of a crossing vessel but a similar composition of muscle and fibrosis. These data suggest that UPJO with an associated lower-pole vessel may represent a chronic process, which would explain why patients with a crossing vessel present later in life. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the cost-effectiveness of shockwave lithotripsy (SWL) versus ureteroscopic lithotripsy (URS) for patients with ureteral stones less than 1.5 cm in diameter. Methods: Patient age, stone diameter, stone location, and stone-free status were recorded for patients treated with SWL or URS for ureteral stones under 1.5 cm over a 1 year period. Institutional charges were obtained from in-house billing. A decision analysis model was constructed to compare the cost-effectiveness of SWL and URS using our results and success rates for modeling. Three separate models were created to reflect differing practice patterns. Results: A total of 113 patients were included-51 underwent SWL and 62 underwent URS as primary treatment. Single procedure stone-free rates for SWL and URS were 47.1 and 88.7 %, respectively ( p < 0.002). Decision analysis modeling demonstrated cost-effectiveness of SWL when SWL single procedure stone-free rates (SFR) were greater than or equal to 60-64 % or when URS single procedure SFRs were less than or equal to 57-76 %, depending on practice patterns. Conclusions: This retrospective study revealed superior SFR for ureteral stones less than 1.5 cm treated with URS compared to SWL. Our decision analysis model demonstrated that when SFR for SWL is less than 60-64 % or is greater than 57-76 % for URS, SWL is not a cost-effective treatment option. Based on these findings, careful stratification and selection of stone patients may enable surgeons to increase the cost-effectiveness of SWL. [ABSTRACT FROM AUTHOR]

Aims. Metastatic malignant melanoma of the urinary bladder is a rare clinical entity, with only twenty-three published cases to date. We present a case of this rare entity, a thorough review of the literature, and differential diagnosis of melanoma in the bladder. Methods and Results. A 55-year-old woman with a history of malignant melanoma of the right thigh, excised eight years ago, presented with back pain, fatigue, and hematuria. She underwent computed tomography (CT) scan and was found to have metastases within the liver, spleen, lungs, and urinary bladder. She underwent cystoscopy and transurethral resection of three polypoid lesions. Histologic and immunohistochemical examination revealed metastatic malignant melanoma involving bladder mucosa. Conclusions. This case illustrates the importance of including malignant melanoma in the differential diagnosis of high grade neoplasms of bladder, especially in cases where the relevant clinical history is not available. [ABSTRACT FROM AUTHOR]

Background and Purpose: While the power needed to initiate bipolar vaporization is higher than conventional monopolar resection, the energy needed to maintain bipolar vaporization is significantly lower and may result in less thermal tissue injury. This may have implications for hemostasis, scarring, and perioperative morbidity. The objective of this study is to assess histopathologic changes in prostatic tissue after bipolar transurethral vaporization of the prostate. Patients and Methods: Male patients older than 40 years with a diagnosis of benign prostatic hyperplasia (BPH) who elected to undergo bipolar transurethral vaporization of the prostate were included in this study. Patients were excluded if they had a previous transurethral resection of the prostate (TURP) or prostate radiation therapy. An Olympus button vaporization electrode was used to vaporize prostate tissue. A loop electrode was then used to obtain a deep resection specimen. The vaporized and loop resection surfaces were inked and sent for pathologic analysis to determine the presence of gross histologic changes and the depth of penetration of the bipolar vaporization current. Results: A total of 12 men underwent bipolar TURP at standard settings of 290 W cutting and 145 W coagulation current. Mean patient age was 70±10.2 years (range 56-88 years). Mean surgical time was 48.7±20.2 minutes (range 30-89 min). Mean depth of thermal injury was 2.4±0.84 mm (range 0.3-3.5 mm). Histopathologic evaluation demonstrated thermal injury in all specimens, but no gross char was encountered. Conclusions: In bipolar systems, resection takes place at much lower peak voltages and temperatures compared with monopolar systems. Theoretically, this leads to less collateral thermal damage and tissue char. Our tissue study illustrates that the button vaporization electrode achieves a much larger depth of penetration than previous studies of bipolar TURP. This may be because thermal injury represents a gradual continuum of histologic changes. [ABSTRACT FROM AUTHOR]

This review will summarize reported complications of laparoscopic renal surgery (LRS) and provide a concise summary and clinical pathway to prevent, identify and manage complications associated with LRS. Complications are not reported in a uniform manner and we strongly encourage the use of the Clavien or other classification systems to facilitate future comparison. Comorbidities, body mass index, renal function, renal anomalies, and lack of surgeon proficiency may adversely affect outcomes whereas age does not. Trocar access, pneumoperitoneum, and patient positioning reflect aspects unique to laparoscopy that may present specific challenges to the urologist. Articles pertaining to complications in LRS are examined and discussed. Major and minor complication rates for LRS have reportedly ranged from 1–6% and 6–17%, respectively. Vascular, bowel, and ureteral injuries are reported as the most commonly encountered intraoperative complications. An appreciation for the data presented may allow the urologist to better avert complications in LRS. [ABSTRACT FROM AUTHOR]

Associate Editor Ash Tewari Editorial Board Ralph Clayman, USA Inderbir Gill, USA Roger Kirby, UK Mani Menon, USA OBJECTIVE To describe our experience with laparoscopic renal surgery (LRS) in the octogenarian. Octogenarians are generally suboptimal surgical candidates but the recent upsurge of minimally invasive options for the management of kidney lesions, such as laparoscopic excision, cryoablation and radiofrequency ablation (RFA), have changed that perception. PATIENTS AND METHODS In all, 26 patients aged ≥80 years underwent LRS at Brown University and the University of Wisconsin between 2000 and 2006. Demographic information, anatomical location, tumour stage, comorbidities, type of laparoscopic approach, management and outcomes were assessed. Complications during and after LRS, hospital stay, analgesia requirements and return to normal activity were analysed. RESULT The mean age of the patients was 81 years. The procedures performed included hand-assisted laparoscopic partial nephrectomy (three patients), hand-assisted laparoscopic radical nephrectomy (10), hand-assisted laparoscopic nephroureterectomy (four), laparoscopic-assisted cryoablation (seven), laparoscopic RFA (one), and laparoscopic unroofing of a renal cyst (one). The mean (range) follow-up was 40 (8–84) months. The mean American Society of Anesthesiologists score was 2.5. The average hospital stay was 5.6 days and the mean time to normal activity after discharge was 19 days. There were two major and five minor complications. Nineteen of 22 patients evaluable had no evidence of disease at the last follow-up. The three deceased patients died of unrelated causes. CONCLUSION LRS in the octogenarian is safe to perform in patients with multiple comorbidities. The major and minor complication rates were 7% and 19%, respectively. Recent trends show that ablative procedures are being performed more commonly than surgical excision in this age group. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate whether the skin-to-stone distance (SSD), body mass index (BMI), and Hounsfield unit (HU) density can be used as independent predictors of stone-free (SF) status after shock wave lithotripsy (SWL) of lower pole kidney stones. No studies have evaluated the SSD by non-contrast-enhanced computed tomography (NCCT) as a predictor of SWL success. Studies have suggested that the BMI and HU density of urinary calculi on NCCT may predict the SF rate after SWL. Methods: The radiographs of 64 patients treated with SWL (DoliS lithotripter) from March 2000 to April 2004 with lower pole kidney stones measuring 0.5 to 1.5 cm on NCCT were reviewed. The average SSD was calculated by measuring three distances from the center of the stone to the skin (0 degrees, 45 degrees, and 90 degrees angles) on NCCT. The BMI and HU density were determined, and chemical analysis was performed on all stones. Radiographic assessment of the kidneys, ureter, and bladder at 6 weeks categorized patients into the SF or residual stone group. Logistic regression was fit, using SSD, BMI, and HU density as predictors, to assess the SF rates after SWL. Results: Of 64 patients, 30 were SF and 34 had residual stones. The mean SSD was 8.12 +/- 1.74 cm for the SF group versus 11.53 +/- 1.89 cm for the residual stone group (P <0.01). Logistic regression analysis revealed only SSD to be a significant predictor of outcome (odds ratio 0.32, 95% confidence interval 0.29 to 0.35, P <0.01). An SSD greater than 10 cm predicted treatment failure. Conclusions: The SSD may predict the outcome after SWL of lower pole kidney stones. SWL in patients with an SSD greater than 10 cm is likely to fail. The use of the SSD may be transferable to the treatment of all urinary stones, regardless of location. [ABSTRACT FROM AUTHOR]

