Improving Compliance with 24-H Urine Collections: Understanding Inadequacies in the Collection Process and Risk Factors for Poor Compliance.

PURPOSE OF REVIEW: The purpose of this review paper is to describe the 24-h urine collection in terms of its utility, collection process, and common problems with its acquisition. RECENT FINDINGS: Although 24-h urine collections are standard of care for high-risk stone formers, several nuances in test acquisition including inaccurate urine collections 50% of the time and poor patient compliance limit its potential utility. Compliance in obtaining 24-h urine collections has been shown to be improved in patients who have not undergone surgical treatment of urinary calculi, patients with metabolic stone disease or family history of stone disease, Caucasian ethnicity, and in those with more sedentary occupations. Studies show conflicting data of compliance regarding patient age and gender. Physicians must understand the difficulties regarding 24-h urine collections including patient compliance, variability between collections, and complexities with interpretation to best utilize this tool in guiding clinical management for the treatment of nephrolithiasis.

Dual-Energy CT for Urinary Stone Evaluation.

PURPOSE OF REVIEW: Conventional CT imaging is an excellent tool for the diagnosis of nephrolithiasis however is limited in its ability to detect stone composition. Dual-energy CT (DECT) scans have demonstrated promise in overcoming this limitation. We review the current utility of DECT in nephrolithiasis. RECENT FINDINGS: DECT is superior to conventional CT in differentiating uric acid stones from non-uric acid stones, with numerous studies reporting sensitivities and specificities approaching > 95%. Dose reduction protocols incorporating low-dose CT scans are commonly used, providing significantly lower effective radiation doses compared to conventional CT. DECT remains an effective diagnostic tool in patients with large body habitus. DECT can accurately detect uric acid stones, which can help guide which stones may be suitable to medical dissolution. Further studies evaluating the effectiveness of DECT in guiding management of patients with nephrolithiasis can help to promote its widespread use.

Do Urinary Cystine Parameters Predict Clinical Stone Activity?

PURPOSE: An accurate urinary predictor of stone recurrence would be clinically advantageous for patients with cystinuria. A proprietary assay (Litholink, Chicago, Illinois) measures cystine capacity as a potentially more reliable estimate of stone forming propensity. The recommended capacity level to prevent stone formation, which is greater than 150 mg/l, has not been directly correlated with clinical stone activity. We investigated the relationship between urinary cystine parameters and clinical stone activity. MATERIALS AND METHODS: We prospectively followed 48 patients with cystinuria using 24-hour urine collections and serial imaging, and recorded stone activity. We compared cystine urinary parameters at times of stone activity with those obtained during periods of stone quiescence. We then performed correlation and ROC analysis to evaluate the performance of cystine parameters to predict stone activity. RESULTS: During a median followup of 70.6 months (range 2.2 to 274.6) 85 stone events occurred which could be linked to a recent urine collection. Cystine capacity was significantly greater for quiescent urine than for stone event urine (mean ± SD 48 ± 107 vs -38 ± 163 mg/l, p <0.001). Cystine capacity significantly correlated inversely with stone activity (r = -0.29, p <0.001). Capacity also correlated highly negatively with supersaturation (r = -0.88, p <0.001) and concentration (r = -0.87, p <0.001). Using the suggested cutoff of greater than 150 mg/l had only 8.0% sensitivity to predict stone quiescence. Decreasing the cutoff to 90 mg/l or greater improved sensitivity to 25.2% while maintaining specificity at 90.9%. CONCLUSIONS: Our results suggest that the target for capacity should be lower than previously advised.

Endoscopic Management of Ureteral Strictures: an Update.

PURPOSE OF REVIEW: This review focuses on the role of endoscopic treatment of ureteral stricture disease (USD) in the era of minimally invasive surgery. RECENT FINDINGS: There is a relative paucity of recent literature regarding the endoscopic treatment of USD. Laser endopyelotomy and balloon dilation are associated with good outcomes in treatment-naïve patients with short (< 2 cm), non-ischemic, benign ureteral strictures with a functional renal unit. If stricture recurs, repetitive dilation and laser endopyleotomy is not recommended, as success rates are low in this scenario. Patients with low-complexity ureteroenteric strictures and transplant strictures may benefit from endoscopic treatment options, although formal reconstruction offers higher rates of success. Formal ureteral reconstruction remains the gold-standard treatment for ureteral stricture disease as it is associated with higher rates of complete resolution. However, in carefully selected patients, endoscopic treatment modalities provide a low-cost, low-morbidity alternative.

