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Introduction: Patient-centered communication after surgery can enhance patient satisfaction and reduce unplanned clinical contact. However, patient information needs following kidney stone surgery are not well understood, limiting quality improvement efforts. We aimed to characterize patient-reported needs in and preferences for postoperative communication following kidney stone surgery., Methods: Patients undergoing common stone procedures were surveyed about the content, volume, and satisfaction with the communication they received after surgery. Patients indicated which information resources they consulted and found most helpful to address their postoperative care questions., Results: Among 52 patients, the majority (75%) identified varying degrees of deficiencies in the communication they received after surgery. Regarding content, respondents were most interested in understanding how their surgery went (90%), the plan for follow-up care (85%), and the specific location of their stone (85%). Regarding volume, respondents consistently indicated interest in intraoperative findings (stone appearance and location) and postoperative care (stent symptoms and location) but the majority did not recall receiving enough information. To address their questions after surgery, respondents most commonly consulted their urologist (71%), discharge paperwork (42%), electronic health record (27%), and the person with whom their urologist spoke after surgery (25%); among these, the majority (54%) reported that their urologist was the single most helpful source of information., Conclusions: Following kidney stone surgery, patients report unmet communication needs related to specific intraoperative findings and follow-up care. Patients indicate high levels of satisfaction with urologist-provided resources. These exploratory findings support quality improvement efforts to optimize delivery of effective, patient-centered communication after surgery.

Untethered microrobots offer the possibility to perform medical interventions in anatomically complex and small regions in the body. Presently, it is necessary to access the upper urinary tract to diagnose and treat Upper Tract Urothelial Carcinoma (UTUC). Diagnostic and treatment challenges include ensuring adequate tissue sampling, accurately grading the disease, achieving completeness in endoscopic treatment, and consistently delivering medications to targeted sites. This work introduces microgrippers (µ-grippers) that are autonomously triggered by physiological temperature for biopsy in the upper urinary tract. The experiments demonstrated that µ-grippers can be deployed using standard ureteral catheters and maneuvered using an external magnetic field. The μ-grippers successfully biopsied tissue samples from ex vivo pig ureters, indicating that the thin-film bilayer springs' autonomous, physiologically triggered actuation exerts enough force to retrieve urinary tract tissue. The quality of these biopsy samples is sufficient for histopathological examination, including hematoxylin and eosin (H&E) and GATA3 immunohistochemical staining. Beyond biopsy applications, the µ-grippers' small size, wafer-scale fabrication, and multifunctionality suggest their potential for statistical sampling in the urinary tract. Experimental data and clinical reports underscore this potential through statistical simulations that compare the efficacy of µ-grippers with conventional tools, such as ureteroscopic forceps and baskets., (© 2024 Wiley‐VCH GmbH.)

Extrapolations from the adult population have suggested that opioids should be avoided in the management of pediatric urolithiasis, but the literature is sparse with regards to actual practice patterns and the downstream implications. We sought to investigate the rate of oral opioid administration for children presenting to the emergency room (ER) with urolithiasis and to identify associations between opioid administration and return visits and persistent opioid use. The TriNetX Research and Diamond Networks were used for retrospective exploratory and validation analyses, respectively. Patients <18 years presenting to the emergency room with urolithiasis were stratified by the receipt of oral opioids. Propensity score matching was performed in a 1:1 fashion. Incident cases of opioid administration and risk ratios (RRs) for a return ER visit within 14 days and the presence of an opioid prescription at 6 to 12 months were calculated. Of the 4672 patients in the exploratory cohort, 11.9% were prescribed oral opioids. Matching yielded a total of 1084 patients. Opioids at the index visit were associated with an increased risk of return visits (RR 1.51, 95% CI 1.04-2.20, P = 0.03) and persistent opioid use (RR 4.00, 95% CI 2.20-7.26, P < 0.001). The validation cohort included 6524 patients, of whom 5.7% were prescribed oral opioids. Matching yielded a total of 722 patients and demonstrated that opioids were associated with an increased risk of return visits (RR 1.50, 95% CI 1.04-2.16, P = 0.03) but not persistent opioid use (RR 1.70, 95% CI 0.79-3.67, P = 0.17). We find that the opioid administration rate for pediatric urolithiasis appears reassuringly low and that opioids are associated with a greater risk of return visits and persistent use., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Kidney stone disease (KSD) is a common urological condition that often requires long-term care. Mobile health (mHealth) and eHealth technologies have the potential to enhance chronic disease management and behavioral change. To assess opportunities to apply these tools to improve KSD treatment and prevention, we aimed to assess current evidence on the use, benefits, and limitations of mHealth and eHealth in KSD., Methods: We performed a systematic review of primary research studies of mHealth and eHealth in the evaluation and management of KSD. Two independent researchers screened citations by title and abstract for relevance, then full-text review was performed for descriptive summary of the studies., Results: A total of 37 articles were included for analysis. Primary domains of evidence included: 1) "smart" water bottles and mobile-device apps for tracking fluid consumption, which showed increased intake in most studies; 2) ureteral stent tracking platforms, which improved the rate of long-term retained stents; 3) virtual stone clinics, which have been suggested to increase access, lower costs, and have satisfactory outcomes; 4) smartphone-based endoscopy platforms, which offered cost-effective image quality in resource-limited settings; 5) patient information about KSD online, which was typically characterized as poor quality and/or accuracy, particularly on YouTube. Most studies were proof-of-concept or single-arm intervention designs, with limited assessment of effectiveness or long-term clinical outcomes., Conclusions: Mobile and eHealth technologies have significant real-world applications to KSD prevention, intervention, and patient education. A lack of rigorous effectiveness studies currently limits evidence-based conclusions and incorporation in clinical guidelines., (Copyright © 2023 AEU. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: We sought to examine the practice patterns of pain management in the emergency room (ER) for renal colic and the impact of opioid prescriptions on return ER visits and persistent opioid use. Methods: TriNetX is a collaborative research enterprise that collects real-time data from multiple health care organizations within the United States. The Research Network obtains data from electronic medical records and the Diamond Network provides claims data. We queried the Research Network for adults who visited the ER for urolithiasis, stratified by receipt of oral opioid prescriptions, to calculate the risk ratio (RR) of patients returning to the ER within 14 days and persistent opioid use ≥6 months from the initial visit. Propensity score matching was performed to control for confounders. The analysis was repeated in the Diamond Network as a validation cohort. Results: There were 255,447 patients in the research network who visited the ER for urolithiasis, of whom 75,405 (29.5%) were prescribed oral opioids. Black patients were less likely to receive opioid prescriptions than other races ( p  < 0.001). After propensity score matching, patients who were prescribed opioids had an increased risk of a return ER visit (RR 1.25, confidence interval [95% CI] 1.22-1.29, p  < 0.001) and persistent opioid use (RR 1.12, 95% CI 1.11-1.14, p  < 0.001) compared with patients who were not prescribed opioids. These findings were confirmed in the validation cohort. Conclusions: A significant proportion of patients presenting to the ER for urolithiasis receive opioid prescriptions, which carries a markedly increased risk of return ER visits and long-term opioid use.

