Management of large kidney stones in the geriatric population.

PURPOSE: The aim of this review is to highlight the unique factors that predispose geriatric patients to nephrolithiasis and to compare the utility and efficacy of surgical techniques in this specific patient population. METHODS: PubMed and EMBASE databases were reviewed, and studies were organized according to surgical treatments. RESULTS: Few prospective studies exist comparing kidney stone removal in the elderly to younger cohorts. In addition, various age cut-offs were used to determine who was considered elderly. Most studies which analyzed Percutaneous Nephrolithotomy (PCNL) found a slightly higher rate of minor complications but comparable stone free rate and operative time. For ureteroscopy (URS) and extracorporeal shockwave lithotripsy (ESWL), there were minimal complications observed and no difference in clinical success in the elderly. All surgical techniques were presumed to be safe in the elderly and most found no difference in stone-free rates. CONCLUSIONS: Unique attributes of the geriatric population contribute to stone formation and must be considered when determining appropriate management modalities. This review provides an overview of the utility and efficacy of PCNL, URS and ESWL in the elderly, as well as a porposed algorithm for management in this population.

Evaluating the association between food insecurity and risk of nephrolithiasis: an analysis of the National Health and Nutrition Examination Survey.

PURPOSE: This study aimed to investigate the relationship between self-reported food security and kidney stone formation. METHODS: Data were collected from the National Health and Nutrition Examination Survey (NHANES), a database representative of the United States population. Food security status was assessed using the US Household Food Security Survey Module: Six-Item Short Form. Characteristics of patients were compared using the Chi-square test and the student t-test. Multivariate logistic regression was performed using a multi-model approach. RESULTS: We analyzed 6,800 NHANES survey respondents. 37.2% of respondents were categorized as having "low food security" (scores 2-4) and 24.0% having "very low food security" (scores 5-6). 8.4% of respondents had a history of kidney stones. We found that people with very low food security had a 42% increased likelihood of developing kidney stones compared to those with high or marginal food security, after controlling for race, age, and comorbidities (OR 1.42; 95% CI 1.01-1.99). Between the different food security groups, no significant differences were observed in age, race/ethnicity, body mass index, gout history, osteoporosis history, or coronary artery disease history. Lower food security was associated with slightly younger age (< 1 year difference, p = 0.001), higher poverty-income ratio (p = 0.001), and many comorbidities, including kidney stones (p = 0.007). CONCLUSION: Our study provides evidence for an association between food access and the risk of kidney stone disease. Given these findings, food insecurity should be investigated as a modifiable risk factor for the development of kidney stone disease.

Rezum therapy for patients with large prostates (≥ 80 g): initial clinical experience and postoperative outcomes.

PURPOSE: Rezum is a minimally invasive surgery for benign prostatic hyperplasia. Current guidelines recommend Rezum for prostates < 80 cc, but little data exist describing outcomes in patients with prostates ≥ 80 cc. We compare outcomes after Rezum between men with small < 80 cc (SP) and large ≥ 80 cc prostates (LP). METHODS: Patients undergoing Rezum between Jan 2017-Feb 2020 were subdivided by prostate volume (< 80, ≥ 80 cc). Outcomes were documented pre- and postoperatively. Descriptive analyses of urodynamics data (Qmax, PVR), symptom scores (AUA-SS, SHIM), disease management (medications, catheterization, retreatments), and clinical outcomes were conducted. RESULTS: 36 (17.6%) men had prostates ≥ 80 cc (LP mean prostate size 106.8 cc). LP men had improved Qmax and PVR postoperatively; those with longitudinal follow-up exhibited improved Qmax, PVR, and AUA-SS. After one year, alpha-blocker usage decreased significantly (LP 94.44-61.11%, p = 0.001, SP 73.96-46.15%, p = 0.001); other medication usage and self-catheterization rates remained unchanged. Compared to SP patients, differences in passing trial void (LP 94.44%, SP 93.45%), postoperative UTI (LP 19.44%, SP 10.12%), ED visits (LP 22.22%, SP 17.86%), readmissions (LP 8.33%, SP 4.76%), and retreatment (LP 8.33%, SP 4.76%) were insignificant. However, mean days to foley removal (LP 9, SP 5.71, p = 0.003) and urosepsis rates (LP 5.56%, SP 0.00%, p = 0.002) differed. CONCLUSION: In select LP patients, Rezum provided short-term symptomatic relief and improved voiding function comparable to SP patients. Postoperatively, though alpha-blocker usage decreased significantly, use of other medications did not change, and nearly two-thirds of patients still needed alpha-blockade. Further efforts should explore the possibility of expanding Rezum's inclusion criteria.

