Use of ultra-low dose computed tomography versus abdominal plain film for assessment of stone-free rates after shock-wave lithotripsy: implications on emergency room visits, surgical procedures, and cost-effectiveness.

The aims of this investigation were: (1) to compare residual stone-fragment (RSF) detection rates of ultra-low dose computed tomography (ULD-CT) and abdominal plain film (KUB) in urolithiasis patients undergoing shock-wave lithotripsy (SWL), and (2) to evaluate the downstream sequelae of utilizing these two disparate imaging pathways of differing diagnostic fidelity. A retrospective chart-review of patients undergoing SWL at two high-volume surgical centers was undertaken (2013-2016). RSF diagnostic rates of ULD-CT and KUB were assessed, and the impact of imaging modality used on subsequent emergency room (ER) visits, unplanned procedures, and cost-effectiveness was investigated. Adjusted analyses examined association between imaging modality used and outcomes, and Markov decision-tree analysis was performed to identify a cost advantageous scenario for ULD-CT over KUB. Of 417 patients studied, 57 (13.7%) underwent ULD-CT while the remaining 360 underwent KUB. The RSF rates were 36.8% and 22.8% in the ULD-CT and KUB groups, respectively (p = 0.019). A 5.6% and 18% of the patients deemed stone-free on ULD-CT and KUB, respectively, returned to the ER (p = 0.040). Similarly, 2.8% and 15.1% needed an unplanned surgery (p = 0.027). These findings were confirmed on multivariable analyses, Odds ratios CT-ULD versus KUB: 0.19 and 0.10, respectively, p < 0.05. With regards to cost-effectiveness, at low ULD-CT charges, the ULD-CT follow-up pathway was economically more favorable, but with increasing ULD-CT charges, the KUB follow-up pathway superseded. ULD-CT seems to provide a more 'true' estimate of stone-free status, and in consequence mitigates unwanted emergency and operating room visits by reducing untimely stent removals and false patient reassurances. Further, at low ULD-CT costs, it may also be economically more favorable.

Endocrine, Sexual Function, and Infertility Side Effects of Immune Checkpoint Inhibitor Therapy for Genitourinary Cancers.

PURPOSE OF REVIEW: Immune checkpoint therapy has grown in prominence in the last few decades and is being increasingly utilized in treatment of advanced cancers. Although information on toxicities of these drugs is forthcoming, not much is known regarding the toxicity profile of these drugs from a sexual function standpoint. We undertook the current review to appraise the literature for endocrine/sexual side effects of anti-PD-1/PD-L1 and anti-CTLA-4 therapy. RECENT FINDINGS: Our review included 32 articles and focused primarily on the programmed death (PD) pathway. We found that endocrine side effects after anti-PD-1/PD-L1 therapy are relatively rare, with hypothyroidism (range < 1 to 40%) and hypophysitis (range < 1 to 10%) being the two most common. None of the studies specifically commented on the infertility or sexual side effects of these drugs. However, two studies evaluating biochemical profiles of patients undergoing therapy with ipilimumab (a CTLA-4 inhibitor) or combination therapy (CTLA-4 + PD-1/PD-L1 inhibitors) noted that about < 1 to ~ 60% of the patients developed hypogonadotropic hypogonadism. None of the studies provided information regarding clinically meaningful sexual health endpoints such as libido, erectile function assessments, or sexual function-related quality of life. Endocrine side effects, although uncommon, are important and unique side effects of immune checkpoint therapy because they are often complex and can be life threatening. While side effects on sexual health may not be life threatening, they are lifestyle limiting. Thus, long-term follow-up, post-marketing surveillance, and future studies will need to elucidate the true rates of endocrine/sexual side effects and the mechanisms underlying them. This will aid in better counseling of the patients, as more of them undergo these novel immune checkpoint inhibitor therapies.