OBJECTIVE To determine whether an electrode array with a bipolar radiofrequency ablation (RFA) energy source can be used to perform a haemostatic partial nephrectomy by simultaneously ablating and coagulating renal tissue. MATERIALS AND METHODS Lower-pole partial nephrectomy was performed in 12 porcine kidneys using a bipolar RFA system. Intraoperative ultrasonography was used to identify and avoid the collecting system. Tissues were positioned between opposing electrodes and tissue impedance monitored using a proprietary feedback and control algorithm. Ablation time and power, lesion width and length, and tissue thickness were recorded. The kidneys were assessed in vivo to show haemostasis of the remaining renal unit. Collecting system integrity was assessed with methylene blue injection, and the resected tissue analysed histologically. RESULTS Partial nephrectomies were successful in all 12 porcine kidneys; the mean nephrectomy specimen was 3.2 × 2.6 cm. The total ablation time ( sem) per lesion was 211 (15) s and the mean power was 23 W. Methylene blue injection showed an intact collecting system in 11 of the 12 kidneys, and haematoxylin and eosin staining showed a mean zone of necrosis of 9 mm at the resection margin. Ultrasonography revealed flow to the remaining kidneys after RFA and the in vivo assessment of haemostasis revealed no abnormal bleeding or haemorrhage from the kidneys. CONCLUSIONS Applying bipolar RF energy to an electrode array can enable transmural excision of renal parenchyma in vivo in a bloodless fashion without collecting system injury. [ABSTRACT FROM AUTHOR]

Abstract: Minimally invasive treatments continue to evolve as an alternative method for the treatment of kidney and prostatic tumors. Of the mainstream ablative procedures reported in the literature, the cryotherapy data appear to be the most durable. Currently, select kidney and prostatic lesions are treated using cryotherapy. Although limited long-term survival data using cryotherapy are available, recent series have provided compelling results, promoting interest in renal and prostatic cryoablation. This article assesses the current status of cryotherapy in urology, specifically the indications, techniques, and clinical results in treating kidney and prostate tumors. [Copyright &y& Elsevier]

Abstract: Objectives: To determine whether body mass index (BMI) and Hounsfield units (HUs) could be used as independent predictors of stone-free status after extracorporeal shock wave lithotripsy (ESWL). No detailed studies have assessed BMI as an independent predictor of ESWL outcome. Some studies have suggested that HUs of urinary calculi on noncontrast computed tomography may predict the stone-free rate after ESWL. Methods: We evaluated 100 patients who had undergone ESWL for 5-mm to 10-mm upper urinary tract stones. The BMI was calculated for each patient. HU determination and chemical analysis was performed for each stone. Radiographic assessment at 6 weeks categorized patients into a stone-free (SF) or residual-stone (RS) group. Statistical analysis, using BMI and HUs as predictors, was performed to assess the stone-free rate after ESWL. Results: Of 100 patients, 72 were in the SF and 28 in the RS group. The mean BMI for the SF group was 26.9 ± 0.5 versus 30.8 ± 0.9 in the RS group (P <0.05). The difference in the mean HU values for the SF and RS groups was statistically significant (577.8 ± 182.5 versus 910.4 ± 190.2, respectively; P <0.05). A successful outcome was significantly related to BMI (odds ratio 1.34, 95% confidence interval 1.09 to 1.65, P <0.01) and HUs (odds ratio 1.01, 95% confidence interval 1.007 to 1.019, P <0.01). The following equation was formulated to compute the probability of treatment failure: 1/1 + 2.7−z, where z = 0.294 BMI + 0.13 HU − 18.98. Conclusions: BMI and HUs were statistically significant independent predictors of stone-free rates after ESWL. We believe a predictive model of ESWL outcome may be formulated on the basis of these findings and may be used to select the preferred treatment option for patients with urinary calculi. [Copyright &y& Elsevier]

Purpose : Tumor-associated angiogenesis and increased cellular proliferation in superficial transitional cell carcinoma (TCC) of the bladder represent promising new therapeutic targets, and have emerged as important prognostic indicators for cancer treatment. To our knowledge, these factors have not been studied in recurrent superficial TCC specimens treated with Bacillus Calmette-Guerin (BCG). The purpose of our study was to investigate the clinicopathologic response of BCG instillation on microvessel density (MVD) and cellular proliferation in recurrent superficial TCC of the bladder. Materials and methods : A total of 20 specimens from 10 patients were analyzed: 10 before (control group) and 10 after (treatment group) a 6 week instillation of BCG. In all specimens, tumor grade, MVD and cellular proliferation were analyzed in a blinded fashion. MVD was calculated by counting the number of blood vessels in the superficial lamina propria per high-power field. Immunohistochemistry was used to assess the expression of Ki-67, a marker of cellular proliferation. Statistical analysis was performed using the student t -test. Results : The mean MVD and Ki-67 expression were significantly lower in the treatment group ( p <0.05). Eight of 10 treatment group specimens were downgraded. Vascular ectasia was greater in the 8 post BCG specimens that were downgraded, than those that remained unchanged. Conclusion : Grade, MVD and cellular proliferation were significantly decreased in recurrent superficial TCC after treatment with BCG. In the future, these preliminary results of the angiogenic and proliferation response to BCG may provide additional potential targets of intervention to further enhance therapeutic effect. [ABSTRACT FROM AUTHOR]

