Temporal Trends in Urinary Diversion among Patients Undergoing Radical Cystectomy Between 1986 and 2022: Experience at the University Medical Center Mainz with 2224 Cases.

BACKGROUND: Analysis of temporal trends of urinary diversion (UD) and identification of predictive factors for continent urinary diversion (CUD) in patients with bladder cancer (BC) is scarce and data on large cohorts are missing. We aimed to describe longitudinal temporal trends and predictive factors for UD among patients with BC receiving radical cystectomy (RC). PATIENTS AND METHODS: We retrospectively analysed institutional data collected from patients undergoing RC from 1986 to 2022 to describe changes in patients' characteristics and UD. Primary end points were patients' characteristics associated with type of UD. Logistic regression analysis was used to determine predictive factors for CUD. RESULTS: In total, 2224 patients (77.16% male, 22.84% female) with a mean age of 66 years [standard deviation (SD), 10.64 years] were included. We observed an increase in mean age from 59.86 (10.8) years (1986-1990) to 69.85 (9.99) years (2016-2022) (p < 0.001). The proportion of CUD gradually declined from 43.72% (94/215; 1986-1990) to 18.38% (86/468; 2016-2022). Patients who were male [odds ratio (OR): 1.92, 95% confidence interval (CI): 1.43-2.57, p < 0.001), younger (OR: 0.88, 95% CI: 0.87-0.89, p < 0.001) and had no hydronephrosis prior to RC (OR: 2.2, 95% CI: 1.66-2.92, p < 0.001) were more likely to receive CUD. CONCLUSIONS: We report the largest European single-center cohort of UD after RC, demonstrating a significant shift from CUD to IUD, accompanied by an increasing age. Finally, our data mirrors the development and extensive experience with the Mainz Pouch-I in the 1980's and 1990's together with other colon pouches.

Individualized center-based analysis of urinary and sexual functional outcome after radical prostatectomy based on the prostate cancer outcome study: a post hoc pathway to patient outcome measurement analysis for quality improvement.

PURPOSE: We evaluate differences of patient-reported outcome measurements (PROM) based urinary continence and sexual function 12 months after radical prostatectomy (RPE) based on perioperative, surgical, and patient-specific characteristics in a large European academic urology center. MATERIALS AND METHODS: All men enrolled in the Prostate Cancer Outcome Study (PCO) study who were treated with RPE between 2017 and 2021 completed EPIC-26 information surveys before and 12 months after RPE. Survey data were linked to clinical data of our institution. Logistic regression analyses were performed to examine the correlation between individual surgeons, patient characteristics, patient clinical data, and their urinary continence and sexual function. RESULTS: In total, data of 429 men were analyzed: unstratified mean (SD) EPIC-26 domain score for urinary function decreased from 93.3 (0.7) to 60.4 (1.5) one year after RPE, respectively for sexual function from 64.95 (1.6) to 23.24 (1.1). Patients with preoperative adequate urinary function (EPIC-26 score > 80) reported significantly different mean urinary function scores between 53.35 (28.88) and 66.25 (25.15), p= 0.001, stratified by surgeons experience. On binary logistic regression analyses, only nerve sparing techniques (OR: 1,83, 95% CI: 1.01;3.21; p = 0.045) and low body mass index (OR: 0.91, CI: 0.85;0.99, p= 0.032) predicted adequate postoperative urinary function. CONCLUSIONS: The results show how using provider-specific data from a larger cohort study enables to develop institution-specific analysis for functional outcomes after RPE. These models can be used for internal quality improvement as well as enhanced and provider-specific patient communication and shared decision making.

Value of perilesional biopsies in multiparametric magnetic resonance imaging-targeted biopsy and systematic biopsy in detection of prostate cancer: results of a prospective, non-randomized, surgeon-blinded study.

PURPOSE: The goal of this study is to address if detection rates of clinically significant prostate cancer (csPCa) can be increased by additional perilesional biopsies (PB) in magnetic resonance (MR)/ultrasound fusion prostate biopsy in biopsy-naïve men. METHODS: This prospective, non-randomized, surgeon-blinded study was conducted between February 2020 and July 2022. Patients were included with PSA levels < 20 ng/ml and ≥ one PI-RADS lesion (grades 3-5) per prostate lobe. Prostate biopsy was performed by two urologists. The first performed the MR-fusion biopsy with 3-5 targeted biopsies (TB) and 6 PB in a standardized pattern. The second performed the systematic (12-fold) biopsy (SB) without knowledge of the MR images. Primary outcome of this study is absence or presence of csPCa (≥ ISUP grade 2) comparing TB, PB and SB, using McNemar test. RESULTS: Analyses were performed for each PI-RADS lesion (n = 218). There was a statistically significant difference in csPC detection rate of TB + SB between PI-RADS 3, 4 and 5 lesions (18.0% vs. 42.5% vs. 82.6%, p < 0.001) and TB + PB (19.7% vs. 29.1% vs. 78.3%). Comparing only maximum ISUP grade per lesion, even SB plus TB plus PB did not detect more csPCa compared to SB plus TB (41.3% vs. 39.9%, p > 0.05). CONCLUSION: We present prospective study data investigating the role of perilesional biopsy in detection of prostate cancer. We detected no statistically significant difference in the detection of csPCa by the addition of PB. Therefore, we recommend continuing 12-fold bilateral SB in addition to TB.