Percutaneous nephrolithotomy (PCNL) is the gold-standard treatment for large and complex renal stones. Though associated with higher stone-free rates compared to other minimally invasive stone procedures, this comes at the expense of increased morbidity including postoperative pain and discomfort. We describe our enhanced recovery after surgery (ERAS) protocol for PCNL with emphasis on the use of erector spinae plane blocks to improve patient satisfaction and reduce postoperative opioid use and bother.

Objectives: To compare the carbon footprint and environmental impact of single-use and reusable flexible cystoscopes., Materials and Methods: We analysed the expected clinical lifecycle of single-use (Ambu aScope™ 4 Cysto) and reusable (Olympus CYF-V2) flexible cystoscopes, from manufacture to disposal. Performance data on cumulative procedures between repairs and before decommissioning were derived from a high-volume multispecialty practice. We estimated carbon expenditures per-case using published data on endoscope manufacturing, energy consumption during transportation and reprocessing, and solid waste disposal., Results: A fleet of 16 reusable cystoscopes in service for up to 135 months averaged 207 cases between repairs and 3920 cases per lifecycle. Based on a manufacturing carbon footprint of 11.49 kg CO 2 /kg device for reusable flexible endoscopes and 8.54 kg CO 2 /kg device for single-use endoscopes, the per-case manufacturing cost was 1.37 kg CO 2 for single-use devices and 0.0017 kg CO 2 for reusable devices. The solid mass of single-use and reusable devices was 0.16 and 0.57 kg, respectively. For reusable devices, the energy consumption of reusable device reprocessing using an automated endoscope reprocessor was 0.20 kg CO 2 , and per-case costs of device repackaging and repair were 0.005 and 0.02 kg CO 2 , respectively. The total estimated per-case carbon footprint of single-use and reusable devices was 2.40 and 0.53 kg CO 2 , respectively, favouring reusable devices., Conclusion: In this lifecycle analysis, the environmental impact of reusable flexible cystoscopes is markedly less than single-use cystoscopes. The primary contributor to the per-case carbon cost of reusable devices is energy consumption of reprocessing., (© 2022 BJU International.)

Introduction: Patients who form kidney stones are typically advised to limit intake of nondairy animal protein. Plant-based meat products may be a processed substitute protein source for these patients and have recently gained popularity because of health concerns, increased retail availability, decreased environmental impact, and meat supply shortages during the COVID-19 pandemic. Despite these perceived benefits and tangential association with whole food plant-based diets, the potential lithogenic risks associated with these products are not well characterized. Methods: The U.S. Department of Agriculture database was queried with a sample of plant-based meat products widely available to U.S. consumers. Nutrient profile data were compiled and compared with animal protein data using standardized serving sizes. Primary protein sources were identified using verified ingredient lists. Oxalate content was extrapolated based on dietary data sources. Results: A total 47 plant-based meat products (16 beef, 11 pork, 10 chicken, and 10 seafood) were analyzed. Compared with their respective animal protein, most products contained on average fewer calories (plant-based beef 77%, pork 94%, chicken 86%, and seafood 83%) and less protein (plant-based beef 68%, pork 96%, chicken 53%, and seafood 54%). Most products used soy protein as the primary protein source (55%). Soy-based beef contained the highest average oxalate content (18 mg per serving), whereas soy-based seafood contained the lowest (7 mg). The most common non-soy protein source was pea protein (30%), containing trace amounts of oxalate. Sodium content was higher in most plant-based products overall (72%) and in each category (plant-based beef 109%, pork 128%, chicken 100%, and seafood 148%). Calcium content was higher (plant-based beef 317%, pork 144%, chicken 291%, and seafood 295%) compared with animal protein. Conclusions: Most plant-based meat products consist of protein sources that are, relative to animal protein sources, higher in oxalate, sodium, and calcium. Stone-forming patients should be counseled about the potential lithogenic risk of these processed products.

Objectives: To prospectively analyse robotically administered transperitoneal transversus abdominis plane (robot-assisted transversus abdominis plane [RTAP]) compared with both ultrasonography-guided transversus abdominis plane (UTAP) and local anaesthesia (LA) with regard to pain control and narcotic use in patients undergoing robot-assisted prostatectomy (RARP) or robot-assisted partial nephrectomy (RAPN)., Subjects/patients and Methods: Patients undergoing RARP or RAPN were randomized in a single-blind 2:2:1 fashion to RTAP:UTAP:LA, with the study powered to evaluate superiority of UTAP to LA and non-inferiority of RTAP to UTAP. We compared time to deliver the block, operating room time, postoperative pain scores using the visual analogue scale, and intra-operative and postoperative analgesia consumption., Results: A total of 143 patients were randomized and received treatment. There was no significant difference in patient baseline characteristics. UTAP did not demonstrate superiority to LA in terms of pain control. RTAP and LA were faster to administer than UTAP (time to perform block 2.5 vs 2.5 vs 6.25 min; P &lt; 0.001). There was no difference in postoperative narcotic, acetaminophen, ketorolac or ondansetron requirements among the three groups (P &gt; 0.05). The study was terminated early due to the unexpected efficacy of LA., Conclusion: This study showed that UTAP and RTAP do not provide superior pain control to LA. The efficiency, effectiveness, and ease of administration of LA make it an excellent option for first-line therapy for postoperative analgesia., (© 2022 BJU International.)

Background: Higher temperatures have been associated with increased stone formation and subsequent utilization of hospital resources, including inpatient admission. However, these observations have been derived from the adult population. We sought to examine if this purported association extends to the pediatric population. Methods: We used the 2016 Kids' Inpatient Database to identify nationwide pediatric inpatient admissions related to nephrolithiasis. Temperature data from the National Oceanic and Atmospheric Administration was linked to each admission. Comparative statistics analyzed patient and admission characteristics. Multivariable logistic regression analyzed associations between stone-related admissions and temperature. As a frame of reference, this analysis was replicated using the National Inpatient Sample from 2016 to evaluate associations in the adult population. Results: Of the 2,496,257 pediatric admissions, 8453 (0.33%) were related to nephrolithiasis. Temperatures at the time of stone admission were higher than those during nonstone admission (55.9°F vs 54.8°F, p  < 0.001). The stone admission group had a higher proportion of females than the nonstone admission group (64.8% vs 55.4%, p  < 0.001). Stone admission was significantly associated with temperature (odds ratio [OR] 1.025 per 10°F, confidence interval [95% CI] 1.003-1.049, p  = 0.03) and female gender (OR 1.097, 95% CI 1.027-1.171, p  = 0.006). In the adult population, 380,520 out of 30,000,941 patients (1.3%) were admitted with a stone. The effect of temperature on stone admissions was similar to that in the pediatric population (OR 1.020, 95% CI 1.014-1.026, p  < 0.001), but women were >20% less likely to be admitted for stones than men (OR 0.770, 95% CI 0.757-0.784, p  < 0.001). Conclusions: Increased temperatures were associated with an increased risk of stone-related admission in both the pediatric and adult populations. Females were at increased risk for stone-related admissions during childhood, but this trend reverses in adulthood.