Extracorporeal Shock Wave Therapy: Current Perspectives and Future Directions.

PURPOSE OF REVIEW: Since its introduction, extracorporeal shock wave lithotripsy (ESWL) has undergone a variety of changes; however, it remains one of the most utilized treatment modalities for urolithiasis. The goal of this review is to provide the practicing urologist an update on contemporary trends, new technologies, and related controversies in utilizing ESWL for stone treatment. RECENT FINDINGS: ESWL use has come under scrutiny with a shift in focus to cost-effectiveness and healthcare outcomes. Fortunately, advances in lithotripter technology have spawned several generations of devices that strive to improve stone-free rates and decrease complications. Most of all, a focus on patient selection criteria has helped improve procedural success. Years of experience utilizing ESWL for stone treatment have helped urologists better optimize its use and minimize complications. Improvements in technique along with more stringent patient and stone selection have helped ESWL remain a mainstay in the treatment of stone disease.

Equivocal ureteropelvic junction obstruction on diuretic renogram--should minimally invasive pyeloplasty be offered to symptomatic patients?

PURPOSE: Equivocal ureteropelvic junction obstruction refers to clinical symptoms and/or other radiological suggestions of possible ureteropelvic junction obstruction but with inconclusive results of obstruction on diuretic renogram. We evaluated long-term outcomes in patients with equivocal ureteropelvic junction obstruction treated with minimally invasive pyeloplasty. MATERIALS AND METHODS: We retrospectively analyzed the records of 125 consecutive patients who underwent minimally invasive pyeloplasty as performed by a single surgeon from May 2004 to July 2013. Of 98 patients with followup those with more than 6-month followup were included in analysis. Equivocal ureteropelvic junction obstruction, defined as half-life less than 20 minutes on diuretic renogram, was identified in 23 patients. All patients underwent transperitoneal minimally invasive pyeloplasty. We evaluated patient demographics, preoperative and postoperative symptoms and renal function. RESULTS: The 16 female and 7 male patients with equivocal ureteropelvic junction obstruction had flank pain and associated hydronephrosis on imaging. At a median followup of 20.2 months (range 7 to 75) 95.7% of patients with equivocal obstruction achieved complete symptom resolution. Mean ± SD preoperative and postoperative half-life was 14.1 ± 3.7 and 7.4 ± 4.2 minutes, respectively, for an improvement of 6.7 minutes (p < 0.001). In 1 patient (4.3%) with equivocal obstruction of a complicated iatrogenic etiology treatment ultimately failed postoperatively and endopyelotomy was required. There was no statistically significant difference in clinical or radiological success between the equivocal obstruction group and the 75 patients treated with minimally invasive pyeloplasty for definitive ureteropelvic junction obstruction (p = 0.44 and 0.07, respectively). CONCLUSIONS: In patients with radiographic equivocal ureteropelvic junction obstruction and flank pain minimally invasive pyeloplasty efficaciously provides symptomatic relief and functional preservation. Results are comparable to those in patients with high grade obstruction.

Differences in 24-h urine composition between nephrolithiasis patients with and without diabetes mellitus.

OBJECTIVES: To examine the differences in 24-h urine composition between nephrolithiasis patients with and without diabetes mellitus (DM) in a large cohort of stone-formers and to examine differences in stone composition between patients with and without DM. PATIENTS AND METHODS: A retrospective review of 1117 patients with nephrolithiasis and a 24-h urine analysis was completed. Univariable analysis of 24-h urine profiles and multivariable linear regression models were performed, comparing patients with and without DM. A subanalysis of patients with stone analysis data available was performed, comparing the stone composition of patients with and without DM. RESULTS: Of the 1117 patients who comprised the study population, 181 (16%) had DM and 936 (84%) did not have DM at the time of urine analysis. Univariable analysis showed significantly higher total urine volume, citrate, uric acid (UA), sodium, potassium, sulphate, oxalate, chloride, and supersaturation (SS) of UA in individuals with DM (all P < 0.05). However, patients with DM had significantly lower SS of calcium phosphate and pH (all P < 0.05). Multivariable analysis showed that patients with DM had significantly lower urinary pH and SS of calcium phosphate, but significantly greater citrate, UA, sulphate, oxalate, chloride, SSUA, SS of calcium oxalate, and volume than patients without DM (all P < 0.05). Patients with DM had a significantly greater proportion of UA in their stones than patients without DM (50.2% vs 13.5%, P < 0.001). CONCLUSIONS: DM was associated with multiple differences on 24-h urine analysis compared with those without DM, including significantly higher UA and oxalate, and lower pH. Control of urinary UA and pH, as well as limiting intake of dietary oxalate may reduce stone formation in patients with DM.