Clinical development of novel therapeutics for castration-resistant prostate cancer: historic challenges and recent successes.

There have been more drugs approved by the US Food and Drug Administration for the treatment of castration-resistant prostate cancer in the past 3 years than in the prior 3 decades, with additional drugs on the verge of approval based on the results of recently reported randomized trials. While an improvement in the understanding of the pathogenesis of castration-resistant prostate cancer has undeniably accelerated the transition of novel approaches from "bench to bedside," the recent successes in the treatment of prostate cancer are also a result of the efforts of clinical investigators to redefine the framework in which drugs for castration-resistant disease are evaluated. This review will explore the shifting paradigm in drug development for castration-resistant prostate cancer over the past several decades, and highlight how new definitions, trial designs, and endpoints have facilitated the emergence of new therapies for this challenging disease.

Analysis of evidence within the AUA's clinical practice guidelines.

INTRODUCTION: Surgical subspecialty societies release clinical practice guidelines (CPGs) to provide topic-specific recommendations to healthcare providers. We hypothesize that there may be significant differences in statement strength and evidence quality both within the American Urological Association (AUA) guidelines and compared to those published by the American Academy of Orthopedic Surgeons (AAOS) and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). MATERIALS AND METHODS: CPGs issued through 2017 were extracted from the AUAnet.org. Statements were characterized by evidence basis, strength, and evidence quality. CPGs were compared among urologic subspecialties and to those from the AAOS and AAO-HNS. Analysis used Fisher's exact tests and Student's t-tests with significance p < 0.05. RESULTS: A total of 25 AUA CPGs (672 statements) were reviewed and 34.6% were non-evidence based with the highest proportions in pediatrics (47.5%) and sexual medicine (46.5%). The AUA has published over twice as many statements as the AAOS and quadruple that of the AAO-HNS. A smaller proportion of the AUA statements were evidence-based (65.4%) compared to the AAOS (80.5%, p < 0.001) and AAO-HNS (99.8%, p < 0.001), and fewer used "high" quality evidence (AUA 7.2% versus AAOS 21.2%, p < 0.001; versus AAO-HNS 16.1%, p < 0.001). CONCLUSIONS: The AUA has published broad CPGs that far exceed those from the AAOS and AAO-HNS. The AUA has utilized extensive resources to provide guidance to help standardize care among urologists. The AAOS and AAO-HNS may not provide guidelines when evidence is limited. With the continued increase of high quality clinical trials, the AUA will be able to continue improving its robust set of evidence-based CPGs.

Impact of positive preoperative urine cultures before pediatric lower urinary tract reconstructive surgery.

PURPOSE: Children who undergo lower urinary tract reconstruction (LUTR) often have asymptomatic bacteriuria or recurrent urinary tract infections (UTI). We aimed to determine the prevalence of positive preoperative urine cultures (PPUC) before LUTR and to analyze any impact on postoperative outcomes. METHODS: This retrospective review included all pediatric LUTR procedures utilizing bowel segments performed by one surgeon over 2 years. Preoperative cultures were obtained 1-2 days before surgery. Baseline characteristics and 90-day infection/readmission rates between patients with and without PPUC were compared using descriptive statistics, Fisher's exact, and Mann-Whitney tests with significance p < 0.05. RESULTS: 54 patients with mean age 10.1 ± 5.6 years underwent LUTR procedures using bowel including continent catheterizable channel (85%), enterocystoplasty (81%), and/or urinary diversion (9%). PPUC was present in 28 patients (52%). Postoperatively, 20% had inpatient infections, including eight UTI, four surgical site infections, and two bloodstream infections with no difference between those with or without PPUC. Within 90 days of discharge, 28% of patients were readmitted to the hospital, and there was no difference between groups. Postoperative urine cultures were positive in 83% of patients within 90 days. CONCLUSIONS: Half of the patients undergoing LUTR have PPUC, but it does not increase the risk of postoperative infections or hospital readmissions. We believe complex LUTR can be safely performed in patients with PPUC.

