Extreme Percutaneous Nephrolithotomy: A Case Series of Procedures Requiring Five or More Access Tracts.

Introduction: Percutaneous nephrolithotomy (PCNL) remains the gold standard treatment for patients with complete staghorn stones, for which multiple access tracts may be required. In this study, we describe a series of patients undergoing PCNL with a minimum of five dilated access tracts. Materials and Methods: We performed a multi-institutional retrospective review of 10 patients with complete staghorn stones who underwent PCNL requiring five or more access tracts. We recorded patient demographics, stone characteristics postoperative complications, and stone-free rates (SFRs). The primary endpoint was any postoperative complication. Secondary endpoints included SFR, operative time, and length of stay. SFR was defined as absence of stones or residual fragments <4 mm. Results: A total of 10 patients from two institutions were included. Access tract number ranged from 5 to 11, and median stone volume was 233,042 mm3. Seven patients (70%) experienced postoperative complications, ranging from Clavien II to IVa. Three patients (30%) required blood transfusions. Median operative time was 312 minutes ranging from 180 to 560 minutes. Five patients (50%) were stone-free after the initial procedure. Of those with residual fragments, 4 (40%) required reoperation to be rendered stone-free. Median length of stay was 2.5 days, with a range of 1-6 days. Conclusion: To our knowledge, this is the largest series of patients undergoing PCNL with five or more access tracts reported to date. This study confirms that PCNL with five or more tracts is feasible and relatively safe, albeit with a high rate of complications in the immediate postoperative period.

Impact of exercise on continence in prostate cancer patients post robotic assisted radical prostatectomy: a systematic review.

INTRODUCTION: Urinary incontinence is one of the most common long term side effects after robotic prostatectomy (RALP), and significantly impacts patient quality of life. Pelvic floor muscle training (PFMT) has been a standard part of the urologist's armamentarium for maximizing continence outcomes post-op. Recently, aerobic and resistance exercises have been described as improving functional outcomes post RALP. We performed a systematic review to determine the influence of exercise, in the form of PFMT, aerobic exercise, and resistance training, on incontinence post-RALP. MATERIALS AND METHODS: This systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with database searches performed on January 14, 2022 and again on August 10, 2022 to account for any new publications. The search identified 1675 papers. Of the 1675 papers, 1007 were found to be duplicates, leaving 668 total studies for screening. Of the 668 papers, nine met all inclusion criteria. Of the nine, four studies presented data from patients who had undergone RALP and were included in the final descriptive systematic review. RESULTS: Sayilan et al. and Milios et al. showed postoperative PFMT and physical activity resulted in significantly improved continence outcomes at 1 and 6 months and 2, 6, and 12 weeks postoperatively, respectively. Heydenreich et al. combined PFMT with an oscillating rod therapy, which was found to significantly improve both postoperative urinary continence and health related quality of life compared to PFMT and relaxation techniques alone. On the contrary, Goode et al. examined delivery of exercise information and demonstrated no difference in continence outcomes between focused telehealth PFMT program and generic prostate cancer education. CONCLUSION: Pelvic floor muscle training, with or without adjunct therapies, results in improved continence outcomes post RALP. Supervised training programs may or may not accelerate this finding. There is no recent literature to support or refute the benefit of aerobic exercise or resistance training on reducing post-prostatectomy incontinence after RALP.

Early perioperative outcomes of single-port compared to multi-port robot-assisted laparoscopic partial nephrectomy.

Single-port (SP) robot-assisted laparoscopic partial nephrectomy (RAPN) is a promising new technique. The aim of this study was to compare surgical and oncological outcomes of SP-RAPN to the multi-port (MP) surgical platform. This is a retrospective, cohort-based study involving patients undergoing SP-RAPN between 2019 and 2020 at a single institution. Demographic, preoperative, surgical, and postoperative outcomes data were gathered and compared to a 1-to-1 matched MP cohort. A total of 50 SP and 50 matched MP cases were included. Length of surgery and ischemia time were not statistically significant between the two cohorts; however, estimated blood loss (EBL) was significantly lower in the SP group than in the MP (IQR 25-50 vs. IQR 50-100 mL, p = 0.002). No differences were seen in regard to the 30-day readmission rate, surgical margin status, pain scores, and complications between the two approaches. We found no statistically significant differences in positive margins, pain score, length of stay, or readmission rate between matched SP and MP patients. These data support the viability of the SP technique as an alternative to MP-RAPN when in the hands of experienced surgeons.