Diet: from food to stone.

Dietary factors have been shown to influence urine composition and modulate the risk of kidney stone disease. With the rising prevalence of stone disease in many industrialized nations, dietary modification as therapy to improve lithogenic risk factors and prevent stone recurrence has gained appeal, as it is both relatively inexpensive and safe. While some dietary measures, such as a high fluid intake, have been shown in long-term randomized clinical trials to have durable effectiveness, other dietary factors have been subjected to only short-term clinical or metabolic studies and their efficacy has been inferred. Herein, we review the current literature regarding the role of diet in stone formation, focusing on both the effect on urinary stone risk factors and the effect on stone recurrence.

Single- versus dual-console robot-assisted radical prostatectomy: impact on intraoperative and postoperative outcomes in a teaching institution.

OBJECTIVE: To compare the outcomes of robotic-assisted laparoscopic prostatectomy (RALP) using a dual versus single-console system in a resident training program using intraoperative, perioperative and postoperative measures. METHODS: Patients with PCa who underwent RALP prior to and after implementing a dual-console system at an academic institution were reviewed from 2006-2012. All surgeries were performed by a single-faculty surgeon well after the learning curve was established. In all cases, chief residents participated in the surgery and performed progressively more portions. Demographic, intraoperative and pathologic parameters were obtained. Continence and erectile function were assessed at 6 and 12 months. Postoperative complications were graded using the Clavien-Dindo classification. Predictors of outcomes on univariate analysis were included in multivariate logistic or linear models. RESULTS: Of 381 patients, 185 and 196 underwent single- or dual-console RALP, respectively. There was a significant decrease in mean operative time using the dual-console system (222 vs. 171 min, p < 0.0001) as well as in the incidence of intraoperative complications (8.65 vs. 1.53%, p < 0.0001) and postoperative complications (14.1 vs. 6.63%, p = 0.03.) Complications of Clavien grade ≥3a occurred more frequently with a single-console system (7 vs. 1%, p = 0.003.) Differences persisted when controlling for potential confounders by multivariate regression. Postoperative measures of continence, erectile function and the rate of biochemical recurrence were similar between cohorts. CONCLUSIONS: When training resident surgeons to perform RALP, a dual-console system may improve intraoperative and perioperative outcomes. The dual-console may represent a safer, more efficient modality for robotic surgical education as compared to a single-console system.

Association of serum biochemical metabolic panel with stone composition.

INTRODUCTION: To determine the association of the basic metabolic panel with stone type. METHODS: The present study was a retrospective review of 492 stone formers with both stone composition analysis and basic metabolic panel available. Analysis of a basic metabolic panel across stone types was carried out using Fisher's exact test and analysis of variance. Multinomial logistic regression was used to predict stone type based on a basic metabolic panel. RESULTS: A total of 272 (55%) patients had predominantly calcium oxalate stones, 100 (21%) had uric acid stones, 93 (19%) had calcium phosphate stones, 16 (3%) had mixed stones and 11 (2%) had other types of stones. Uric acid stone formers had the highest serum glucose, blood urea nitrogen and creatinine levels. Calcium oxalate stone formers had the highest serum sodium. No significant differences in mean serum calcium levels across different stone types were identified. The predicted risk of uric acid stone over the other stone types increased with an increase in serum glucose and decreased with an increase in carbon dioxide levels. The predicted risk of calcium oxalate stones increased with an increase in serum sodium and chloride levels. The predicted risk of calcium phosphate and oxalate stones over the other stone types increased with an increase in serum calcium levels. The overall accuracy of the basic metabolic panel alone to predict stone type was 59%. CONCLUSION: A basic metabolic panel alone or in combination with 24-h urinalysis and demographics does not accurately predict stone type. However, it can be used in combination with other variables to predict stone composition.

Stenting for malignant ureteral obstruction: Tandem, metal or metal-mesh stents.