The New York Section EMPIRE Collaborative: Piloting a Multi-Institutional, Simulation-Based Surgical Skills Boot Camp for Junior Urology Residents.

INTRODUCTION: Since the integration of the intern year into urology residencies, programs are mandated to introduce fundamental skills to junior residents. Our goal was to assess the impact of one such program: the 2023 New York Section of the AUA (NYS-AUA) EMPIRE (Educational Multi-institutional Program for Instructing REsidents) Boot Camp. METHODS: Junior urology residents from all 10 NYS-AUA institutions attended a free EMPIRE Boot Camp on June 9, 2023. The seminar covered procedural skills including urethral catheterization, cystoscopy, renal and bladder ultrasound, transrectal prostate ultrasound with biopsy, and an introduction to robotics/laparoscopy. Sessions focused on urologic emergencies and postoperative scenarios. Participants completed questionnaires before, immediately after, and 6 months post course, assessing comfort with procedures and overall program quality using a 5-point Likert scale and free text responses. t Tests compared pre and immediate/6-month post scores. RESULTS: Forty junior residents, along with faculty and resident instructors from all 10 NYS-AUA programs, participated. Of the 40 trainees, 35 (87.5%) completed pre- and immediate post-boot camp surveys, while 23 (57.5%) responded to the 6-month follow-up survey. Ratings showed significant improvement in comfort with basic urologic technical skills for 13 out of 14 domains (93%) immediately after the course and at the 6-month mark. Attendees reported notably higher comfort levels in managing obstructive pyelonephritis (P = .003) and postoperative complications (P = .001) following didactic sessions. CONCLUSIONS: A skills-based, free collaborative urology boot camp for junior residents is feasible and can be effective. Trainees reported improved comfort performing certain technical skills and managing urologic emergencies both immediately after the course and at 6 months of follow-up.

Cytoreductive nephrectomy for metastatic renal cell carcinoma in the era of targeted therapy in the United States: a SEER analysis.

PURPOSE: Two randomized trials published in 2001 provided level 1 evidence for the use of cytoreductive nephrectomy (CyNx) for the treatment of metastatic renal cell carcinoma (mRCC). However, the regulatory approval of vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) in 2005 has left an "evidence void" regarding the use of CyNx. We evaluated the patterns in the use of CyNx in the cytokine and VEGFR-TKI eras, and the patient characteristics associated with the use of CyNx. METHODS: The Surveillance, Epidemiology, and End Results registry was used to identify patients with histologically or cytologically confirmed stage IV RCC between 2001 and 2008. Patients were classified as treated during the cytokine (2001-2005) or VEGFR-TKI (2006-2008) eras. A multivariate logistic regression analysis was performed to calculate the odds of undergoing CyNx according to treatment era and socioeconomic characteristics. RESULTS: Overall, 1,112 of 2,448 patients (45%) underwent CyNx. CyNx use remained stable between 2001 and 2005 (50%), but decreased to 38% in 2008. Logistic regression analysis revealed that older age (OR 0.82, 95% CI: 0.68, 0.99), black race (OR 0.64, 95% CI: 0.46, 0.91), Hispanic ethnicity (OR 0.71, 95% CI: 0.54, 0.93), and treatment in the VEGFR-TKI era (OR 0.82, 95% CI: 0.68, 0.99) were independently associated with decreased use of CyNx. CONCLUSIONS: Use of CyNx in the United States has declined in the VEGFR-TKI era. Older patients and minorities are less likely to receive CyNx. Results of ongoing phase III trials are needed to refine the role of this treatment modality.

Trends and variations in utilization of nephron-sparing procedures for stage I kidney cancer in the United States.

PURPOSE: The incidental detection of early-stage kidney tumors is increasing in the United States. Nephron-sparing approaches (NS) to managing these tumors are equivalent to radical nephrectomy (RN) in oncologic outcomes and have a decreased impact on renal function. Our objective was to evaluate trends in the use of NS over the past decade and the socioeconomic factors associated with its use. METHODS: The National Cancer Database was queried to identify patients with stage I kidney cancer between 2000 and 2008. Patients were classified by the type of surgery as NS (local destruction and local excision) or RN. Patients were further categorized by age, race, insurance status, and income. Log-binomial regression was used to estimate prevalence ratios (PR) for the proportion of NS to RN according to demographic and socioeconomic characteristics. RESULTS: From 2000 to 2008, there were 142,194 cases of kidney cancer reported to the NCDB. In these cases, 43,034 (30.3 %) patients had NS, and 86,431 (60.78 %) patients had RN. The prevalence of NS increased 10 % per year (PR = 1.10, p < 0.0001)-from 20.0 % in 2000 to 45.1 % in 2008. Older age, lower income, Black race, Hispanic ethnicity, and lack of health insurance were associated with a decreased prevalence of NS. CONCLUSIONS: NS as a treatment for stage I kidney cancer has increased steadily since 2000. Age, racial, and socioeconomic differences may exist in the utilization of NS. Additional analyses, with patient level data, are required to address the independent significance of these variables in an effort to develop strategies to mitigate these potential disparities.