Background: Oncological equivalency of minimally-invasive partial nephrectomy compared to open partial nephrectomy (OPN) continues to be challenged by proponents of open urologic oncology surgery., Objective: To compare patterns of recurrence, recurrence-free survival, cancer-specific survival, and overall survival between patients who underwent open or minimally-invasive partial nephrectomy., Materials and Methods: Data from prospectively maintained databases from 2 urban quaternary referral centers was retrospectively collected from 2003 to 2018. Patients who underwent either open or minimally-invasive (laparoscopic or robotic-assisted) partial nephrectomy and found to have malignant pathology were included. The groups subsequently underwent propensity-score matching to ensure homogeneity prior to analysis. The primary outcomes were incidence of recurrence, time to recurrence, time from recurrence to death, location of recurrence, and recurrence-free survival. Secondary outcomes included overall survival and cancer-specific survival., Results: A total of 190 patients underwent OPN and 190 underwent minimally-invasive partial nephrectomy. Recurrence was more common in patients undergoing OPN (10% vs. 3.2%, P = 0.01), but surgical approach was not predictive of location of recurrence (P = 1) or time to recurrence (23.8 vs. 26.3 months, P = 0.73). All-cause mortality was more common in the OPN group (10.5% vs. 2.6%, P = 0.003). On multivariable analysis, only surgical approach was associated with increased risk for recurrence (OR 3.88, P = 0.009)., Conclusion: This propensity-score matched analysis of patients undergoing partial nephrectomy suggests that minimally invasive surgical approach is resulted in decreased risk of recurrence and overall survival, and does not increase the risk for atypical sites of recurrence., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Multimodal analgesic regimens incorporating peripheral nerve blocks (PNBs) have demonstrated reduced postoperative pain, opioid use, and recovery time in various disease states. However, this remains a subject of limited investigation in the percutaneous nephrolithotomy (PCNL) domain. In the face of an ongoing opioid epidemic and collective push to enhance prescribing stewardship, we sought to examine the potential opioid-sparing effect of PNBs in PCNL. Methods: A systematic review of Embase and PubMed was performed to identify all randomized controlled trials evaluating the use of a PNB with general anesthesia (GA) vs GA alone for pain control following PCNL. Studies evaluating neuraxial (epidural and spinal) anesthesia and those without GA as the control arm were excluded. Results: Seventeen trials evaluating 1,012 procedures were included. Five different blocks were identified and evaluated: paravertebral ( n  = 8), intercostal nerve ( n  = 3), quadratus lumborum ( n  = 2), transversus abdominis plane ( n  = 1), and erector spinae ( n  = 3). Nine of 16 (56%) studies observed lower pain scores with PNB use throughout the 24-hour postop period. By comparison, improved pain scores with PNBs were limited to the early (<6 hours) recovery period in five studies and two found no difference. Total analgesic and opioid requirements were significantly higher in the GA control arm in nearly all studies (12/14, 86%). Operative times were similar and there were no differences in rates of intercostal access or nephrostomy tube insertion between study arms in any trial. Conclusions: While greater analgesic use with GA alone likely minimizes or obscures differences in patient-reported pain scores, PNBs may offer a significant opioid-sparing analgesic effect during postoperative recovery after PCNL.

Introduction: Procedure-specific guidelines for postsurgical opioid use can decrease overprescribing and facilitate opioid stewardship. Initial recommendations were based on feasibility data from limited pilot studies. This study aims to refine opioid prescribing recommendations for endourological and minimally invasive urological procedures by integrating emerging clinical evidence with a panel consensus. Materials and Methods: A multistakeholder panel was convened with broad subspecialty expertise. Primary literature on opioid prescribing after 16 urological procedures was systematically assessed. Using a modified Delphi technique, the panel reviewed and revised procedure-specific recommendations and opioid stewardship strategies based on additional evidence. All recommendations were developed for opioid-naive adult patients after uncomplicated procedures. Results: Seven relevant studies on postsurgical opioid prescribing were identified: four studies on ureteroscopy, two studies on robotic prostatectomy including a combined study on robotic nephrectomy, and one study on transurethral prostate surgery. The panel affirmed prescribing ranges to allow tailoring quantities to anticipated need. The panel noted that zero opioid tablets would be potentially appropriate for all procedures. Following evidence review, the panel reduced the maximum recommended quantities for 11 of the 16 procedures; the other 5 procedures were unchanged. Opioids were no longer recommended following diagnostic endoscopy and transurethral resection procedures. Finally, data on prescribing decisions supported expanded stewardship strategies for first-time prescribing and ongoing quality improvement. Conclusion: Reductions in initial opioid prescribing recommendations are supported by evidence for most endourological and minimally invasive urological procedures. Shared decision-making before prescribing and periodic reevaluation of individual prescribing patterns are strongly recommended to strengthen opioid stewardship.

The presence of lower pole stones poses a unique challenge due to the anatomical considerations involved in their management and treatment. Considerable research has been performed to determine the optimal strategy when faced with this highly relevant clinical scenario. Standard options for management include observation, shock wave lithotripsy, retrograde intrarenal surgery, or percutaneous nephrolithotomy. Indeed, each approach confers a distinct set of risks and benefits, which must be placed into the context of patient preference and expected outcomes. The current state of practice reflects a combination of lessons learned from managing calculi not only in the lower pole, but also from other locations within the kidney as well., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Objective: The aim of this study was to comprehensively evaluate the quality of patient-oriented, mobile health applications (apps) available for medical management of kidney stone disease (KSD). Materials and Methods: A systematic search was performed to identify apps from the Apple and Google Play app stores. Eligible apps were divided into two categories: (1) fluid apps and (2) dietary apps. Descriptive characteristics were summarized and app quality was independently evaluated on the basis of technical quality, usability, clinical value, and privacy/security. The validated Mobile App Rating Scale (MARS) was the backbone for the evaluation framework. Results: In total, 31 apps (18 fluid apps and 13 dietary apps) were included. Fluid apps outscore dietary apps in all dimensions of MARS quality. All but one fluid app exceeded the minimum acceptable MARS score of 3.0 vs 46% of dietary management apps. Dietary apps feature less functionality and most are limited to noninteractive informational content. While most data-capturing apps provide a privacy policy and ensure that security measures are taken to protect user identity, only 36% offer users choice or consent for secondary use of their data after data have already been collected. Overall, only one app has undergone any form of real-world clinical investigation. Conclusions: Fluid management apps outperform dietary apps in technical quality, usability, and clinical value at the cost of greater privacy/security risks. Despite not being targeted to patients with KSD, they are higher in most quality measures and offer greater functionality to support long-term disease management compared with dietary apps.