Extrinsic malignant compression of the ureter is not uncommon, often refractory to decompression with conventional polymeric ureteral stents, and frequently associated with limited survival. Alternative options for decompression include tandem ureteral stents, metallic stents and metal-mesh stents, though the preferred method remains controversial. We reviewed and updated our outcomes with tandem ureteral stents for malignant ureteral obstruction, and carried out a PubMed search using the terms "malignant ureteral obstruction," "tandem ureteral stents," "ipsilateral ureteral stents," "metal ureteral stent," "resonance stent," "silhouette stent" and "metal mesh stent." A comprehensive review of the literature and summary of outcomes is provided. The majority of studies encountered were retrospective with small sample sizes. The evidence is most robust for metal stents, whereas only limited data exists for tandem or metal-mesh stents. Metal and metal-mesh stents are considerably more expensive than tandem stenting, but the potential for less frequent stent exchanges makes them possibly cost-effective over time. Urinary tract infections have been associated with all stent types. A wide range of failure rates has been published for all types of stents, limiting direct comparison. Metal and metal-mesh stents show a high incidence of stent colic, migration and encrustation, whereas tandem stents appear to produce symptoms equivalent to single stents. Comparison is difficult given the limited evidence and heterogeneity of patients with malignant ureteral obstruction. It is clear that prospective, randomized studies are necessary to effectively scrutinize conventional, tandem, metallic ureteral and metal-mesh stents for their use in malignant ureteral obstruction.

Prompt management of anastomotic leak or acute obstruction after minimally invasive pyeloplasty with percutaneous nephrostomy preserves outcomes.

PURPOSE: Urine leak or obstruction in the early postoperative period is a worrisome complication of pyeloplasty. Suboptimal management may risk long-term success. We evaluated percutaneous nephrostomy to manage complications of minimally invasive pyeloplasty. MATERIALS AND METHODS: We retrospectively analyzed the records of 125 patients who underwent minimally invasive pyeloplasty performed by a single surgeon from May 2004 to May 2013. All complications were catalogued and patients with anastomotic urine leakage or postoperative obstruction were identified. Less than 7 days postoperatively percutaneous nephrostomy was done in each case. Surgical success was defined as resolution of flank pain and/or improved half-time (less than 20 minutes) on diuretic renogram. RESULTS: Early percutaneous nephrostomy placement was required in 12 patients (9.6%) for symptomatic obstruction (6) or anastomotic urine leakage (6) a median of 4.5 days (range 2 to 7) postoperatively. Percutaneous nephrostomies remained in place a median of 9.5 days (range 5 to 42). Median followup was 15 months (range 2 to 80). Mean half-time was 36.4 minutes preoperatively and 11.1 minutes postoperatively. Continued postoperative obstruction (half-time greater than 20 minutes) was documented in 1 (8%) and 13 patients (11.5%) who did and did not require percutaneous nephrostomy placement, respectively. There was no statistical difference in radiological and clinical success rates between the percutaneous nephrostomy group and the 113 patients in whom minimally invasive pyeloplasty was uncomplicated (p = 0.74 and 0.28, respectively). CONCLUSIONS: In patients treated with minimally invasive pyeloplasty aggressive management of acute urinary complications with percutaneous nephrostomy placement preserved radiographic and symptomatic outcomes that were comparable to those in patients without complications.

The surgical spectacle: a survey of urologists viewing live case demonstrations.

OBJECTIVE: To evaluate perspectives of urologists viewing live case demonstrations (LCD) and taped case demonstrations (TCD). METHOD: A 15-question anonymous survey was distributed to attendees of the live surgery session at the American Urological Association 2012 national meeting (Atlanta) and the second International Challenges in Endourology meeting (Paris). RESULTS: Of 1000 surveys distributed, 253 were returned completed (response rate 25%). Nearly half of respondents were in the academic practice setting and nearly 75% were beyond training. Just over 30% had performed a LCD previously. The perceived benefit of an LCD was greater than unedited and edited videos (chi-squared P = 0.014 and P < 0.001, respectively). Nearly no one selected 'not helpful' and a few selected 'minimally helpful' for any of the three forms of demonstration. Most respondents identified that opportunity to ask questions (61%) and having access to the full unedited version (72%), two features inherent to LCD, improved upon the educational benefit of edited videos. Most (78%) identified LCD as ethical. However, those that did not perceived lower educational benefit from LCD (P = 0.019). A slim majority (58%) would allow themselves or a family member to be a patient of a LCD and the vast majority (86%) plan to transfer knowledge gained at the LCD session into their practice. CONCLUSIONS: Urologists who attended these LCD sessions identified LCDs as beneficial and applicable to their practice. LCDs are preferred over videos. The large majority considers LCD ethical, although not as many would volunteer themselves for LCD. Further studies are necessary to determine if there is actual benefit from LCD over TCD to patient care.