: BackgroundWe reviewed our experience with bladder perforations to better understand the causes of these injuries and to describe their management and its effect on longterm outcomes.: Study designOur bladder trauma database yielded 65 patients during a 12-year period, followed for a mean of 36 months, who had sustained iatrogenic bladder perforations. Endourologic procedures were excluded. Demographic data, surgical details, mechanism of injury, anatomic location, grading, diagnosis, management, and outcomes were assessed.: ResultsGynecologic procedures accounted for 40 perforations (61.5%), general surgical procedures for 17 (26.2%), and urologic procedures for 8 (12.3%). The type of gynecologic surgery included abdominal hysterectomy in 16 (40%), resection of a pelvic mass in 12 (30%), cesarean section in 10 (25%), and diagnostic laparoscopy in 2 (5%). Of the general surgical procedures, eight were for colon cancer (47.1%), six for diverticulitis (35.3%), and three for inflammatory bowel disease (17.6%); of the urologic injuries, six occurred during vaginal surgery and two during laparoscopy. Predisposing factors were identified in 52 patients (80%). Intraoperative urologic consultation was obtained in 63 of 65 patients, with prompt identification and repair. In two cases a concurrent left ureteral injury was identified and managed by reimplantation. The sole complication was a vesicovaginal fistula 2 months postoperatively, so the success rate for repair was 98.4%.: ConclusionsAlthough infrequent, iatrogenic bladder perforations can occur during any pelvic, abdominal, or vaginal procedure. Prompt intraoperative recognition is paramount to ensure satisfactory outcomes. Adequate repair usually can be achieved simply by vesicorrhaphy, limiting unnecessary extravesical dissection. With this approach, morbidity can be minimized. [Copyright &y& Elsevier]

• PDA, IDC-P and CC-P differ in terms of genetics, prognosis, and response to treatment. • PTEN mutations are frequently present in IDC-P and CC-P. • The clinical benefit may be dependent on the specific HRR gene mutated. • All morphologies other than PAA are not recommended for focal therapy. • PDA, ICD-P and CC-P are particularly associated with poor prognosis compared with PAA. Prostatic acinar adenocarcinoma accounts for approximately 95% of prostate cancer (CaP) cases. The remaining 5% of histologic subtypes of CaP are known to be more aggressive and have recently garnered substantial attention. These histologic subtypes – namely, prostatic ductal adenocarcinoma (PDA), intraductal carcinoma of the prostate (IDC-P), and cribriform carcinoma of the prostate (CC-P) – typically exhibit distinct growth characteristics, genomic features, and unique oncologic outcomes. For example, PTEN mutations, which cause uncontrolled cell growth, are frequently present in IDC-P and CC-P. Germline mutations in homologous DNA recombination repair (HRR) genes (e.g., BRCA1, BRCA2, ATM, PALB2, and CHEK2) are discovered in 40% of patients with IDC-P, while only 9% of patients without ductal involvement had a germline mutation. CC-P is associated with deletions in common tumor suppressor genes, including PTEN, TP53, NKX3–1, MAP3K7, RB1, and CHD1. Evidence suggests abiraterone may be superior to docetaxel as a first-line treatment for patients with IDC-P. To address these and other critical pathological attributes, this review examines the molecular pathology, genetics, treatments, and oncologic outcomes associated with CC-P, PDA, and IDC-P with the objective of creating a comprehensive resource with a centralized repository of information on PDA, IDC-P, and CC-P. [ABSTRACT FROM AUTHOR]

The article focuses on the minimally invasive therapies for benign prostatic hyperplasia (BPH) and the criteria used to determine which are used. Transurethral microwave thermotherapy is a form of surgery completed with local or oral pain medication in an outpatient setting. Transurethral radiofrequency needle ablation results in a coagulation necrosis and subsequent tissue ablation. Water-induced thermotherapy is another heat-based therapy for BPH. Furthermore, the technique, transurethral ethanol ablation of the prostate (TEAP) relies on hemorrhagic coagulation necrosis as a mechanism of prostate tissue ablation.

Objectives: The American Urological Association Hands on Laparoscopy course was designed to help practitioners without laparoscopic training advance their skills. We evaluated the long-term effect of this course on urologists'' practice. Methods: A total of 52 urologists, 37-61 years old (mean 50.7), participated in one of three courses given from August 2002 to October 2003. The 2-day course included performing standardized tasks with videotape analysis and participating in porcine and pelvic trainer laboratory sessions with intense mentoring from known experts. Surveys were sent by regular and electronic mail in February 2007 to assess the effect of the course. The mean follow-up was 48 months (range 41-55). Results: Of the 52 surveys mailed, 32 were returned (61%). Most respondents were in private practice and had previous experience with extirpative urologic laparoscopy. Of the 32 respondents, 31 (97%) reported that their laparoscopic practice had expanded after taking the course. Also, 24 (75%) reported having sutured laparoscopically after taking the course, with 61% having sutured a bleeding vessel, and 80% reported that the video mentoring during the course was helpful. Of those who purchased a pelvic trainer, 90% reported practicing on it regularly. Conclusions: The results of our study have shown that the Hands on Laparoscopy course has a significant long-term (mean 48 months) effect on the laparoscopic practice of course alumni. The experience gained from skills-based lectures, videotape analysis of pelvic trainer performance, and a mentored porcine laboratory session resulted in most participants expanding their practice (97%) and suturing laparoscopically (75%). [Copyright &y& Elsevier]

Abstract: Objectives: To evaluate the impact of the American Urological Association Hands on Laparoscopy course on the participants’ practices. Many urologists without fellowship training perform laparoscopy, but do not advance beyond hand-assisted, extirpative laparoscopy. The American Urological Association Hands on Laparoscopy course was designed to help these practitioners advance their skills. Methods: A total of 68 urologists, aged 31 to 61 years (mean 46.6), participated in one of the four courses given between August 2002 and March 2004. The 2-day course included performing standardized tasks under videotape analysis and participating in porcine and pelvic trainer laboratory sessions. Surveys were sent by regular and electronic mail in September 2004 to assess the courses’ impact. The mean follow-up was 15.2 months (range 7 to 25). Results: Of the 68 surveys mailed, 54 were returned (79%). Most respondents were in private practice and had had prior experience with extirpative laparoscopy. Of the respondents, 41 (76%) reported that their laparoscopic practice had expanded after taking the course, with 34% performing at least 2 cases per month. Also, 33 respondents (61%) reported performing laparoscopic suturing after taking the course, with 35% having sutured a bleeding vessel. Of the respondents, 85% reported that the video mentoring during the course was helpful. Of those who purchased a pelvic trainer, 90% reported practicing on it regularly. Conclusions: The Hands on Laparoscopy course appeared to contribute to expansion of laparoscopic practices. Experience gained from skills-based lectures, videotape analysis of pelvic trainer performance, and a mentored porcine laboratory resulted in most (61%) participants expanding their practice to include clinical laparoscopic suturing. [Copyright &y& Elsevier]