Introduction: Historically, staging and treatment for upper tract urothelial carcinoma were extrapolated from bladder urothelial carcinoma literature. However, embryological, genetic, and anatomical differences exist between them. We sought to explore the relationship between location of urothelial cancer and overall survival (OS)., Methods: Data was culled from the National Cancer Database from 2004-2015. Patients with pT2-pT4 treated with definitive surgery were included; those with metastatic disease or who received neoadjuvant or adjuvant treatment were excluded. Patients were stratified by tumor location and pathological stage. The primary outcome was OS. Secondary outcomes were predictors of mortality in each pT stage stratum., Results: A total of 11 330 patients with bladder, 954 patients with ureteral, and 1943 patients with renal pelvis urothelial carcinoma were analyzed. Mean followup was 43.3, 39.4, and 41.4 months for bladder, ureteral, and renal pelvis, respectively. On univariable analysis, ureteral pT2 was associated with worse OS compared to both bladder (61.3 vs. 80.4 months, p=0.007) and renal pelvis (61.3 vs. 80.5 months, p=0.014). Renal pelvis pT3 was associated with improved OS compared to both bladder (42.5 vs. 28.6 months, p=0.003) and ureteral (42.5 vs. 25.7 months, p<0.001). Renal pelvis pT4 had decreased survival compared to bladder (11.4 vs. 17.7 months, p<0.001). On multivariable Cox regression, only renal pelvis pT3 was associated with a 20% decreased risk of mortality compared to bladder pT3 (hazard ratio 0.80, 95% confidence interval 0.72-0.88, p<0.001)., Conclusions: Renal pelvis pT3 is associated with lower mortality. Mutational and embryological differences may play a role in this disparity.

Radical cystectomy (RC) is the gold standard treatment for muscle-invasive and high-risk, noninvasive bladder cancer. Since 2003, robot-assisted radical cystectomy (RARC) has been gaining popularity. Metanalyses show that the primary advantage of RARC is less blood loss and the primary advantage of open radical cystectomy (ORC) is shorter operative times. There do not appear to be significant differences in complications, cancer-related outcomes or survival between the two approaches. Cost analyses comparing RARC and ORC are complicated by the often-ill-defined distinction between the cost to the hospital versus the cost to payors. However, it is likely that for both hospitals and payors, RARC is cost effective at high-volume centers. It is feasible that in the future, increased experience with RARC will lead to improved outcomes and justify the use of RARC over ORC., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tau.2019.11.32). The series “Controversies in Minimally Invasive Urologic Oncology” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2021 Translational Andrology and Urology. All rights reserved.)

Purpose: Transperineal prostate biopsy offers improved sampling of the anterior prostate compared to the transrectal approach. The objective of this study was to determine if transperineal prostate biopsy is associated with an increased incidence of cancer upgrading among men on active surveillance for very low or low risk prostate cancer., Materials and Methods: Our active surveillance registry was queried to identify patients who underwent a surveillance biopsy following the introduction of transperineal prostate biopsy at our institution. Patients were dichotomized by the type of biopsy performed. The baseline characteristics and rates of cancer upgrading were compared between groups., Results: Between November 2017 and June 2020, 790 men with very low or low risk prostate cancer underwent a surveillance biopsy. In total, 59 of 279 men (21.2%) in the transperineal prostate biopsy group were upgraded to grade group ≥2 as compared to 75 of 511 (14.7%) in the transrectal biopsy group (p=0.01). Among patients who were upgraded to grade group ≥2, 26 of 59 (44%) had grade group ≥2 detected in the anterior/transition zone with transperineal prostate biopsy compared to 14 of 75 (18.7%) with transrectal biopsy (p=0.01). Additionally, 17 of 279 men (6.1%) who underwent transperineal prostate biopsy were upgraded to grade group ≥3 vs 17 of 511 (3.3%) who underwent transrectal biopsy (p=0.05). After adjusting for age, prostate specific antigen density, use of magnetic resonance imaging, and number of prior transrectal biopsies, transperineal prostate biopsy was significantly associated with upgrading to grade group ≥2 (OR 1.49, 95% CI 1.11-2.19, p=0.01)., Conclusions: Among men on active surveillance for very low or low risk prostate cancer, transperineal prostate biopsy was associated with an increased likelihood of upgrading to clinically significant prostate cancer. This is likely due to improved sampling of the anterior prostate with the transperineal approach.

Background: Clinical guidelines have conflicting recommendations on the role of prostate artery embolization (PAE), a novel interventional radiology technique used to treat benign prostatic hyperplasia (BPH). In the absence of consensus among clinicians, patients may seek information online, where consumer-targeted content has proliferated in recent years. Our objective was to assess the content and quality of online information about prostate artery embolization (PAE)., Methods: We evaluated patient interest and exposure to PAE by searching Google Trends for PAE and searching Google for BPH and treatment-related terms. To assess online content about PAE safety and efficacy, we queried Google for patient-oriented websites and YouTube for consumer videos, assessing quality using the validated DISCERN instrument and performing an evidence-based content analysis of how indications, risks, and benefits of PAE were presented., Results: Worldwide searches for PAE peaked in 2019; PAE was mentioned in 15 (26%) of the 57 general BPH-related websites. From our PAE-specific searches, we identified 50 websites and 31 videos. Academic hospitals were the most common sponsor of both PAE-related websites (16, 32%) and videos (15, 48%). Among sources offering PAE to patients, only 15% of websites and 11% of videos explicitly did so as part of a clinical trial. The average DISCERN rating of quality of content was 3.0 out of 5 for websites and 2.0 out of 5 for videos (p < 0.001). Over a quarter of websites and more than half of videos contained potential misinformation, inaccuracies, or non-evidence-based claims about PAE (p = 0.02)., Conclusions: Online consumer information about PAE is of low to moderate quality, with a high frequency of non-evidence-based claims. In the absence of guideline consensus about the role of PAE, clinicians should offer shared decision making and evidence-based counseling about the risks and benefits of PAE.

Objective: To assess the quality and accuracy of online videos about the medical management of nephrolithiasis., Materials and Methods: To evaluate trends in online interest, we first examined the frequency of worldwide YouTube searches for 'kidney stones' from 2015 to 2020. We then queried YouTube with terms related to symptoms and treatment of kidney stones and analysed English-language videos with >5000 views. Quality was assessed using the validated DISCERN instrument. Evidence-based content analysis of video content and viewer comments was performed., Results: Online searches for videos about kidney stones doubled between 2015 and 2019 (P < 0.001). We analysed 102 videos with a median (range) number of views of 46 539 (5024-3 631 322). The mean (sd) DISCERN score was 3.0 (1.4) out of 5, indicating 'moderate' quality; scores were significantly higher for the 21 videos (21%) authored by academic hospitals (mean 3.7 vs 2.8, P = 0.02). Inaccurate or non-evidence-based claims were identified in 23 videos (23%); none of the videos authored by academic institutions contained inaccurate claims. Videos with inaccurate statements had more than double the viewer engagement (viewer-generated comments, 'thumbs up' and 'thumbs down' ratings) compared to videos without inaccuracies (P < 0.001). Among viewer comments, 43 videos (43%) included comments with inaccurate or non-evidence-based claims, and a large majority (82 videos, 80%) had 'chatbot' recommendations., Conclusions: Interest in YouTube videos about nephrolithiasis has doubled since 2015. While highly viewed videos vary widely in quality and accuracy, videos produced by academic hospitals have significantly fewer inaccurate claims. Given the high prevalence of stone disease and poor-quality videos, patients should be directed to evidence-based content online., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)