Masked pneumothorax: risk of valveless trocar systems.

PURPOSE: Unlike traditional valved trocars, the valveless trocar maintains pneumoperitoneum during laparoscopy by forming a CO(2) curtain at the proximal end of the trocar. This gas barrier instantaneously maintains exact intraperitoneal pressure that yields to the transient physiological changes seen with breathing. Due to this different mechanism of action, pneumothorax development may be masked by the valveless trocar system. MATERIALS AND METHODS: We retrospectively reviewed 850 transperitoneal laparoscopic kidney and adrenal surgeries in which a valveless trocar system was used to determine any record of pneumothorax detected intraoperatively or postoperatively. A patient with pneumothorax was considered a case and anesthetic parameters were reviewed. A matched control group was generated from patients treated with transperitoneal laparoscopic kidney and adrenal surgery using the valveless trocar with no complications. RESULTS: Pneumothorax was diagnosed in 10 patients (1.2%). Two cases were the result of intentional excision of the diaphragm, which were repaired intraoperatively, while 8 were not recognized until the postoperative period. Five of the patients (63%) with unintentional pneumothorax required chest tube placement for a mean of 2.4 days. The remaining 3 patients (37%) were treated conservatively and followed with serial chest x-rays. The only anesthetic variable that was significantly different between the groups was Δ end tidal CO(2) with greater fluctuations in end tidal CO(2) in the pneumothorax group than in controls (p = 0.03). CONCLUSIONS: Pneumothorax is a rare complication of laparoscopic urological surgery that is usually recognized intraoperatively through physiological changes. Valveless trocar systems mask these findings and can delay identification until the postoperative period.

Using 24-hour urinalysis to predict stone type.

PURPOSE: We determined the accuracy of 24-hour urinalysis in predicting stone type and identify the associations between 24-hour urine elements with stone type. MATERIALS AND METHODS: We performed a retrospective review of 503 stone formers with stone composition analysis and 24-hour urinalysis available. Analysis of 24-hour urine elements across stone types was performed using Fisher's exact test and ANOVA. Multinomial logistic regression was used to predict stone type based on 24-hour urinalysis. RESULTS: A total of 280 (56%) patients had predominantly calcium oxalate, 103 (20%) had uric acid, 93 (19%) had calcium phosphate, 16 (3%) had mixed and 11 (2%) had other stone types. There were several significant patient characteristics and 24-hour urinalysis differences across stone type groups. The statistical model predicted 371 (74%) calcium oxalate, 78 (16%) uric acid, 52 (10%) calcium phosphate, zero mixed and 2 (less than 1%) other stone types. The model correctly predicted calcium oxalate stones in 85%, uric acid in 51%, calcium phosphate in 31%, mixed in 0% and other stone types in 18% of the cases. Of the predicted stone types, correct predictions were 61%, 69%, 56% and 71% for calcium oxalate, uric acid, calcium phosphate and other stones types, respectively. The overall accuracy was 64%. Plots were used to explore the associations between each 24-hour urine element with each predicted stone type adjusted for all the others urinary elements. CONCLUSIONS: A 24-hour urinalysis alone does not accurately predict stone type. However, it may be used in conjunction with other variables to predict stone composition.

Percutaneous Nephrolithotomy Access: A Meta-Analysis Comparing Access by Urologist vs Radiologist.