Purpose : Radical prostatectomy remains an attractive treatment option for localized prostate cancer. The decision to perform a radical retropubic prostatectomy (RRP) or radical perineal prostatectomy (RPP) fundamentally depends on the practice of the particular urologist. We sought to contrast these two approaches in terms of perioperative outcome measures and economic implications. Materials and methods : From July 1998 to June 2003, 148 patients at our institution underwent radical prostatectomy for clinically organ confined adenocarcinoma of the prostate (T1-T2, N0, M0). There were 109 RRPs and 39 RPPs. Preoperative characteristics including age, Gleason score and PSA were obtained. The perioperative parameters evaluated included total hospital charges, operative time, estimated blood loss, transfusion rate and length of hospital stay. Statistical analyses using a Student's t -test were performed. Results : The two patient groups (RRP vs. RPP) were statistically identical in terms of mean age (60 vs. 58 years), mean Gleason score (6.9 vs. 7.0) and mean PSA (7.8 vs. 7.9 ng/ml). The mean hospital charge was nearly $4000 less for the RPP group ($17,739 vs. $13,779). No difference existed in the mean operative durations of each procedure (227 vs. 218 min). The estimated blood loss (857 vs. 521 cc), transfusion rate (58% vs. 36%), and mean length of hospital stay (4.6 vs. 3.6 days), were statistically less for the RPP group ( p =0.03, p =0.02, p <0.01, respectively). Conclusions : Radical perineal prostatectomy offers the patient a perioperative advantage in terms of lower blood loss, transfusion requirement and shorter hospital stay in addition to a significant charge benefit appeal compared to radical retropubic prostatectomy. [ABSTRACT FROM AUTHOR]

Introduction: For localized clinically significant prostate cancer (csPCa), robotically assisted laparoscopic radical prostatectomy (RALP) is the gold standard surgical treatment. Despite low overall complication rate, continued quality assurance (QA) efforts to minimize complications of RALP are important, particularly given movement toward same-day discharge. In 2019, National Surgical Quality Improvement Program (NSQIP) began collecting RALP-specific data. In this study, we assessed pre- and perioperative factors associated with postoperative complications for RALP to further QA efforts. Materials and Methods: Surgical records of csPCa patients who underwent RALP were retrieved from the 2019 to 2021 NSQIP database, including new RALP-specific data. Multivariate logistic regression evaluated the association between risk factors and outcomes specific to RALP and pelvic lymph node dissection (PLND). Input variables included American Society of Anesthesiologists (ASA) class, age, operative time, and body mass index (BMI). Variables from the extended dataset with PLND information included number of nodes evaluated, perioperative antibiotics, postoperative venous thromboembolism (VTE) prophylaxis, history of prior pelvic surgery, and history of prior radiotherapy (RT). Outcomes of interest were any surgical complication, infection, pulmonary embolism, deep venous thrombosis, acute kidney injury, pneumonia, lymphocele, and urinary/anastomotic leak (UAL). Results: A total of 11,811 patients were included with 6.1% experiencing any complication. Prior RT, prior pelvic surgery, older age, higher BMI, lack of perioperative antibiotic therapy, longer operative time, PLND, and number of lymph nodes dissected were associated with higher risk of postoperative complications. Regarding procedure-specific complications, there were increased odds of UAL with prior RT, prior pelvic surgery, longer operative time, and higher BMI. Odds of developing lymphocele increased with prior pelvic surgery, performance of PLND, and increased number of nodes evaluated. Conclusion: In contemporary NSQIP data, RALP is associated with low complication rates; however, these rates have increased compared with historical studies. Attention to and counseling regarding risk factors for peri- and postoperative complications are important to set expectations and minimize risk of unplanned return to a health care setting after discharge. [ABSTRACT FROM AUTHOR]

The incidence of stone disease has increased significantly in the past 30 years, with a reported prevalence of 11% of the U.S. population in 2022, up from 9% in 2012 and 5.2% in 1994.1 While prevention is a vital aspect of management, many patients present with symptomatic urolithiasis requiring surgical management. Emerging advances in endoscopy and technology has led to a dynamic shift in the surgical management of stone disease. This paper will serve as a comprehensive review to inform urologic and non-urologic medical professionals alike, as well as the layperson, on the surgical treatment of nephrolithiasis, starting from the initial evaluation, laboratory and radiographic studies, and various surgical options. Additionally, the nuances of managing the pediatric and pregnant patient with nephrolithiasis will be explored. Using the most up-to-date urologic data, our aim is to provide a comprehensive resource for readers who interact with patients experiencing acute episodes of urolithiasis. [ABSTRACT FROM AUTHOR]

Numerous imaging modalities are available to the provider when diagnosing or surveilling kidney stones. The decision to order one over the other can be nuanced and especially confusing to non-urologic practitioners. This manuscript reviews the main modalities used to image stones in the modern era - renal bladder ultrasound, Kidney Ureter Bladder plain film radiography (KUB), magnetic resonance imaging (MRI), and non-contrast computerized tomography (NCCT). While NCCT has become the most popular and familiar modality for most practitioners, particularly in the acute setting, ultrasound is a cost-effective technology that is adept at monitoring interval stone development in patients and evaluating for the presence of hydronephrosis. KUB and MRI also occupy unique niches in the management of urolithiasis. In the correct clinical setting, each of these modalities has a role in the acute workup and management of suspected nephrolithiasis. [ABSTRACT FROM AUTHOR]

The article focuses on the history of robotics in urology. The word "robot" is derived from the Czechoslovakian term "robota" which means forced work. A surgical robot is described as a computer-controlled manipulator with artificial sensing and modern surgical robotic systems are categorized into off-line and on-line. Licensed commercial rights to the SRI Green Telepresence Surgery Systems are used to establish Intuitive Surgical Systems in 1995. The master-slave system, Zeus Surgical System, from Computer Motion received approval from the U.S. Food and Drug Administration (FDA) for limited abdominal operations in October 2001.

Introduction and Objectives: In recent years, there has been a shift to minimally invasive partial nephrectomy (MIPN) with the dissemination of robot-assisted technology. However, contemporary data on the comparative morbidity of open partial nephrectomy (OPN) and MIPN are lacking. We, therefore, evaluated the perioperative morbidity of OPN and MIPN using a contemporary national cohort. Methods: We identified 13,658 patients aged 18 to 89 who underwent PN from 2010 to 2015 in the National Surgical Quality Improvement Program (NSQIP) database, of whom 9018 (66.0%) underwent MIPN. The associations of MIPN with 30-day morbidity were evaluated using logistic regression, adjusted for patient features. Results: Median age at surgery was 60 (interquartile range [IQR] 51, 68) years. Overall, 30-day complications occurred in 6.7% of patients. Compared with OPN, MIPN was associated with lower rates of 30-day complications (4.9% vs 10.1%, p < 0.0001), perioperative blood transfusion (3.8% vs 12.5%, p < 0.0001), prolonged hospitalization (5.6% vs 23.4%, p < 0.0001), readmission (4.4% vs 7.8%, p < 0.0001), reoperation (1.8% vs 3.2%, p < 0.0001), and 30-day mortality (0.3% vs 0.6%, p = 0.001). On multivariable analysis, MIPN was independently associated with a reduced risk of 30-day complications (odds ratio [OR] 0.46, p < 0.0001), perioperative blood transfusion (OR 0.27, p < 0.0001), prolonged hospitalization (OR 0.19, p < 0.0001), readmission (OR 0.59, p < 0.0001), and reoperation (OR 0.57, p < 0.0001). Postoperative complications occurred predominantly early after surgery, whereas hospital readmissions and reoperation occurred at a consistent rate. Conclusions: In this contemporary national cohort, MIPN was independently associated with reduced rates of 30-day complications, perioperative blood transfusion, prolonged hospitalization, hospital readmission, and reoperation, compared with OPN. [ABSTRACT FROM AUTHOR]

The article discusses various reports published within the issue, including one on an update on minimally invasive urologic surgery (MIUS) techniques and clinical experiences, one on a special report on men's health and one on the urologic medicine practice in Rhode Island.