Objective: To compare transperineal (TP-TBx) and transrectal (TR-TBx) targeted prostate biopsy in a prospective non randomized single surgeon series of MR/US fusion-guided targeted biopsy performed using an electromagnetic tracking platform (NCT04026763)., Materials and Methods: In this single-institution prospective study, 168 patients who underwent transperineal systematic 12-core biopsy and TP-TBx with electromagnetic tracking (UroNav, Invivo, Gainesville, FL) were compared to 211 patients who underwent a similar procedure by a transrectal approach. Univariate and multivariate analyses were used to assess if biopsy technique impacted all cancer detection rates or clinically significant (Gleason score >3+4) cancer detection rates., Results: Patients who underwent TP-TBx were older (68 vs 65 y, P = .014), with a slightly higher rate of PI-RADSv2.0 score (39% vs 28%, P = .039) and higher lesion volume on mpMRI (0.54 vs 0.41 cc, P = .039). The rates of CS disease detection by TP-TBx and TR-TBx were 59% and 54%, respectively. In a multivariate analysis adjusting for PSA, previous biopsy status, prostate volume, PI-RADS score, lesion volume, and lesion location, there was no statistically significant difference in likelihood to detect any PCa (OR, 0.98; 95% CI, 0.56-1.71; P = .940) or CS PCa (OR, 0.94, 95% CI, 0.58-1.51; P = .791)., Conclusion: Transperineal targeted biopsy with electromagnetic-tracking is comparable to the transrectal fusion-guided approach in the detection of any PCa and csPCa cancer., Competing Interests: Conflicts of Interest MAG is a consultant for BK Medical ApS, KOELIS Inc., and Perineologic YB – nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate the feasibility and safety of performing robotic-assisted laparoscopic partial nephrectomy (RAPN) as outpatient surgery in patients with renal masses., Materials and Methods: We analyzed RAPN performed by a single surgeon at an academic medical center from July 2018 to June 2019 and identified those individual patients who were discharged on the same day. These cases were then compared to a concurrent inpatient RAPN group. Relationships with outcome analyzed using Fisher's exact test and Student's t test., Results: Twenty-three of 84 RAPNs (27.4%) were performed as ambulatory. Mean age was 57.4 years. Average tumor size was 2.24 cm. The mean total operative time was 99.4 minutes. Average estimated blood loss was 51.0 mL. When compared to the cohort of patients who stayed overnight, on multivariate analysis, the tumor size (2.24 ± 0.71 vs 3.65 ± 1.55 cm, P <0.001), and operative time (99.5 ± 25.1 vs 131.2 ± 30.8 minutes, P <0.001) were less in ambulatory cases. No differences were seen in regards to Charlson comorbidity index, age, gender, body mass index, estimated blood loss, or surgical approach. Within 90 days of postoperative period, the readmission rate for the entire cohort was 0., Conclusion: RAPN can be performed safely as ambulatory in select patients with comparable outcome without complication or hospital readmission., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Accurate estimation of stone fragment size during ureteroscopic lithotripsy procedures facilitates operative efficiency and predicts the safety of fragment extraction or spontaneous passage. Using a novel stone measurement software application, this study assesses the feasibility of performing integrated real-time digital stone measurement during ureteroscopy. Methods: This workflow feasibility study was conducted in two phases. First, in the ex vivo simulation, mock stone fragments were placed in a renal collecting system training model. A basket extraction task was performed using a digital ureteroscope, with and without digital stone measurement. The time required to perform the tasks was recorded and compared. Second, in the in vivo workflow trial, adult patients undergoing ureteroscopic stone procedures were prospectively enrolled. Intraoperative measurements of stone fragments were performed to determine the time required to complete the measurements. Technical failures and perioperative complications were recorded. Results: In the ex vivo simulation, 20 mock stones mimicking varied fragmentation conditions were tested in the training model. The mean completion time of the basketing task without vs with digital stone measurement was 16.5 seconds (range 10.2-33.7) vs 38.9 seconds (range 27.2-60.0). Mean additional time required to measure stones was 22.3 seconds (range 8.4-42.7). In the in vivo workflow trial, nine patients undergoing ureteroscopy were enrolled. A median of five fragments (range 3-10) were measured in each patient. Mean completion time for each measurement was 10.1 seconds (range 8.2-12.8). Mean total time required to perform digital measurement per procedure was 50.8 seconds (range 25.9-99.0). No technical failures or clinical complications were observed. Conclusions: Integrating real-time digital stone measurement during ureteroscopy is safe and feasible. The findings support clinical trials of digital stone measurement to enhance intraoperative decision-making during ureteroscopy.

The ability to accurately determine a complete clinical response (cCR) to neoadjuvant chemotherapy (NAC) before cystectomy could have paradigm-shifting implications for the management of muscle-invasive bladder cancer. Level 1 evidence demonstrates that up to 40% of patients are downstaged to pT0 disease following NAC, presenting an intriguing opportunity to identify select patients who might be spared the morbidity of radical surgery. However, clinical investigations in this space are hindered by lack of a uniform approach to postchemotherapy restaging and a standardized definition of cCR. PATIENT SUMMARY: In this mini-review, we discuss the current limitations to restaging of muscle-invasive bladder cancer following neoadjuvant chemotherapy and their implications for personalized medicine and translational research. We conclude that there is an unmet need to optimize and standardize restaging evaluation and definitions of a complete clinical response., (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate the ability to detect clinically significant prostate cancer (PCa) using a novel electromagnetically (EM) tracked transperineal magnetic resonance imaging (MRI)/ultrasonography (US) fusion-guided targeted biopsy (transperineal TBx) platform and the impact of inter-reader variability on cancer detection., Materials and Methods: A total of 176 patients with suspicious lesions detected on multiparametric MRI (mpMRI) underwent a systematic modified Barzel template biopsy (12-core) transperineal biopsy (transperineal SBx) and transperineal TBx with EM tracking (UroNav; Philips Healthcare, Best, the Netherlands) in the same setting. Cancer detection rates (CDRs) were stratified by Prostate Imaging Reporting and Data System (PI-RADS) v2 scores and compared with Fisher's exact test. Area under the curve (AUC) was calculated for prostate-specific antigen (PSA), PSA density (PSAD), PI-RADS score, and subgroup analysis of individual readers' PI-RADS scores with respect to overall CDR and clinically significant CDR., Results: The overall CDR was 76.7% (135/176), of which 76.3% (103/135) was clinically significant PCa. Among the 135 patients with PCa, transperineal TBx detected 90.4% of cases (122/135), either alone or in combination with transperineal SBx. The remaining 9.6% of cases (13/135) missed by transperineal TBx were diagnosed by transperineal SBx alone, of which three were clinically significant. Conversely, transperineal SBx missed 14% of cases (19/135), 14 of which were clinically significant PCa. Sensitivities for transperineal TBx and transperineal SBx were 90.4% and 85.9%, respectively. On a per-lesion basis, PI-RADS score (AUC 0.74) outperformed both PSA (AUC 0.59) and PSAD (AUC 0.63) in discriminating clinically significant from non-clinically significant PCa on transperineal TBx. Although not formally statistically tested, AUCs amongst different mpMRI readers appeared to display considerable variability. There were no adverse events, including sepsis., Conclusions: Electromagnetically tracked transperineal TBx of MRI-visible lesions enhanced the ability of transperineal SBx to detect PCa, with greater sensitivity for clinically significant disease. These findings suggest transperineal TBx is a safe, alternative fusion platform for patients with a suspicious lesion on prostate MRI. The assessment of inter-reader variability, in conjunction with prediction of clinically significant PCa and CDR, is an important first step for quality control in implementing an MRI-based screening programme., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

Due to their large size, rapid growth, and attendant morbidity, staghorn calculi are complex clinical entities that impose significant treatment-related challenges. Moreover, their relative heterogeneity-in terms of both total stone burden and anatomic distribution-limits the ability to standardize their characterization and the reporting of surgical outcomes. Several morphometry systems currently exist to define the volumetric distribution of renal stones, in general, and to predict the outcomes of percutaneous nephrolithotomy; however, they fall short in their applicability to staghorn stones. In this review, we aim to discuss the clinical utility of morphometry systems and the influence of pelvicalyceal anatomy on the management of these complex calculi., (© 2020 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V.)