Introduction: Percutaneous nephrolithotomy is a minimally invasive procedure indicated for the management of staghorn calculi or renal calculi >2.0 cm. Percutaneous renal access is a critical step in this procedure and can be performed by either urologists or interventional radiologists. The purpose of this study is to perform a meta-analysis to compare outcomes between urologist and interventional radiologist-mediated access. Methods: An electronic literature search was conducted to identify studies comparing urologist- and interventional radiologist-acquired access. Studies must have included both urologist- and intervention radiologist-acquired access data but were excluded if (1) not in English; (2) abstract without full text; (3) unable to determine who acquired access; and (4) only included either urologist or interventional radiologist data. Meta-analysis comparison was generated with the Review Manager 5.4 software. Results: After screening the abstracts and title, 55 relevant studies were identified. Nine articles were utilized in the meta-analysis. Urologist-acquired access was associated with a greater stone-free rate (risk ratio [RR] = 1.10; 95% confidence interval [CI], 1.01-1.20), a reduction in major complications (RR = 0.69; 95% CI, 0.53-0.92), and a shorter hospital stay (mean difference -0.40; 95% CI, -0.64 to -0.16) in comparison with radiologist-acquired access. Urologist-acquired access was associated with greater blood loss (mean difference 0.46; 95% CI, 0.32-0.60) when compared with interventional radiology-acquired access. No significant differences were found with regard to unusable access, multiple tracts, supracostal access, ancillary procedure requirement, operative time, minor complications, and transfusions. Conclusions: Urologist-acquired access may be associated with a higher stone-free rate and a reduction in major complications, whereas interventional radiologist-mediated access may be associated with a reduction in blood loss, despite similar transfusion rates.

Fulguration for Hunner ulcers: long-term clinical outcomes.

PURPOSE: Cystoscopic fulguration of Hunner ulcers in patients with interstitial cystitis/bladder pain syndrome is a recommended therapy because it has the potential to rapidly ameliorate symptoms. We reviewed our experience with Hunner ulcer fulguration. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with interstitial cystitis/bladder pain syndrome treated with Hunner ulcer fulguration who were seen at our pelvic pain referral center between 1993 and 2011. Patient demographics, clinical characteristics, intraoperative findings and long-term clinical outcomes were assessed. The Kaplan-Meier product limit method was used to evaluate time to the first repeat procedure. Potential risk factors associated with repeat procedures were examined using the log rank test. RESULTS: A total of 106 procedures were performed in 59 patients. The mean history of illness before first fulguration was 5 years and overall median followup was 44.8 months (IQR 52.2), as calculated from the time of the first fulguration. There were no significant associations between time to the first repeat procedure and any demographic criteria analyzed, patient reported interstitial cystitis/bladder pain syndrome associated conditions or the number of Hunner ulcers fulgurated at the initial session. A total of 27 patients (45.8%) required repeat fulguration. Time to event analysis demonstrated that 12 months after the initial fulguration 13.1% of patients required repeat treatment. This rate increased to 57.2% at 48 months, when it plateaued. CONCLUSIONS: Fulguration of Hunner ulcers can be an effective treatment for patients with interstitial cystitis/bladder pain syndrome and focal Hunner ulcers involving less than 25% of the bladder who have symptoms refractory to other therapies. However, a significant subset requires repeat treatment and some patients may even go on to require cystectomy.

Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions.

What's known on the subject? and What does the study add? Nearly 90% of patients with interstitial cystitis/bladder pain syndrome (IC/BPS) report sensitivities to a wide variety of dietary comestibles. Current questionnaire-based literature suggests that citrus fruits, tomatoes, vitamin C, artificial sweeteners, coffee, tea, carbonated and alcoholic beverages, and spicy foods tend to exacerbate symptoms, while calcium glycerophosphate and sodium bicarbonate tend to improve symptoms. At present we recommend employing a controlled method to determine dietary sensitivities, such as an elimination diet, in order to identify sensitivities while at the same time maintain optimal nutritional intake. We review current literature with regard to diet's effect upon IC/BPS and common comorbidities (irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, neuropathic pain, vulvodynia, and headache) with a focus upon questionnaire-based investigations. We discuss the pathologic mechanisms that may link diet and IC/BPS related-pain, concentrating upon specific comestibles such as acidic foods, foods high in potassium, caffeine, and alcohol. Up to 90% of patients with interstitial cystitis/bladder pain syndrome (IC/BPS) report sensitivities to a wide variety of comestibles. Pathological mechanisms suggested to be responsible for the relationship between dietary intake and symptom exacerbation include peripheral and/or central neural upregulation, bladder epithelial dysfunction, and organ 'cross-talk', amongst others. Current questionnaire-based data suggests that citrus fruits, tomatoes, vitamin C, artificial sweeteners, coffee, tea, carbonated and alcoholic beverages, and spicy foods tend to exacerbate symptoms, while calcium glycerophosphate and sodium bicarbonate tend to improve symptoms. Specific comestible sensitivities varied between patients and may have been influenced by comorbid conditions. This suggests that a controlled method to determine dietary sensitivities, such as an elimination diet, may play an important role in patient management.