Implementation and Usability of an Electronic Medical Record-based Ureteral Stent Tracker.

OBJECTIVE: To design and implement a simple electronic medical record-based ureteral stent tracker. To assess its impact on stent dwell time and stent-related complications. METHODS: Patients with stents placed 12 months before and 6 months after stent tracker implementation were identified at 3 urban hospitals. Those with stents-on-strings and intentional chronic indwelling stents (greater than 90 days) were excluded. Patient demographics, stent characteristics (eg, indication, string, dwell time), and clinical outcomes (eg, positive urine cultures, complications) were reviewed and compared between pre- and posttracker cohorts. A 12-question usability survey was administered to surgical nurses to assess usability. RESULTS: A total of 323 stents (173 pre- and 150 posttracker) were placed in 217 patients. The prestent tracker cohort had a longer mean dwell time (pre: 40.9 ± 59.1 days vs post: 28.8 ± 22.0 days, P = .02) and a higher retention rate >90 days (pre: 8.1% [14/173] vs post: 1.3% [2/150], P = .005). The 2 cohorts had no significant differences in positive urine culture rates, patient phone calls to providers, stent-related emergency department visits, or hospitalizations. The usability survey showed that 86.4% of surgical nurses found the tracker to be user-friendly and 95.5% reported that it added less than 1 minute of work per procedure. CONCLUSION: Implementation of an electronic medical record-based ureteral stent tracker decreased average stent dwell time and frequency of retained stents. Surgical nurses reported the tracker to be user-friendly and convenient. Stent trackers can improve the efficiency of postoperative removal of indwelling ureteral stents.

Should Men Eat More Plants? A Systematic Review of the Literature on the Effect of Plant-Forward Diets on Men's Health.

OBJECTIVE: To perform a systematic review of the literature on plant-based and plant-forward diets and the prevention/treatment of the following common men's health conditions: prostate cancer (PCa), erectile dysfunction (ED), and benign prostatic hyperplasia (BPH). METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses system criteria were utilized to search PubMed and Medline databases for the following search terms: "Diet (Mesh)" OR "Diet Therapy (Mesh)" AND "Prostatic Hyperplasia (Mesh)" OR "Prostatic Neoplasm (Mesh)" OR "Erectile Dysfunction (Mesh)." Articles in English published from 1989 to 2022 using human participants were analyzed, data summarized, and assessed for bias. RESULTS: Studies reporting on plant-based or vegetable-forward diets (Mediterranean) as an intervention were included. Cohort and cross-sectional studies using food frequency questionnaires or diet classification indices to quantify plant-based food intake patterns were included in the study. Ultimately, 12 PCa articles, 4 BPH articles, 6 ED articles, and 2 articles related to both BPH and ED were reviewed. Overall, the literature suggests plant-forward diets confer a protective effect on the men's health conditions reviewed. CONCLUSIONS: Evaluation of the literature on the impact of plant-forward diets on urologic conditions includes a heterogenous range of dietary patterns and study designs. The greatest amount of research has evaluated the application of plant-forward diets for PCa. While there is currently a lack of high-quality evidence for the use of plant-forward diets as prevention and/or treatment for PCa, ED, or BPH, reported outcomes suggest a consistent small beneficial impact alongside well-established benefits for common chronic conditions.

Evaluating the American Urologic Association (AUA) dietary recommendations for kidney stone management using the National Health And Nutritional Examination Survey (NHANES).