Purpose: There has been an increase in the number of staghorn calculi that form in the absence of infection (metabolic staghorns). It is unknown why some large metabolic calculi form as solitary or multiple separate, nonbranching caliceal stones, whereas others develop as staghorn stones forming a cast of the collecting system. We sought to compare these two groups of metabolic stone formers (SFs) in an attempt to shed light on these disparate stone-forming phenomena. Materials and Methods: From January 2017 to September 2018, 190 patients underwent percutaneous nephrolithotomy for stones >2 cm. We identified 86 (45%) patients with a metabolic stone, defined as ≥80% calcium oxalate monohydrate or dihydrate and/or calcium phosphate. Exclusion criteria included stones composed of cystine, >20% uric acid, or any infectious element (struvite or carbonate apatite). Metabolic staghorn and nonstaghorn SFs were compared with respect to medical comorbidity, 24-hour urine parameters, stone and urine microbiology, stone compositions, and intraoperative findings. Statistical differences were assessed using chi-square analysis, Fisher's exact test, and Student's t -test. Results: In total, 25 (29%) staghorn and 61 (71%) nonstaghorn SFs were included for analysis. The groups were statistically similar in age, sex, body mass index, and medical comorbidity. Staghorn SFs had larger stone burdens ( p  < 0.0001), but did not require more punctures ( p  = 0.783). Staghorn SFs were more likely to have hyperoxaluria ( p  = 0.041) and higher mean 24-urine oxalate levels ( p  = 0.040). There were no other significant differences in 24-hour urine profiles, rates of metabolic abnormalities, stone compositions, stone or urine cultures, presence of collecting system obstruction, or pelvicaliceal anatomy. Conclusions: Although potentially driven by urinary oxalate, whether a metabolic stone will form into a staghorn configuration or not does not appear significantly influenced by standard determinants of stone development, including metabolic profile, cultures, hydronephrosis, and pelvicaliceal anatomy, among others. Further work is needed to elucidate the physicochemical factors that govern the pathogenesis of this increasingly prevalent entity.

Biocompatible gold nanoparticles designed to absorb light at wavelengths of high tissue transparency have been of particular interest for biomedical applications. The ability of such nanoparticles to convert absorbed near-infrared light to heat and induce highly localized hyperthermia has been shown to be highly effective for photothermal cancer therapy, resulting in cell death and tumor remission in a multitude of preclinical animal models. Here we report the initial results of a clinical trial in which laser-excited gold-silica nanoshells (GSNs) were used in combination with magnetic resonance-ultrasound fusion imaging to focally ablate low-intermediate-grade tumors within the prostate. The overall goal is to provide highly localized regional control of prostate cancer that also results in greatly reduced patient morbidity and improved functional outcomes. This pilot device study reports feasibility and safety data from 16 cases of patients diagnosed with low- or intermediate-risk localized prostate cancer. After GSN infusion and high-precision laser ablation, patients underwent multiparametric MRI of the prostate at 48 to 72 h, followed by postprocedure mpMRI/ultrasound targeted fusion biopsies at 3 and 12 mo, as well as a standard 12-core systematic biopsy at 12 mo. GSN-mediated focal laser ablation was successfully achieved in 94% (15/16) of patients, with no significant difference in International Prostate Symptom Score or Sexual Health Inventory for Men observed after treatment. This treatment protocol appears to be feasible and safe in men with low- or intermediate-risk localized prostate cancer without serious complications or deleterious changes in genitourinary function., Competing Interests: Conflict of interest statement: A.R.R. is the national principal investigator for the multiinstitutional trial of GSN-directed ablation, funded by Nanospectra Biosciences. He is also a consultant for Nanospectra Biosciences. J.L.W. and N.J.H. cofounded Nanospectra Biosciences in 2001 to transfer the photothermal therapeutics process from their labs into the clinic. They both have a small equity stake in this company but are not involved in any way with the company’s business or strategic decisions., (Copyright © 2019 the Author(s). Published by PNAS.)

Introduction: Transgender individuals suffer from significant health disparities, due in part to deficiencies in physician knowledge or comfort with addressing transgender health care needs. In this study we assessed the attitudes and clinical knowledge in caring for transgender patients of a representative sample of urologists in the New York metropolitan area., Methods: An anonymous, online based questionnaire was sent to members of the New York Section of the American Urological Association. Statements evaluating knowledge and attitudes toward transgender care were scored on a 5-point Likert scale., Results: A total of 92 providers (83.7% male) participated in the study, of whom 78.3% (72) have been in practice for at least 15 years. With respect to physician attitudes, there was a trend toward greater comfort with discussion of gender identity and counseling on gender confirmation surgery based on total number of transgender patients cared for during the course of their career. Regarding knowledge scores there were no significant associations with physician age, gender or years of practice. Despite the relatively weak self-reported fund of knowledge (2.64) and overall clinical competence (2.09), there was no overwhelming support to incorporate transgender care into urology training curricula (3.11)., Conclusions: Despite growing education and awareness of transgender specific medical issues, many urologists self-report deficiencies in requisite knowledge and comfort in providing adequate, culturally competent care for transgender patients. Further work is needed to increase our collective comfort level with this new and evolving aspect of our field.