Simple Summary: Recently, radiogenomics has played a significant role and offered a new understanding of cancer's biology and behavior in response to standard therapy. It also provides a more precise prognosis, investigation, and analysis of the patient's cancer. Over the years, Artificial Intelligence (AI) has provided a significant strength in radiogenomics. In this paper, we offer computational and oncological prospects of the role of AI in radiogenomics, as well as its offers, achievements, opportunities, and limitations in the current clinical practices. Radiogenomics, a combination of "Radiomics" and "Genomics," using Artificial Intelligence (AI) has recently emerged as the state-of-the-art science in precision medicine, especially in oncology care. Radiogenomics syndicates large-scale quantifiable data extracted from radiological medical images enveloped with personalized genomic phenotypes. It fabricates a prediction model through various AI methods to stratify the risk of patients, monitor therapeutic approaches, and assess clinical outcomes. It has recently shown tremendous achievements in prognosis, treatment planning, survival prediction, heterogeneity analysis, reoccurrence, and progression-free survival for human cancer study. Although AI has shown immense performance in oncology care in various clinical aspects, it has several challenges and limitations. The proposed review provides an overview of radiogenomics with the viewpoints on the role of AI in terms of its promises for computational as well as oncological aspects and offers achievements and opportunities in the era of precision medicine. The review also presents various recommendations to diminish these obstacles. [ABSTRACT FROM AUTHOR]

Background: The previous COVID-19 lung diagnosis system lacks both scientific validation and the role of explainable artificial intelligence (AI) for understanding lesion localization. This study presents a cloud-based explainable AI, the "COVLIAS 2.0-cXAI" system using four kinds of class activation maps (CAM) models. Methodology: Our cohort consisted of ~6000 CT slices from two sources (Croatia, 80 COVID-19 patients and Italy, 15 control patients). COVLIAS 2.0-cXAI design consisted of three stages: (i) automated lung segmentation using hybrid deep learning ResNet-UNet model by automatic adjustment of Hounsfield units, hyperparameter optimization, and parallel and distributed training, (ii) classification using three kinds of DenseNet (DN) models (DN-121, DN-169, DN-201), and (iii) validation using four kinds of CAM visualization techniques: gradient-weighted class activation mapping (Grad-CAM), Grad-CAM++, score-weighted CAM (Score-CAM), and FasterScore-CAM. The COVLIAS 2.0-cXAI was validated by three trained senior radiologists for its stability and reliability. The Friedman test was also performed on the scores of the three radiologists. Results: The ResNet-UNet segmentation model resulted in dice similarity of 0.96, Jaccard index of 0.93, a correlation coefficient of 0.99, with a figure-of-merit of 95.99%, while the classifier accuracies for the three DN nets (DN-121, DN-169, and DN-201) were 98%, 98%, and 99% with a loss of ~0.003, ~0.0025, and ~0.002 using 50 epochs, respectively. The mean AUC for all three DN models was 0.99 (p < 0.0001). The COVLIAS 2.0-cXAI showed 80% scans for mean alignment index (MAI) between heatmaps and gold standard, a score of four out of five, establishing the system for clinical settings. Conclusions: The COVLIAS 2.0-cXAI successfully showed a cloud-based explainable AI system for lesion localization in lung CT scans. [ABSTRACT FROM AUTHOR]

Background: COVID-19 is a disease with multiple variants, and is quickly spreading throughout the world. It is crucial to identify patients who are suspected of having COVID-19 early, because the vaccine is not readily available in certain parts of the world. Methodology: Lung computed tomography (CT) imaging can be used to diagnose COVID-19 as an alternative to the RT-PCR test in some cases. The occurrence of ground-glass opacities in the lung region is a characteristic of COVID-19 in chest CT scans, and these are daunting to locate and segment manually. The proposed study consists of a combination of solo deep learning (DL) and hybrid DL (HDL) models to tackle the lesion location and segmentation more quickly. One DL and four HDL models—namely, PSPNet, VGG-SegNet, ResNet-SegNet, VGG-UNet, and ResNet-UNet—were trained by an expert radiologist. The training scheme adopted a fivefold cross-validation strategy on a cohort of 3000 images selected from a set of 40 COVID-19-positive individuals. Results: The proposed variability study uses tracings from two trained radiologists as part of the validation. Five artificial intelligence (AI) models were benchmarked against MedSeg. The best AI model, ResNet-UNet, was superior to MedSeg by 9% and 15% for Dice and Jaccard, respectively, when compared against MD 1, and by 4% and 8%, respectively, when compared against MD 2. Statistical tests—namely, the Mann–Whitney test, paired t-test, and Wilcoxon test—demonstrated its stability and reliability, with p < 0.0001. The online system for each slice was <1 s. Conclusions: The AI models reliably located and segmented COVID-19 lesions in CT scans. The COVLIAS 1.0Lesion lesion locator passed the intervariability test. [ABSTRACT FROM AUTHOR]

The prevalence of kidney stones is climbing in the United States several investigators have demonstrated an association between metabolic syndrome and kidney stones and some have proposed a causal link. Risk factors for nephrolithiasis can be identified with a 24-hour urine collection and preventive measures can be customized to meet the needs of individual patients. Dietary and pharmacologic interventions are available to address urinary risk factors such as inadequate urine volume, hypercalcuria, hyperoxaluria, hyperuricosuria and hypocitraturia. Given that morbidity and healthcare costs associated with nephrolithiasis are on the rise, deterring stone formation is increasingly important. Multidisciplinary clinics that foster collaboration between urologists, nephrologists and dieticians offer patients effective prevention and treatment strategies. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether percutaneous nephrolithotomy (PCNL) can be safely performed in the high-risk patient. Methods: The records of 84 patients undergoing 98 consecutive PCNL procedures from January 2005 to January 2007 at a single institution were examined. Patients were divided into a high-risk preoperative group, which comprised patients having American Society of Anesthesiologist scores of III or IV (n = 25) and a low-risk preoperative group of patients with an American Society of Anesthesiologist score of II or less (n = 59). Results: A total of 33 and 65 procedures were performed in the high- and low-risk groups, respectively. The high-risk group had significantly more comorbidities than the low-risk group (5.4 vs 1.5) (P <.001). No significant difference was noted in the mean cumulative stone size for single or multiple stones in either group. A significant difference was observed between the average anesthesia time (45 vs 25 minutes) and average length of hospital stay (4.0 ± 3.5 vs 2.7 ± 1.2 days) but no significant difference in estimated blood loss (132 vs 150 mL) or mean operative time (118 vs 100 minutes) between the high- and low-risk groups, respectively. The overall complication rate was similar between the high-risk (12.1%) and low-risk (12.3%) groups (P = .41). The stone-free rate for the high-risk group was 61% compared with 92% for the low-risk group (P = .028). Conclusions: PCNL can be safely performed in the high-risk preoperative patient population. [Copyright &y& Elsevier]