The objective of this study is to evaluate the conventional dietary recommendations for stone prevention among patients in the National Health and Nutritional Examination Survey (NHANES) and compare dietary components and special diets between stone formers and non-stone formers. We analyzed the NHANES 2011-2018 dietary and kidney condition questionnaires, among 16,939 respondents who were included in this analysis. Dietary variables were selected based on the American Urological Association (AUA) guideline for Medical Management of Kidney Stones and from other studies on kidney stone prevention. Weighted multivariate logistic regression models were used to assess the relationship of dietary food components (categorized into quartiles) and dietary recommendations with kidney stone formation (yes vs no), adjusted for total caloric intake, comorbidities, age, race/ethnicity, and sex. The prevalence of kidney stones was 9.9%. Our results showed association of kidney stones with lower levels of potassium (p for trend = 0.047), which was strongest for < 2000 mg (OR = 1.35; 95% CI 1.01-1.79). Higher vitamin C intake was inversely associated with stone formation (p for trend = 0.012), particularly at daily intake levels between 60 and 110 mg (OR = 0.76; 95% CI 0.60-0.95) and above 110mcg (OR = 0.80; 95% CI 0.66-0.97). There were no associations between other dietary components and kidney stone formation. Higher levels of dietary vitamin C and potassium intake may be indicated for stone prevention and warrants further investigation.

Prevalence and characteristics of patients with metastatic cancer who receive no anticancer therapy.

BACKGROUND: A subset of patients who present with metastatic solid tumors never receive anticancer therapy. Reasons may include poor functional status, comorbidities, and patient preference. To the authors' knowledge, the prevalence and characteristics of this population have not previously been described. METHODS: The National Cancer Data Base was queried for patients diagnosed with metastatic (stage IV according to the American Joint Committee on Cancer) solid tumors (including those of the breast, cervix, colon, and kidney; small cell and nonsmall cell lung cancer [NSCLC]; and tumors of the prostate, rectum, and uterus) who received neither radiotherapy nor systemic therapy. Log-binomial regression analysis was used to estimate prevalence ratios (PRs) for the percentage of untreated to treated patients with stage IV cancer. RESULTS: Between 2000 and 2008, 773,233 patients with stage IV cancer were identified, 159,284 of whom (20.6%; 95% confidence interval, 20.5%-20.7%) received no anticancer therapy. Patients with NSCLC accounted for 55% of the untreated population. Patients with cancers of the kidney and lung had the highest rates of no treatment at 25.5% and 24.0%, respectively, whereas patients with prostate cancer had the lowest rate of no treatment at 11.1%. Across all cancer types, older age (PR range, 1.37-1.49; all P < .001), black race (PR range, 1.05-1.32; all P < .001), lack of medical insurance (PR range, 1.47-2.46; all P < .001), and lower income (except for cancer of the uterus; PR range, 0.91-0.98 for every $10,000-increase in income [all P < .001]) were associated with a lack of treatment. CONCLUSIONS: Approximately 20% of patients who present with stage IV solid tumors do not receive anticancer therapy. Although there are likely multiple reasons for this lack of treatment, including appropriate indications, these findings have potential implications with regard to health care policy and access to care.

The emerging role of circulating tumor cell detection in genitourinary cancer.

PURPOSE: Circulating tumor cells are malignant cells in peripheral blood that originate from primary tumors or metastatic sites. The heterogeneous natural history and propensity for recurrence in prostate, bladder and kidney cancers are well suited for improved individualization of care using circulating tumor cells. The potential clinical applications of circulating tumor cells include early diagnosis, disease prediction and prognosis, and selection of appropriate therapies. MATERIALS AND METHODS: The PubMed® and Web of Science® databases were searched using the key words circulating tumor cells, CTC, prostate, kidney, bladder, renal cell carcinoma and transitional cell carcinoma. Relevant articles and references from 1994 to 2011 were reviewed for data on the detection and significance of circulating tumor cells in genitourinary cancer. RESULTS: Technical challenges have previously limited the widespread introduction of circulating tumor cell detection in routine clinical care. Recently novel platforms were introduced to detect these cells that offer the promise of overcoming these limitations. We reviewed the current state of circulating tumor cell capture technologies and their clinical applications for genitourinary cancers. CONCLUSIONS: In genitourinary cancer circulating tumor cell enumeration has been useful for prognosis in patients with castration resistant prostate cancer. Soon characterizing individual circulating tumor cells in blood will serve as a noninvasive real-time liquid biopsy to monitor molecular changes in cancer, allowing clinicians to custom tailor treatment strategies. Circulating tumor cells will serve as a treatment response biomarker. Finally, circulating tumor cell detection promises to assist in the early detection of clinically localized cancers, facilitating curative therapy.