Purpose: To evaluate the long-term urinary outcomes of men with severe pretreatment lower urinary tract symptoms (LUTS) treated with permanent prostate brachytherapy (PPB) ± external beam radiation therapy for localized prostate cancer., Methods and Materials: A total of 105 men with International Prostate Symptom Score (IPSS) 20-35 before PPB were categorized by IPSS change at last followup: (1) worse = IPSS rise >3; (2) no change = IPSS change within three points of baseline; (3) improved = IPSS fall by >3 points. We then evaluated patients who worsened vs. those who did not (no change or improved) with respect to incontinence outcomes, LUTS medication usage, and predictors of symptom worsening., Results: Mean followup was 80.3 ± 55.8 months. Mean age was 66.3 ± 7.1 years; mean pretreatment IPSS was 23.6 ± 3.0. Overall mean improvement in IPSS was 7.6 ± 9.3. Specifically, 14.3% (15/105) worsened, 21.9% (23/105) had no significant change, and 63.8% (67/105) improved. There were no patient- or treatment-related factors significantly associated with long-term worsening of urinary symptoms. No men required anticholinergic therapy at last followup, whereas 7% (8/105) were using an alpha blocker. Only 2.9% (3/105) of men were using at least one pad daily at last followup. Alternatively, only 7.7% (8/105) reported subjective incontinence., Conclusions: PPB is an acceptable option in the setting of severe baseline LUTS in appropriately selected and counseled patients when performed by a skilled practitioner., (Copyright © 2019 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the oncological and functional outcomes of young men treated with low-dose-rate brachytherapy (BT) for prostate cancer (PCa)., Materials and Methods: 423 men aged ≤60 years with clinically localized PCa were treated with BT ± external beam radiation. Biochemical failure was defined by Phoenix criteria. Freedom from biochemical failure (FFbF) and cancer-specific survival (CSS) at 10 and 15 years were estimated by the Kaplan-Meier method with the log-rank test to compare outcomes between National Comprehensive Cancer Network risk groups. The Cox proportional hazards model was used to determine significant predictors for FFbF and CSS., Results: Median followup was 9.9 years (range, 5.1-21.7). Median age was 57 years (range, 39-60), and median prostate-specific antigen was 6.1 ng/mL (range, 0.8-71). Overall, 10- and 15-year FFbF rates were 89% and 88%; 10- and 15-year CSS rates were 99% and 98%. Increasing disease risk was associated with lower FFbF and CSS (p < 0.0001). Biologically effective dose (p < 0.0001) and use of external beam radiation (p = 0.005) were significantly associated with higher FFbF. In men potent before BT, 64% (151/237) had preserved erectile function at a median 10.2 years. There was no significant difference between treatment groups with respect to long-term urinary function (p = 0.56)., Conclusions: Younger men treated with BT experience excellent long-term PCa control with low rates of treatment-related toxicity., (Copyright © 2018 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine which patient and treatment-related factors are associated with increased American Urological Association symptom score (AUASS) in men who presented with minimal symptoms before treatment for prostate cancer by permanent seed implantation., Patients and Methods: Of 1842 men with a minimum follow-up of 5 years (mean 9.4), 1110 (60.3%) had an initial AUASS of 0-7 and were treated with brachytherapy (BT) alone (n = 491) or BT with neoadjuvant hormone therapy (NHT) and/or external beam radiation therapy (EBRT, n = 619). The median prostate volume was 37 mL. Data were prospectively collected on comorbidities. Initial AUASS was compared to last using a Student's t-test (two-tailed). Freedom from increasing from minimal to moderate or severe symptoms was determined by the Kaplan-Meier method with comparisons by log-rank and Cox hazard rates (HRs)., Results: The change from pre-treatment score for the minimal, moderate and severe symptom groups was: 3.6-7.3 (P < 0.001), 11.6-11.3 (P = 0.426), and 24.1-16.9 (P < 0.001). For those with minimal symptoms the 10- and 15-year estimates for freedom from worse symptoms were 72.9% and 39.1%, respectively. Cox HRs were significant for EBRT boost (HR 1.45, P = 0.004), RT dose >200 Gy 2 (HR 1.25, P = 0.024), hypertension (HR 1.37, P = 0.006), and alcohol use (HR 1.46, P = 0.001)., Conclusion: A substantial number of men with initial low AUASS treated by BT experience worsening urinary symptoms with long-term follow-up. Use of EBRT, RT dose, hypertension and alcohol use are risk factors for an increase in urinary symptom score., (© 2018 The Authors BJU International © 2018 BJU International Published by John Wiley & Sons Ltd.)

Purpose of Review: To discuss contemporary data on the value of multiparametric MRI (mpMRI) for guiding the decision to biopsy men at risk for prostate cancer, as well as its utility in active surveillance programs., Recent Findings: Although a systematic 12-core biopsy is the current standard of care for men with increased suspicion for prostate cancer, MRI with or without targeted biopsy has been shown to reliably improve the detection of clinically significant disease following a prior negative biopsy. At the same time, there is a growing body of evidence to support the use of MRI for diagnostic purposes in biopsy-naive patients, as well for enrolling and monitoring men on active surveillance programs., Summary: mpMRI is an evolving technology with great promise for altering our approach to prostate cancer diagnosis and surveillance. In conjunction with targeted biopsies, MRI offers greater specificity for the detection of clinically significant cancer and therefore may help to reduce overdetection of indolent disease while minimizing the risks and limitations of systematic biopsies.

Objective: To examine post-orchiectomy specimens of transgender individuals to better understand the reproductive implications of hormonal therapy and to look for potential malignant or premalignant changes., Materials and Methods: A retrospective chart review was performed on the orchiectomy specimens from 135 TG individuals who underwent bilateral simple orchiectomy (54) or vaginoplasty with combined orchiectomy (81) at a single institution from 2014-2017. Factors examined included microscopic evidence of spermatogenesis, weight of specimens, evidence of malignant or premalignant changes, and patient demographic information., Results: Four percent (6/135) of all orchiectomy specimens had normal spermatogenesis in both testicles. Twenty-one percent (28/135) demonstrated some stage of spermatogenesis, of which 61% (17/28) were in maturational arrest. The median patient age at surgery was 30 years (range 18-76). Median overall testicle weight was 24 g (range 10.4-71.1), compared with 24 g (range 10-71g) in testicles without evidence of spermatogenesis and 26 g (range 17.9-40.9) in testicles with normal spermatogenesis. None of the specimens demonstrated premalignant or malignant changes., Conclusion: Up to 21% of individuals undergoing a gender affirming surgery had microscopic evidence of spermatogenesis in varying stages. Furthermore, 4% of individuals had normal spermatogenesis. None of the specimens had malignant or premalignant changes. These findings may have implications for counseling transgender individuals on sexual and reproductive health and highlight the need for further research in this sector., (Copyright © 2018. Published by Elsevier Inc.)

Purpose of Review: To review the growth kinetics of small renal masses and available imaging modalities for mass characterization and surveillance, highlight current organizational recommendations for the active surveillance of small renal masses, and discuss the most recently reported oncological outcomes of patients as they relate to various surveillance imaging protocols and progression to delayed intervention., Recent Findings: Overall, organizational guideline recommendations are broad and lack specifics regarding timing and modality for follow-up imaging of small renal masses. Additionally, despite general consensus in the literature about certain criteria to trigger delayed intervention, there exist no formal guidelines. Active surveillance of small renal masses is an acceptable management strategy for patients with prohibitive surgical risk; however, standardized imaging protocols for surveillance are lacking, as are randomized, prospective trials to evaluate the ideal follow-up protocol.

Adrenocortical carcinoma (ACC) is a rare malignancy associated with poor prognosis despite available treatments. In patients with localized or locally advanced disease, complete resection with negative margins offers the only potential for cure. Unfortunately, most patients develop local and distant recurrence following initial resection highlighting the importance of meticulous surgical technique in the hands of an experienced surgeon. While minimally invasive surgery (MIS) has supplanted open surgery for small to medium-sized benign adrenal tumors, controversy surrounds the use of MIS for resection of ACC. We sought to provide an overview of the key oncological principles in the surgical management of ACC and to critically review the literature comparing outcomes between the open and MIS approaches.

Men diagnosed with low- to intermediate-risk, clinically localized prostate cancer (PCa) often face a daunting and difficult decision with respect to treatment: active surveillance (AS) or radical therapy. This decision is further confounded by the fact that many of these men diagnosed, by an elevated PSA, will have indolent disease and never require intervention. Radical treatments, including radical prostatectomy and whole-gland radiation, offer greater certainty for cancer control, but at the risk of significant urinary and/or sexual morbidity. Conversely, AS preserves genitourinary function and quality of life in exchange for burdensome surveillance and the psychological impact of living with cancer.