Clinical Impact and Management of Incidental Renal Findings on Pre-TAVI CT Scan from the Urologist's Perspective.

INTRODUCTION: The aim of the study was to investigate prevalence and impact of incidental renal masses (IRMs) accompanying increasing computed tomography (CT) work-up for symptomatic aortic valve stenosis (sAVS) of the elderly with regard to the relevance of urological consultation for overall survival (OS). METHODS: A retrospective analysis of pre-transcatheter aortic-valve implantations (TAVIs) CT scans of patients with sAVS (N = 1,253) harboring IRM was performed for 2014-2019. According to the clinical management, groups 1 (urologic consultation) and 2 (findings ignored) were formed and analyzed in terms of OS. RESULTS: The prevalence of IRM was 9% (119/1,253). In 19% (23/119), urological advice was sought (group 1). At baseline, group 1 showed a significantly higher rate of malignancy-specific lesions compared to 2 (p < 0.01). Other clinical parameters (e.g., age, cardiological scores, comorbidities) did not differ between groups (p > 0.05). In group 1, 4 (17%) findings were histologically confirmed, of which 3 (13%) underwent surgery. There was no significant difference in median OS at a median follow-up of 24.7 months between groups 1 and 2 with 35.7 (95% CI, 5.9; 65.4) and 47.4 months (95% CI, 33.0; 61.7), respectively (p = 0.4). In Cox regression analysis, chronic kidney disease but not urologic work-up or chronic obstructive pulmonary disease or heart failure emerged as an independent unfavorable predictor of OS (HR 2.44, 95% CI 1.37; 4.36, p = 0.003). CONCLUSION: For the first time, a TAVI population with IRM was analyzed from the urologist's perspective. Urologic co-evaluation and work-up does not confer a significant benefit in terms of OS in this particular population.

Single-center, prospective phase 2 trial of high-intensity focused ultrasound (HIFU) in patients with unilateral localized prostate cancer: good functional results but oncologically not as safe as expected.

PURPOSE: Focal therapy (FT) for localized prostate cancer (PCa) is only recommended within the context of clinical trials by international guidelines. We aimed to investigate oncological follow-up and safety data of focal high-intensity focused ultrasound (HIFU) treatment. METHODS: We conducted a single-center prospective study of 29 patients with PCa treated with (focal) HIFU between 2016 and 2021. Inclusion criteria were unilateral PCa detected by mpMRI-US-fusion prostate biopsy and maximum prostate specific antigen (PSA) of 15 ng/ml. Follow-up included mpMRI-US fusion-re-biopsies 12 and 24 months after HIFU. No re-treatment of HIFU was allowed. The primary endpoint was failure-free survival (FFS), defined as freedom from intervention due to cancer progression. RESULTS: Median follow-up of all patients was 23 months, median age was 67 years and median preoperative PSA was 6.8 ng/ml. One year after HIFU treatment PCa was still detected in 13/ 29 patients histologically (44.8%). Two years after HIFU another 7/29 patients (24.1%) were diagnosed with PCa. Until now, PCa recurrence was detected in 11/29 patients (37.93%) which represents an FFS rate of 62%.One patient developed local metastatic disease 2 years after focal HIFU. Adverse events (AE) were low with 70% of patients remaining with sufficient erectile function for intercourse and 97% reporting full maintenance of urinary continence. CONCLUSION: HIFU treatment in carefully selected patients is feasible. However, HIFU was oncologically not as safe as expected because of progression rates of 37.93% and risk of progression towards metastatic disease. Thus, we stopped usage of HIFU in our department.

Global change of surgical and oncological clinical practice in urology during early COVID-19 pandemic.