Wilson's disease (WD) is caused by copper accumulation in the brain and liver, and if not treated early, can lead to severe disability and death. WD has shown white matter hyperintensity (WMH) in the brain magnetic resonance scans (MRI) scans, but the diagnosis is challenging due to (i) subtle intensity changes and (ii) weak training MRI when using artificial intelligence (AI). Design and validate seven types of high-performing AI-based computer-aided design (CADx) systems consisting of 3D optimized classification, and characterization of WD against controls. We propose a "conventional deep convolution neural network" (cDCNN) and an "improved DCNN" (iDCNN) where rectified linear unit (ReLU) activation function was modified ensuring "differentiable at zero." Three-dimensional optimization was achieved by recording accuracy while changing the CNN layers and augmentation by several folds. WD was characterized using (i) CNN-based feature map strength and (ii) Bispectrum strengths of pixels having higher probabilities of WD. We further computed the (a) area under the curve (AUC), (b) diagnostic odds ratio (DOR), (c) reliability, and (d) stability and (e) benchmarking. Optimal results were achieved using 9 layers of CNN, with 4-fold augmentation. iDCNN yields superior performance compared to cDCNN with accuracy and AUC of 98.28 ± 1.55, 0.99 (p < 0.0001), and 97.19 ± 2.53%, 0.984 (p < 0.0001), respectively. DOR of iDCNN outperformed cDCNN fourfold. iDCNN also outperformed (a) transfer learning–based "Inception V3" paradigm by 11.92% and (b) four types of "conventional machine learning–based systems": k-NN, decision tree, support vector machine, and random forest by 55.13%, 28.36%, 15.35%, and 14.11%, respectively. The AI-based systems can potentially be useful in the early WD diagnosis. [ABSTRACT FROM AUTHOR]

Background: Nephrolithiasis patients undergo repeated imaging increasing their radiation risk. Guidelines recommend imaging following ureteroscopic lithotripsy (URSL), but not the modality or frequency of imaging. As such, we sought to elucidate common imaging practices following URSL and current knowledge of radiation exposure among endourologists. Methods: A web-based survey of Endourological Society members was used to evaluate knowledge and clinical practices regarding radiation exposure in post-URSL imaging. Respondents were grouped by years of experience (< 10, >= 10 years) and geographic location (USA or non-USA). An interaction term was included in the models to allow response rate to vary across experience level with geographic location and P values were derived from model main effects. Results: A total of 309 respondents answered the survey out of the 1800 active members of the Endourological Society that received the survey (17.2% total response rate). 204 of the respondents were included in our analysis as fellowship trained endourologists that perform URSL with a mean of 13.3 years in practice (IQR 6.75, 20 years). Overall, routine postoperative imaging is performed by 92% of respondents: 97% in the USA and 88% outside the US (P = 0.143). 39% of respondents correctly estimated standard dose CT scan (SCT) dose, while 36% correctly estimated that of a low-dose CT scan (LCT). American urologists correctly identified the SCT radiation dose more often than non-US respondents (54% vs 32%, respectively) (P value = 0.004). Respondents with < 10 years of experience more frequently identified the correct SCT dose (52% vs. 34%, respectively), though not significantly so (P value = 0.171). 79% of respondents consider LCT quality to be similar to SCT and 50% would use LCT on obese patients. However, only 26% of respondents identified that image quality deteriorates with BMI > 30 kg/m2. Conclusions: We demonstrate a knowledge gap regarding radiation exposure during CT scans and the limitations of low-dose CT imaging. This gap is wider in non-US-based urologists and in those with over 10 years of experience. However, all urologists would benefit from improved education and clear guidelines regarding radiation exposure in nephrolithiasis patients. [ABSTRACT FROM AUTHOR]

Rheumatoid arthritis (RA) is a systemic chronic inflammatory disease that affects synovial joints and has various extra-articular manifestations, including atherosclerotic cardiovascular disease (CVD). Patients with RA experience a higher risk of CVD, leading to increased morbidity and mortality. Inflammation is a common phenomenon in RA and CVD. The pathophysiological association between these diseases is still not clear, and, thus, the risk assessment and detection of CVD in such patients is of clinical importance. Recently, artificial intelligence (AI) has gained prominence in advancing healthcare and, therefore, may further help to investigate the RA-CVD association. There are three aims of this review: (1) to summarize the three pathophysiological pathways that link RA to CVD; (2) to identify several traditional and carotid ultrasound image-based CVD risk calculators useful for RA patients, and (3) to understand the role of artificial intelligence in CVD risk assessment in RA patients. Our search strategy involves extensively searches in PubMed and Web of Science databases using search terms associated with CVD risk assessment in RA patients. A total of 120 peer-reviewed articles were screened for this review. We conclude that (a) two of the three pathways directly affect the atherosclerotic process, leading to heart injury, (b) carotid ultrasound image-based calculators have shown superior performance compared with conventional calculators, and (c) AI-based technologies in CVD risk assessment in RA patients are aggressively being adapted for routine practice of RA patients. [ABSTRACT FROM AUTHOR]

Purpose: Cystinuria is a genetic disorder with both autosomal recessive and incompletely dominant inheritance. The disorder disrupts cystine and other dibasic amino acid transport in proximal tubules of the kidney, resulting in recurrent kidney stone formation. Currently, there are no consensus guidelines on evaluation and management of this disease. This article represents the consensus of the author panel and will provide clinicians with a stepwise framework for evaluation and clinical management of patients with cystinuria based on evidence in the existing literature. Materials and Methods: A search of MEDLINE®/PubMed® and Cochrane databases was performed using the following key words: "cystine nephrolithiasis," "cystinuria," "penicillamine, cystine," and "tiopronin, cystine." In total, as of May 2018, these searches yielded 2335 articles, which were then evaluated for their relevance to the topic of evaluation and management of cystinuria. Evidence was evaluated by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Results: Twenty-five articles on the topic of cystinuria or cystine nephrolithiasis were deemed suitable for inclusion in this study. The literature supports a logical evaluation process and step-wise treatment approach beginning with conservative measures: fluid intake and dietary modification. If stone formation recurs, proceed to pharmacotherapeutic options by first alkalinizing the urine and then using cystine-binding thiol drugs. Conclusions: The proposed clinical pathways provide a framework for efficient evaluation and treatment of patients with cystinuria, which should improve overall outcomes of this rare, but highly recurrent, form of nephrolithiasis. [ABSTRACT FROM AUTHOR]