Purpose: We evaluated the predictive value of the ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Program®) surgical risk calculator in a tertiary referral cohort of patients who underwent robot-assisted partial nephrectomy., Materials and Methods: We queried our prospectively maintained, multi-institutional database of patients treated with robot-assisted partial nephrectomy and input the preoperative details of 300 randomly selected patients into the calculator. Accuracy of the calculator was assessed by the ROC AUC and the Brier score., Results: The observed rate of any complication in our cohort was 14% while the mean predicted rate of any complication using the calculator was 5.42%. The observed rate of serious complications (Clavien score 3 or greater) was 3.67% compared to the predicted rate of 4.89%. Low AUC and high Brier score were calculated for any complication (0.51 and 0.1272) and serious complications (0.55 and 0.0352, respectively). The calculated AUC was low for all outcomes, including venous thromboembolism (0.67), surgical site infection (0.51) and pneumonia (0.44)., Conclusions: The ACS NSQIP risk calculator poorly predicted and discriminated which patients would experience complications after robot-assisted partial nephrectomy. These findings suggest the need for a more tailored outcome prediction model to better assist urologists risk stratify patients undergoing robot-assisted partial nephrectomy and counsel them on individual surgical risks., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Studies suggest that thrombocytopaenia is associated with a higher mortality in several diseases. Little is known about the effect of low platelet count on mortality in patients with heart failure with reduced ejection fraction (HFrEF). The aim of this study was to determine the prognostic value of thrombocytopaenia in these patients by assessing all-cause mortality., Methods: A total of 1,907 patients with HFrEF, defined by left ventricular ejection fraction <40% on echocardiography, were analysed in this multi-centre retrospective study. All patients were on medical therapy with a beta-blocker and an angiotensin-converting enzyme inhibitor. Patients were categorised into two groups based on platelet count measured within one month of the diagnosis of HFrEF: normal to mild thrombocytopaenia (platelet count 100,000-450,000 per uL); and moderate to severe thrombocytopaenia (platelet count <100,000 per uL). One-year all-cause mortality was compared between the two groups., Results: Mean age was 65±15 years and 62% of patients were male. Overall one-year mortality was 17.2% with higher mortality among patients with HFrEF and moderate/severe thrombocytopaenia compared to those with normal/mild thrombocytopaenia (33.0% vs. 15.4%, p <0.001). After adjusting for baseline characteristics, patients with HFrEF and moderate/severe thrombocytopaenia had a higher mortality compared to patients with normal/mild thrombocytopaenia (HR 1.84, 95% CI 1.33-2.56, p <0.001)., Conclusion: In patients with HFrEF, higher degree of thrombocytopaenia is associated with higher all-cause mortality. These findings may support the use of platelet counts as a prognostic marker in the assessment of the patient with HFrEF., (Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Established prognostic factors for pulmonary hypertension (PH) include brain natriuretic peptide, troponins and hemodynamic measures such as central venous pressure and cardiac output. The prognostic role of thrombocytopenia, however, has yet to be determined in patients with PH. The aim of this study was to evaluate effect of thrombocytopenia on mortality in patients with PH., Methods: 521 patients with severe PH, defined by a pulmonary artery systolic pressure >60 mm Hg on transthoracic echocardiography and a platelet count measured within one month after diagnosis were enrolled from three hospitals of Montefiore Medical Center. The cohort was divided into two groups: mild thrombocytopenia to a normal platelet count (platelet count 100,000-450,000 per uL); and moderate to severe thrombocytopenia (platelet count <100,000 per uL). Inpatient and social security death records were used to determine 1-year all-cause mortality., Results: Mean age was 70.3 ± 15.6 with 40% of patients being male. Overall mortality at 1 year was 30.7%, with increased mortality in PH patients with mild thrombocytopenia compared to those with moderate to severe thrombocytopenia (46.5% vs. 27.0%, p < 0.001). In multivariate analysis, moderate to severe thrombocytopenia remained an independent predictor of mortality (HR 1.798, 95% CI 1.240-2.607, p = 0.002)., Conclusions: Moderate to severe thrombocytopenia is an independent predictor of higher mortality in patients with severe PH. These findings may support the use of thrombocytopenia as a useful prognostic indicator in patients with severe PH., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Paradoxical embolization through a right-to-left shunt (RLS), often from a patent foramen ovale (PFO), has been associated with cryptogenic stroke. While transesophageal echo (TEE) bubble study is the current standard reference for diagnosing PFO, transthoracic echo (TTE) remains the most commonly used screening test for RLS due to its noninvasiveness and easy availability. The aim of this meta-analysis was to determine the accuracy of TTE compared to TEE as the reference., Methods and Results: A systematic review of Medline, Cochrane, and Embase was done to look for all the prospective studies assessing for intracardiac RLS using conventional TTE compared to TEE as the reference; both TTE and TEE were performed with a contrast agent and a maneuver to provoke RLS in all studies. A total of 13 studies with 1436 patients fulfilled the inclusion criteria. The weighted mean sensitivity and specificity for TTE were 46% and 99%, respectively. Likewise, the positive likelihood ratio and negative likelihood ratio were 20.85 and 0.57, respectively. Using different contrast agents, different microbubble cutoffs for a positive TTE/TEE, and different cardiac cycle cutoffs for a positive TTE/TEE did not affect the accuracy of TTE. In a population of patients with cryptogenic stroke, a TTE that tests positive for RLS has a 95% probability of being a true positive., Conclusion: Transthoracic echocardiogram has a low sensitivity and extremely high specificity, making it a poor rule out test but an excellent rule in test for the detection of intracardiac RLS., (© 2014, Wiley Periodicals, Inc.)

Right-to-left shunting (RLS), usually through a patent foramen ovale (PFO), has been associated with migraine, cryptogenic stroke and hypoxemia. With emerging observational studies and clinical trials on the subject of PFO, there is a need for accurate diagnosis of PFO in patients being considered for transcatheter closure. While transesophageal echo (TEE) bubble study is the current standard reference for diagnosing PFO, transthoracic echo with second harmonic imaging (TTE-HI) may be a preferable screening test for RLS due to its high accuracy and non-invasiveness. The aim of this meta-analysis was to determine the accuracy of TTE-HI compared to TEE as the reference. A systematic review of Medline, Cochrane and Embase was done for all the prospective studies assessing for intracardiac RLS using TTE-HI compared to TEE as the reference; both TTE-HI and TEE were performed with a contrast agent and a maneuver to provoke RLS in all studies. A total of 15 studies with 1995 patients fulfilled the inclusion criteria. The weighted mean sensitivity and specificity for TTE-HI were 91 and 93 % respectively. Likewise, the positive and negative likelihood ratios were 13.52 and 0.13 respectively. TTE-HI is a reliable, non-invasive test with proficient diagnostic accuracies. The high sensitivity and specificity of TTE-HI make it a useful initial screening test for RLS. If the precise anatomy is required, then TEE can be obtained before scheduling a patient for transcatheter PFO closure.