Targeting the androgen receptor signalling axis in castration-resistant prostate cancer (CRPC).

What's known on the subject? and What does the study add? Castration resistance has been appreciated for decades, and several mechanisms theorising on this effect have been proposed. A rich pipeline of novel agents, including abiraterone and MDV3100, have provided proof of principle that novel agents targeting the AR signalling pathway with superior selectivity and activity than predecessors have yielded significant clinical benefit for patients with metastatic castration-resistant prostate cancer. Our review provides an update in the development of several novel agents targeting the AR signalling pathway now in clinical testing, as well as review novel therapies in development with distinct mechanisms of action showing promising preclinical activity. • Despite undergoing local therapy with curative intent, 20-30% of patients with prostate cancer will ultimately development metastatic disease, leading to morbidity and mortality. • Androgen-deprivation therapy (ADT) for men with metastatic prostate cancer results in transient clinical benefit, but ultimately, cancers progress despite castrate levels of serum testosterone, a clinical state classically referred to as 'hormone refractory' disease. • In this review, we examine mechanisms of resistance to ADT that have redefined our understanding of the more appropriately termed 'castration resistant' disease, and have paved the way for a new generation of therapeutics targeting the androgen signalling axis in advanced prostate cancer.

Overcoming castration resistance in prostate cancer.

PURPOSE OF REVIEW: Recent advances in our understanding of the androgen axis signaling pathway have led to the development of therapeutic strategies to overcome the state of 'castration resistance' in prostate cancer. In this review, we examine the mechanisms of castration resistance, as well as recently reported and ongoing clinical studies, which will further identify therapeutic opportunities for novel therapeutics targeting the androgen-signaling axis in advanced prostate cancer. RECENT FINDINGS: As evidenced by recently reported positive phase III clinical trials, secondary hormonal agents such as abiraterone and MDV3100 may still be very effective in the treatment of castration-resistant prostate cancer, even after the use of docetaxel chemotherapy. SUMMARY: Novel agents targeting this pathway have demonstrated a proof of principle that overcoming castration resistance is possible, leading to significant changes in the landscape of treatment in this disease. The optimal combination, sequence, and pattern of use in these novel therapies will be the focus of clinical research in the near future.

Evaluating perceptions and usage of natural remedies, herbal medicine, and dietary supplements for kidney stones among a diverse, international, urban patient population.

Our goal was to assess the use and perceptions of complementary and alternative medicine (CAM) for kidney stones among a diverse, urban population. This was a cross-sectional study of patients treated for kidney stones in the Bronx, NY. We assessed demographic information, personal history of kidney stones, as well as knowledge and use of CAM for kidney stones. Patient demographics and responses were analyzed using chi-squared, t tests, and binomial logistic regression. 113 patients were surveyed. 90% identified as non-white, of whom 58% indicated Hispanic, 46% Latinx, and 23% Black. 56% of patients were born outside the United States. 56% of patients had heard of CAM for kidney stones and 44% had used CAM for kidney stones. The most common CAM were fruits (N = 42, 84%). Recurrent stone formers were more likely than first-time stone formers to have heard of CAM (68 vs 44% p = 0.013) and to have used CAM (56 vs 30%, p = 0.008). Those identifying as Hispanic were more likely to have both heard of and tried CAM for kidney stones (p = 0.036 and 0.022, respectively) compared to non-Hispanic patients. CAM are commonly used among our diverse, urban patient population. While some remedies are high in citrate and alkali (i.e., lemon, cranberry), others are high in oxalate (i.e., beets) and could potentially contribute to stone formation. These findings underpin the importance that medical providers educate themselves on the CAM used in their specific patient populations and discussing use with patients. Providers should aim to identify and reconcile therapeutics that oppose goals of treatment.

Adrenalectomy outcomes predicted by a 5-item frailty index (5-iFI) in the ACS-NSQIP database.