The objectives of this study are to (1) examine the "10-year cardiovascular risk" in the common carotid artery (CCA) versus carotid bulb using an integrated calculator called "AtheroEdge Composite Risk Score 2.0" (AECRS2.0) and (2) evaluate the performance of AECRS2.0 against "conventional cardiovascular risk calculators." These objectives are met by measuring (1) image-based phenotypes and AECRS2.0 score computation and (2) performance evaluation of AECRS2.0 against 12 conventional cardiovascular risk calculators. The Asian–Indian cohort (n = 379) with type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), or hypertension were retrospectively analyzed by acquiring the 1516 carotid ultrasound scans (mean age: 55 ± 10.1 years, 67% males, ∼92% with T2DM, ∼83% with CKD [stage 1-5], and 87.5% with hypertension [stage 1-2]). The carotid bulb showed a higher 10-year cardiovascular risk compared to the CCA by 18% (P <.0001). Patients with T2DM and/or CKD also followed a similar trend. The carotid bulb demonstrated a superior risk assessment compared to CCA in patients with T2DM and/or CKD by showing: (1) ∼13% better than CCA (0.93 vs 0.82, P =.0001) and (2) ∼29% better compared with 12 types of risk conventional calculators (0.93 vs 0.72, P =.06). [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Port site metastases after hand-assisted laparoscopic radical nephrectomy have been described in the literature. There is no uniform agreement among urologists regarding the use of a retrieval bag before intact specimen removal. The aim of this study was to determine whether LapSac renal extraction bag washings contain malignant cells. Methods: We prospectively obtained washings from the LapSac retrieval bag after hand-assisted laparoscopic radical nephrectomy and intact specimen removal for renal cell carcinoma. In 30 consecutive cases, after removal of the kidney specimen from the LapSac, the LapSac was irrigated with 50 mL sterile Hank’s balanced salt solution. These washings were sent for cytologic examination. Cytologic evaluation was performed with a Thin Prep and the Papanicolaou method. Results: We performed 30 hand-assisted laparoscopic radical nephrectomies for suspected renal cell carcinoma with the above protocol. One specimen was benign and one showed transitional cell carcinoma; these were excluded from the study. Six specimens were stage T1a, 17 were T1b, 1 was T2, 2 were T3a, and 2 were T3b. Histopathology revealed 27 specimens with clear cell renal cell carcinomas with Fuhrman grades from 1 to 4; 1 specimen showed chromophobe renal cell carcinoma. Margins were negative in all cases, and there were no gross or microscopic tumor violations. The cytologic results from 27 cases were negative and in 1 case with T3b renal cell carcinoma the LapSac washings were positive for malignant cells. Conclusions: The preliminary findings from our study show that low-stage, low-grade tumors removed laparoscopically with minimal manipulation do not exfoliate cells into their LapSac retrieval bags. [Copyright &y& Elsevier]

Objective: To evaluate the personal protective equipment (PPE) utilized in common urologic procedures before and during the COVID-19 outbreak in the United States. As elective urologic procedures are being reduced to conserve resources, we sought to quantify the PPE used per case to determine the impact on potentially limited resources needed for protecting healthcare providers treating COVID-19 patients.Methods: An IRB approved retrospective analysis of all urologic procedures in March 2019 and March 2020 was performed. Additionally, all urologic procedures performed by vascular interventional radiology (VIR) in May 2019 and March 2020 were included in the analysis. Case length, surgical and operating room staff present and number of articles of PPE were quantified. Articles of PPE were defined as surgical bonnet/hat and mask, and disposable or reusable gown with 1 pair of surgical gloves.Results: Four hundred and thirty-seven urologic and VIR procedures were included in the analysis. The mean PPE per case varied significantly between endoscopic and robotic categories. Robotic assisted laparoscopic cystectomy required the most hats and masks (14.5 per case in March 2019) whereas percutaneous nephrostomy tube placement by VIR required the fewest (3.1 in May 2019 and March 2020).Conclusion: PPE consumption varied significantly across urologic procedures. Robotic-assisted cases require the most PPE and percutaneous nephrostomy placement by VIR requires the fewest. While PPE shortages are currently being addressed national and internationally, our results provide a baseline benchmark for articles of PPE required should another pandemic or global disaster requiring careful attention to resource allocation occur in the future. [ABSTRACT FROM AUTHOR]

We evaluated the association between automatically measured carotid total plaque area (TPA) and the estimated glomerular filtration rate (eGFR), a biomarker of chronic kidney disease (CKD). Automated average carotid intima–media thickness (cIMTave) and TPA measurements in carotid ultrasound (CUS) were performed using AtheroEdge (AtheroPoint). Pearson correlation coefficient (CC) was then computed between the TPA and eGFR for (1) males versus females, (2) diabetic versus nondiabetic patients, and (3) between the left and right carotid artery. Overall, 339 South Asian Indian patients with either type 2 diabetes mellitus (T2DM) or CKD, or hypertension (stage 1 or stage 2) were retrospectively analyzed by acquiring cIMTave and TPA measurements of their left and right common carotid arteries (CCA; total CUS: 678, mean age: 54.2 ± 9.8 years; 75.2% males; 93.5% with T2DM). The CC between TPA and eGFR for different scenarios were (1) for males and females −0.25 (P <.001) and −0.35 (P <.001), respectively; (2) for T2DM and non-T2DM −0.26 (P <.001) and −0.49 (P =.02), respectively, and (3) for left and right CCA −0.25 (P <.001) and −0.23 (P <.001), respectively. Automated TPA is an equally reliable biomarker compared with cIMTave for patients with CKD (with or without T2DM) with subclinical atherosclerosis. [ABSTRACT FROM AUTHOR]

Purpose: Stent omission after routine ureteroscopy (rtURS) is accepted by current guidelines and may result in decreased patient morbidity and treatment costs. In a value-based healthcare model, the added morbidity and cost of routine stent placement may be scrutinized. Furthermore, data are limited on urologist cost knowledge and it is effect on ureteral stent placement. As such, we seek to describe ureteral stenting practices and urologist cost knowledge amongst US and non-US-based urologists. Methods: The ureteroscopic practice patterns and cost awareness of members of the Endourological Society were surveyed using an international email listserv. Respondents were grouped by practice location (US vs non-US). Logistic regression was used to evaluate the associations of surgeon practice location with stenting practices. Results: 233 completed responses were received with a response rate of 13.5%. Results revealed that 55% and 71% of respondents reported ureteral stent insertion after rtURS more than 75% of the time for ureteral and renal stones, respectively. Reporting stent insertion following more than 75% of rtURS was more common among US participants for both ureteral and renal stones. Overall, reported cost knowledge was high, but lower among US participants. On multivariable analysis, US respondents were more likely to place ureteral stents after rtURS for ureteral stones more than 75% of the time when compared to those abroad (OR 3.43 p < 0.01). Conclusion: Ureteral stenting after rtURS is over utilized in the US compared to other countries. While this phenomenon is multifactorial in nature, cost knowledge may be under recognized as a determinant of ureteral stent placement following rtURS. [ABSTRACT FROM AUTHOR]