Non-Coding RNAs Set a New Phenotypic Frontier in Prostate Cancer Metastasis and Resistance.

Prostate cancer (PCa) mortality remains a significant public health problem, as advanced disease has poor survivability due to the development of resistance in response to both standard and novel therapeutic interventions. Therapeutic resistance is a multifaceted problem involving the interplay of a number of biological mechanisms including genetic, signaling, and phenotypic alterations, compounded by the contributions of a tumor microenvironment that supports tumor growth, invasiveness, and metastasis. The androgen receptor (AR) is a primary regulator of prostate cell growth, response and maintenance, and the target of most standard PCa therapies designed to inhibit AR from interacting with androgens, its native ligands. As such, AR remains the main driver of therapeutic response in patients with metastatic castration-resistant prostate cancer (mCRPC). While androgen deprivation therapy (ADT), in combination with microtubule-targeting taxane chemotherapy, offers survival benefits in patients with mCRPC, therapeutic resistance invariably develops, leading to lethal disease. Understanding the mechanisms underlying resistance is critical to improving therapeutic outcomes and also to the development of biomarker signatures of predictive value. The interconversions between epithelial-to-mesenchymal transition (EMT) and mesenchymal-to-epithelial transition (MET) navigate the prostate tumor therapeutic response, and provide a novel targeting platform in overcoming therapeutic resistance. Both microRNA (miRNA)- and long non-coding RNA (lncRNA)-mediated mechanisms have been associated with epigenetic changes in prostate cancer. This review discusses the current evidence-based knowledge of the role of the phenotypic transitions and novel molecular determinants (non-coding RNAs) as contributors to the emergence of therapeutic resistance and metastasis and their integrated predictive value in prostate cancer progression to advanced disease.

Supracostal Upper Pole Endoscopic-Guided Prone Tubeless "Maxi-Percutaneous Nephrolithotomy": A Contemporary Evaluation of Complications.

OBJECTIVE: To develop a contemporary complication profile for supracostal upper pole endoscopic-guided prone tubeless "maxi-PCNL" to evaluate the need for change. MATERIALS/METHODS: We identified patients undergoing supracostal upper pole percutaneous nephrolithotomy (PCNL) by a single surgeon at a high volume tertiary care stone center between October 2010 and April 2017. Access was obtained with ureteroscopic guidance. The tract was dilated to 30F through radial balloon dilation. All cases were tubeless with ureteral stent for 5-7 days. Preoperative, operative, and postoperative variables were recorded. We recorded need for blood transfusion, angioembolization, thoracentesis and/or chest tube insertion, intensive care unit (ICU) admission, and 30-day readmission. RESULTS: A total of 375 patients were included. Mean age was 57 years and 59% were women. Mean body mass index was 33 kg/m2. Mean stone burden was 35 mm. The mean operative time was 99 minutes. Median stay was 1 day. There were no complications because of prone position. Postoperative complications included pleural drain (4%), transfusion (6.7%), and angioembolization (0.5%). Transfusion rates were higher in patients with preoperative hemoglobin <10 mg/dL (28% vs 5.1%, p < 0.00001). Rate of ICU admission and readmission was 4.5% and 7.5%, respectively. Transfusion (p ≤ 0.001), pleural drain (p = 0.0002), and readmission (p = 0.030) were associated with ICU admission. Male gender was associated with readmission (10.3% vs 5.5%, odds ratio = 3.1, p = 0.012). CONCLUSIONS: In supracostal upper pole endoscopic-guided prone tubeless Maxi-PCNL, pulmonary complication rate was lower than previously reported and bleeding complications were comparable with mini-PCNL series. Establishing contemporary complication rates will help to assess the need for evolution to mini-PCNL or lower pole supine PCNL.