Symptom profile variability of interstitial cystitis/painful bladder syndrome by age.

UNLABELLED: Study Type--Diagnostic (symptom prevalence). Level of Evidence 2b. What's known on the subject? And what does the study add? Symptom variability is profound in the population of patients diagnosed with interstitial cystitis and painful bladder syndrome because these diagnoses represent a very heterogeneous patient population. Recently, younger patients are being diagnosed with these pain syndromes, without any specific investigation into the symptoms they experience. We identified that patients diagnosed with interstitial cystitis and painful bladder syndrome have variable clinical symptom profiles depending on the age at the time of their diagnosis. Dyspareunia, external genitalia pain, urgency, frequency and dysuria were more common in younger patients whereas nocturia, urinary incontinence and the presence of Hunner's ulcers were more common in older patients. Better defining symptom profiles for patients at the time of evaluation may potentially aid in more accurate and expedited diagnosis of these conditions, particularly in the youngest patient population which is being recognized more commonly in recent times. OBJECTIVE: • To investigate the clinical profile differences among patients with interstitial cystitis/painful bladder syndrome (IC/PBS) based upon age at the time of diagnosis from childhood into the geriatric age group. METHODS: • An analysis of 268 patients with IC/PBS seen between 1990 and 2008 was performed. • Three age cohorts were analysed: <30 years, ≥30 years but <60 years, and ≥60 years of age at time of diagnosis. • Patient demographics, disease characteristics and IC/PBS-associated symptoms were compared across the three groups. RESULTS: • Of the 268 patients, 60 were <30 years of age at the time of IC diagnosis (median 22, range 11-29), 105 were ≥30 but <60 years (median 48, range 30-59) and 103 patients were ≥60 years of age (median 69, range 60-88). • Of the patients in the youngest, middle and oldest age cohorts: 12.0, 42.0 and 39.8% had Hunner's ulcers, respectively (P<0.001). • Dyspareunia and external genitalia pain were more common in the youngest age cohort, P<0.001 and P=0.001, respectively. • Urinary urgency (P=0.033), frequency (P=0.006) and dysuria (P<0.001) were also more common in patients diagnosed before 30 years of age. • The reported rate of nocturia and urinary incontinence increased with age, P=0.002 and P<0.001, respectively. CONCLUSIONS: • Patients with IC/PBS analysed across a wide spectrum of ages at time of diagnosis portrayed a unique symptom profile pattern. • Patients diagnosed at the youngest ages experienced significantly more urinary urgency, frequency, dysuria, dyspareunia and pain in their external genitalia. • Older patients had higher rates of nocturia, urinary incontinence and Hunner's ulcer disease.

Comparison of Management and Outcomes of Symptomatic Urolithiasis During the COVID-19 Pandemic to a Comparative Cohort.

OBJECTIVE: To analyze the clinical presentation and outcomes for patients who presented with symptomatic urolithiasis during the initial months of the COVID-19 pandemic. METHODS: We retrospectively reviewed Emergency Department (ED) presentations from a Philadelphia healthcare system for symptomatic urolithiasis between March and June 2020 and compared these with presentations for the same time period from the year prior. Patient demographics, stone characteristics, management, and clinical outcomes were compared between the 2 years. RESULTS: One hundred and thirty-nine patients presented during 2020 compared to 269 in 2019. There were fewer patients who presented during the initial COVID-19 pandemic surge who had obesity (37.41% vs 49.44%, P = .024), hyperlipidemia (18.71% vs 31.60, P = .006), and asthma (5.76% vs 16.73%, P = .002). Although overall stone characteristics did not differ between the 2 groups, a larger proportion of patients in 2020 presented with an obstructing stone (81.16% vs 64.1%, P = .001). Patients who presented during the COVID-19 pandemic did not have higher rates of infection, acute kidney injury, or complications. Rates of surgical modalities, emergent procedures, and discharges from the ED were similar between the 2 years. CONCLUSION: The COVID-19 pandemic initial surge resulted in fewer ED presentations for symptomatic urolithiasis; however, patients who did present were more likely to have obstructing stones, perhaps due to delaying presentation to avoid COVID-19 exposure in the ED. Despite higher rates of obstruction, clinical outcomes and morbidity were similar.