Introduction: Older age is considered a relative contraindication to radical prostatectomy (RP). However, data are limited regarding the impact of age on perioperative outcomes following RP. We examined the association of age with perioperative outcomes following RP to inform risk-stratification and management.Materials and Methods: We identified 35,968 men aged 18 to 89 years who underwent RP from 2010 to 2015 in the National Surgical Quality Improvement Program (NSQIP) database. The associations of age with 30-day complications and perioperative morbidity were evaluated using logistic regression, adjusted for patient features. Age was modeled both as a categorical and nonlinear continuous variable.Results: Median age at surgery was 63 years (IQR: 58-67). Increasing age was associated with greater rates of perioperative morbidity. Compared to men aged<60 years, men aged 70 to 89 years had statistically significantly higher rates of 30-day complications (6.4% vs. 4.4%, P<0.0001), perioperative blood transfusion (6.0% vs. 3.7%, P<0.0001), readmission (4.9% vs. 3.9%, P<0001), and 30-day mortality (0.3% vs. 0.1%, P<0.0001). In multivariable analyses, older age was independently associated with increased risks of perioperative morbidity. Moreover, there was a nonlinear relationship of age with perioperative morbidity, wherein rates of 30-day complications, perioperative blood transfusion, and readmission increased after approximately 70 years of age.Conclusions: In this national cohort, we observed a nonlinear association of age with perioperative morbidity, with increasing rates of 30-day complications, perioperative blood transfusion, and readmission after approximately 70 years of age. These results have implications for risk-stratification, patient counseling, and treatment selection among older men. [ABSTRACT FROM AUTHOR]

Introduction: Immediate ureteroscopic treatment for patients presenting to the emergency room with symptomatic ureterolithiasis is more commonly being utilized. Recent reports demonstrate good efficacy for emergency ureteroscopy (URS); however, preoperative predictors of treatment success have not been described. In this study, we report our multicenter experience with emergency URS and identify predictors of successful treatment. We also describe the Emergency Ureteral Stone Treatment (EUST) score, which integrates these predictors and stratifies patients into those that are likely and unlikely to have successful treatment. Materials and Methods: Laboratory and radiographic data for all patients who underwent emergency URS for acute symptomatic ureterolithiasis from 2010 to 2015 were reviewed. Statistical difference among parameters for patients who were stone free (SF) and not SF was assessed with the Student’s t-test. Cutoff values for significant predictors were determined using sensitivity and specificity analysis. The EUST score was determined based on the number of cutoffs a patient was below. Results: Two hundred two of 247 patients (81.8%) were SF. Two complications (ureteral perforation) occurred. Stone size, duration of symptoms before presentation, and serum white blood count at presentation did not affect SF rates. 95.5% of the treatment failures were attributed to a tight ureter preventing stone access. Patients who received alpha blockers before treatment were more likely to be SF (98.0% vs 55.5%, p < 0.01). Periureteral density (PUD) was lower in SF patients (2.8 HU vs 19.6 HU, p < 0.01), whereas the increase in serum creatinine from baseline (ΔCr) was greater in non-SF patients (0.44 mg/dL vs 0.20 mg/dL, p < 0.01). EUST score of 0, 1, and 2 correlated with SF rates of 20.6%, 81.9%, and 99.2%, respectively. Conclusions: Combined consideration of PUD and ΔCr with the EUST score can assist in selecting optimal candidates for immediate ureteroscopic management. Administration of alpha blockers before surgery may improve success rates by providing preoperative ureteral dilation. [ABSTRACT FROM AUTHOR]

Introduction: The American Urological Association (AUA) guidelines recommend partial nephrectomy (PN) as the gold standard for treatment of small renal masses (SRMs). This study examines the change in utilization of partial and radical nephrectomies at teaching and nonteaching institutions from 2003 to 2012. Materials and Methods: The data sample for this study came from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2003 to 2012. International Classification of Diseases, Ninth Revision and Clinical Modification codes were used to identify patients undergoing PN and radical nephrectomy for renal masses limited to the renal parenchyma. Teaching hospitals were defined, but not limited to any institution with an American Medical Association-approved residency program. Linear regression, bivariate, multivariate, and odds ratio analysis were used to demonstrate statistical significance. Results: 39,685 patients were identified in teaching hospitals, and 22,239 were identified in nonteaching hospitals. Prior to the 2009 AUA guidelines, cumulative rates of PN were 33% vs 20% in teaching vs nonteaching hospitals ( p < 0.0001) compared with postguideline rates of 48% vs 33% in teaching vs nonteaching hospitals ( p < 0.0001). Conclusions: During the 10-year study period, the use of PN to treat SRMs has significantly increased in both teaching hospitals and in nonacademic centers; however, these changes are occurring at a slower rate in nonteaching hospitals. [ABSTRACT FROM AUTHOR]

Purpose. Atypical small acinar proliferation (ASAP) is diagnosed in 1-2% of prostate biopsies. 30–40% of patients with ASAP may be diagnosed with prostate cancer (PCa) on repeat biopsy. Our objective was to examine the association between ASAP and subsequent diagnosis of intermediate/high risk PCa. Materials and Methods. Ninety-six patients who underwent prostate biopsy from 2000 to 2013 and were diagnosed with ASAP were identified. Clinicopathologic features were analyzed. Comparison was made between those with subsequent PCa on repeat biopsy and those with benign repeat pathology. Results. 56/96 (58%) patients had a repeat biopsy. 22/56 (39%) were subsequently diagnosed with PCa. There was no significant difference in patients’ characteristics. Presence of HGPIN on initial biopsy was associated with a benign repeat biopsy (68% versus 23%). 17/22 (77%) had Gleason grade (GG) 3+3 disease and only 5/22 (23%) had GG 3+4 disease. Conclusions. 22/56 patients (39%) of patients who underwent a subsequent prostate biopsy following a diagnosis of ASAP were found to have PCa. 77% of these men were diagnosed with GG 3+3 PCa. Only 23% were found to have intermediate risk PCa and no high risk PCa was identified. Immediate repeat prostate biopsy in patients diagnosed with ASAP may be safely delayed. A multi-institutional cohort is being analyzed. [ABSTRACT FROM AUTHOR]

Purpose: Over the last decade, shockwave lithotripsy (SWL) success rates have been correlated with stone density, skin-to-stone distance (SSD), and stone diameter. However, time constraints and the technical challenge of manual measurement often preclude utilization of these parameters. In this study, we describe a scoring system that accurately predicts SWL stone-free rates, is simple to calculate, and can be easily included in the radiology report. Materials and Methods: Two hundred thirty-five patients who underwent SWL from 2011 to 2014 were evaluated. One hundred thirty-three had available preoperative imaging. Stone density, SSD, ellipsoid stone volume (ESV), and stone-free rates were determined. Receiver operator characteristic (ROC) curves were generated to determine cutoff values for each parameter. The Triple D Score was calculated based upon the number of cutoff values a stone fell below. Results: One hundred forty of the 235 patients (59.5%) who underwent SWL were stone free after single-session treatment. Seventy-six of the 133 (57.1%) patients with available preoperative imaging were stone free. ESV, SSD, and stone density were significant predictors of SWL success. Based upon the ROC curves, cutoffs of <150 μL for ESV, <12 cm for SSD, and <600 HU for stone density were established. A Triple D Score of 0, 1, 2, and 3 correlated with SWL success rates of 21.4%, 41.3%, 78.7%, and 96.1%, respectively. Conclusions: Readily available predictive tools are necessary to enhance SWL cost-effectiveness. The Triple D Score is simple to calculate and can be reported by radiologists. Incorporation of the Triple D Score into preoperative planning may increase the overall SWL success rates. [ABSTRACT FROM AUTHOR]