Increased Use of Cystectomy in Patients 75 and Older: A Contemporary Analysis of Survival and Perioperative Outcomes From the National Cancer Database.

OBJECTIVE: To assess national utilization patterns for cystectomy and nonsurgical treatments for elderly patients with muscle-invasive bladder cancer. METHODS: From the National Cancer Database, we identified patients ≥75 years old with T2-T4, non-metastatic urothelial carcinoma between 2003 and 2012. Patients were grouped by treatment: cystectomy, chemoradiation, or nonstandard treatment. Cochran-Armitage trend test was used to evaluate time trends for treatments and perioperative outcomes. Kaplan-Meier and Cox regression tests were used for overall survival analyses. RESULTS: Of 18,945 patients with muscle-invasive bladder cancer, 3898 (21%) underwent cystectomy. Cystectomy use increased from 14% in 2003 to 24% in 2012 (P <.01 for overall trend). Inpatient length of stay after cystectomy decreased over time (P = .02), whereas 30-day readmission and mortality rates remained stable (P = .86 and P = .73, respectively). Median overall survival (95% confidence interval [CI]) was 26.5 (23.1-28.9) months for cystectomy, 22.1 (20.1-24.2) months for chemoradiation, and 12.0 (11.3-12.7) months for nonstandard treatment (P <.01). The survival benefit of cystectomy compared with nonstandard treatment was seen regardless of comorbidity burden. In the Cox analysis, the hazard of death was 0.69 (95% CI 0.63-0.75, P <.01) for cystectomy and 0.75 (95% CI 0.70-0.82, P <.01) for chemoradiation, compared with nonstandard treatment. CONCLUSION: Cystectomy use is increasing in elderly patients, with stable or improved perioperative outcomes and improved survival compared with nonstandard treatment. These findings support continued use of cystectomy in appropriately selected elderly patients.

Adolescent oxycodone self administration alters subsequent oxycodone-induced conditioned place preference and anti-nociceptive effect in C57BL/6J mice in adulthood.

Adolescent and young adult abuse of short-acting MOP-r agonists such as oxycodone is a pressing public health issue. Few preclinical studies have examined how adolescent exposure to oxycodone impacts its effects in the transition to adulthood. OBJECTIVE: To determine in mice how chronic adolescent oxycodone self-administration (SA) affects subsequent oxycodone-induced conditioned place preference (CPP), locomotor activity, and anti-nociception once mice reach early adulthood. METHODS: Adolescent C57BL/6J male mice (4 weeks old, n = 6-11) and adult mice (10 weeks old, n = 6-10) were surgically implanted with indwelling jugular catheters. Mice then acquired oxycodone self-administration (14 consecutive 2-hr daily sessions; 0.25 mg/kg/infusion) followed by a 14-day drug-free (withdrawal) period in home cage. After the 14-day drug-free period, mice underwent a 10-day oxycodone CPP procedure (0, 1, 3, 10 mg/kg i.p.) or were tested for acute oxycodone-induced antinociception in the hot plate assay (3.35, 5, 7.5 mg/kg i.p.). RESULTS: Mice that self-administered oxycodone during adolescence exhibited greater oxycodone-induced CPP (at the 3 mg/kg dose) than their yoked saline controls and mice that self-administered oxycodone during adulthood. Oxycodone dose-dependently increased locomotor activity, but sensitization developed only to the 3 mg/kg in the mice that underwent oxycodone self-administration as adolescents. Mice that self-administered oxycodone as adolescents decreased in the anti-nociceptive effects of oxycodone in one dose (5 mg/kg), whereas animals that self-administered oxycodone as adults did not show this effect. CONCLUSION: Chronic adolescent oxycodone self-administration led to increased oxycodone-induced CPP (primarily 1 and 3 mg/kg, i.p.) and reduced antinociceptive effect of oxycodone (5 mg/kg, i.p.) in adulthood.