BACKGROUND: Frailty has been shown to be a predictor of adverse postoperative outcomes. This study aims to evaluate a 5-item frailty index (5-iFI) as a predictor of complications as well as healthcare resource utilization (HCRU) following adrenalectomy. METHODS: All adrenalectomy cases recorded in the ACS-NSQIP database from 2015 to 2018 were analyzed. Primary outcomes of interest were Clavien-Dindo [CD] I/II or CD IV complications and HCRU. HCRU outcomes were prolonged length of stay (PLOS), discharge to continued care (DCC), and unplanned 30-day readmission (UR). RESULTS: 4358 patients were included. Higher 5-iFI scores were associated with higher rates of CDI/II, CDIV, and increased HCRU (p < 0.05). On multivariate analysis, 5-iFI scores were found to be independent predictors of adverse clinical and HCRU outcomes. CONCLUSIONS: Frailty tools like the 5i-FI can be useful in preoperative risk-benefit analysis, patient counseling, and planning prehabilitation interventions.

A Comparison of Pharmaceutical Prices for Generic Erectile Dysfunction and Benign Prostatic Hyperplasia Medication in 2 Socioeconomically Disparate New York City Neighborhoods.

INTRODUCTION: Erectile dysfunction (ED) and benign prostatic hyperplasia (BPH) are frequently managed with medications. Variability and poor understanding of medication prices have been shown to hinder patient adherence, leading to worse clinical outcomes. We sought to explore how pharmacy type and neighborhood socioeconomic status influence pricing for generic ED and BPH medications. METHODS: A total of 96 pharmacies within the adjacent higher income Upper East Side (UES) and lower income East Harlem (EH) New York City neighborhoods were classified as chain or independent. Telephone surveys identified cash prices for 30-day supplies of 14 medications including phosphodiesterase 5-inhibitors, 5-alpha reductase inhibitors, alpha blockers and antispasmodics. Pricing variability based on pharmacy type and neighborhood was evaluated using Mann-Whitney U-tests. RESULTS: Of 96 pharmacies, 81 responded (84.4%). Independent pharmacies showed significantly reduced prices for 9/14 and 14/14 medications in UES and EH, respectively. The greatest independent pharmacy price reductions were for tadalafil 20 mg (15.0-fold in UES, 26.7-fold in EH) and sildenafil (8.4-fold in UES, 15.4-fold in EH). The least significant reductions were in mirabegron (1.1-fold in UES, 1.2-fold in EH). Independent pharmacies in EH showed lower prices for 9/14 medications compared to those in UES. CONCLUSIONS: Across both neighborhoods, independent pharmacies offered consistently lower cash prices for ED and BPH medications. Lower independent pharmacy prices in the lower income EH neighborhood suggest that neighborhood socioeconomic status may impact pricing. Physicians and patients alike must understand the factors that influence pricing to ensure more optimal patient compliance for uninsured patients.

Comparison of Patient Satisfaction and Safety Outcomes for Postoperative Telemedicine vs Face-to-Face Visits in Urology: Results of the Randomized Evaluation and Metrics Observing Telemedicine Efficacy (REMOTE) Trial.

INTRODUCTION: There is a need to better understand the role of postoperative care via telemedicine (TM). We evaluated patient satisfaction and outcomes of postoperative face-to-face (F2F) versus TM visits for adult ambulatory urological surgeries in an urban academic center. Methods:This was a prospective, randomized controlled trial. At surgery, patients undergoing ambulatory endoscopic procedures or open surgery were randomized 1:1 to a postoperative F2F or TM visit. After the visit, a telephone survey assessing satisfaction was administered. Primary outcome was patient satisfaction; secondary outcomes were time and cost savings, and 30-day safety outcomes. Results:A total of 197 patients were approached; 165 (83%) consented and were randomized-76 (45%) to F2F and 89 (54%) to TM cohorts. There were no significant differences in baseline demographics between the cohorts. Both cohorts were equally satisfied with their postoperative visit (F2F 98.6% vs TM 94.1%, p=0.28) and found their visit to be an acceptable form of health care (F2F 100% vs TM 92.7%, p=0.06). The TM cohort saved a significant amount of time (TM 66.2% spent <15 minutes vs F2F 43.1% spent 1-2 hours, p <0.0001) and money (44.1% TM saved $5-$25 vs 43.1% F2F spent $5-$25, p=0.041) associated with travel. There were no significant differences in 30-day safety outcomes between the cohorts. Conclusions:TM for postoperative visits after ambulatory adult urological surgery saves patients time and money without compromising satisfaction or safety. TM should be offered as an alternative to F2F for routine postoperative care for certain ambulatory urological surgeries.