OBJECTIVES: While the coronavirus disease 2019 (COVID-19) pandemic captures healthcare resources worldwide, data on the impact of prioritization strategies in urology during pandemic are absent. We aimed to quantitatively assess the global change in surgical and oncological clinical practice in the early COVID-19 pandemic. METHODS: In this cross-sectional observational study, we designed a 12-item online survey on the global effects of the COVID-19 pandemic on clinical practice in urology. Demographic survey data, change of clinical practice, current performance of procedures, and current commencement of treatment for 5 conditions in medical urological oncology were evaluated. RESULTS: 235 urologists from 44 countries responded. Out of them, 93% indicated a change of clinical practice due to COVID-19. In a 4-tiered surgery down-escalation scheme, 44% reported to make first cancellations, 23% secondary cancellations, 20% last cancellations and 13% emergency cases only. Oncological surgeries had low cancellation rates (%): transurethral resection of bladder tumor (27%), radical cystectomy (21-24%), nephroureterectomy (21%), radical nephrectomy (18%), and radical orchiectomy (8%). (Neo)adjuvant/palliative treatment is currently not started by more than half of the urologists. COVID-19 high-risk-countries had higher total cancellation rates for non-oncological procedures (78% vs. 68%, p = 0.01) and were performing oncological treatment for metastatic diseases at a lower rate (35% vs. 48%, p = 0.02). CONCLUSION: The COVID-19 pandemic has affected clinical practice of 93% of urologists worldwide. The impact of implementing surgical prioritization protocols with moderate cancellation rates for oncological surgeries and delay or reduction in (neo)adjuvant/palliative treatment will have to be evaluated after the pandemic.

Prostate Cancer on the Web-Expedient Tool for Patients' Decision-Making?

Many patients diagnosed with cancer search for health information on the Web. We aimed to assess the quality and reliability of online health information on prostate cancer. Google, Yahoo, and Bing were searched for the term "prostate cancer." After selecting the most frequented websites, quality was measured by DISCERN score, JAMA benchmark criteria, and presence of HONcode certification. Popularity was assessed by Alexa tool, while accessibility, usability, and reliability were investigated by LIDA tool. Readability was analyzed by Flesch-Kincaid Reading Grade Level and Automated Readability Index. All 13 selected websites were rated as being of high quality according to the DISCERN instrument (76.5 ± 2.6 out of 80 points). JAMA benchmark criteria were fulfilled by 87 % of websites, whereas only 37 % were certified by the HONcode. Median Alexa Traffic Rank was 2718 ranging from 7 to 679,038. Websites received 2.3 ± 0.5 daily pageviews per visitor and users spent an average of 2 min 58 s ± 39 sec on the website. Accessibility (92 ± 5 %) and usability (92 ± 3 %) scores were high and reliability (88 ± 8 %) moderate according to the LIDA tool. Flesch-Kincaid Grade Level was 7.9 ± 2.2, and Automated Readability Index was 7.5 ± 2.4, rating the websites as fairly difficult to read. In conclusion, quality, accessibility, and usability of websites on prostate cancer provided a high rating in the current analysis. These findings are encouraging in view of the growing frequency of patients' access of health information online.

R.E.N.A.L. Score Outperforms PADUA Score, C-Index and DAP Score for Outcome Prediction of Nephron Sparing Surgery in a Selected Cohort.

PURPOSE: Several nephrometry scores have been proposed to predict perioperative outcomes in renal surgery. We evaluated which nephrometry score correlates best with the MIC (margin, ischemia and complications) score and quantitative perioperative outcomes in nephron sparing surgery. MATERIALS AND METHODS: Data on 188 patients undergoing nephron sparing surgery were retrospectively investigated for patient, operative and tumor characteristics. Nephrometry scores, including R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, hilar tumor touching the main renal artery or vein and location relative to polar lines), PADUA (preoperative aspects and dimensions used for an anatomical), C-index (concordance index) and DAP (diameter-axial-polar), were measured on preoperative computerized tomography or magnetic resonance imaging and coded continuously and categorically. Parameters pertaining to tumor margin, ischemia and complications were recorded as binary scores and classified as MIC achievement. Operative time, estimated blood loss, warm ischemia time and hospital stay were recorded as quantitative perioperative outcomes. RESULTS: The R.E.N.A.L. score correlated best with MIC and quantitative perioperative outcomes. The continuously coded R.E.N.A.L. score was predictive of MIC on univariate analysis (OR 0.75, 95% CI 0.58-0.97, p = 0.03) and it had the best predictive value on multivariate logistic regression analysis (OR 0.31, 95% CI 0.18-0.82, p = 0.03). The C-index but not the PADUA or the DAP score was predictive of MIC on univariate and multivariate logistic regression analysis. MIC achievement rates were significantly higher for low than for high complexity tumors as assessed by categorically coded R.E.N.A.L. score, C-index and DAP scores. Continuously coded R.E.N.A.L. and PADUA scores positively correlated with operative time, warm ischemia time and hospital stay. The C-index and the DAP score correlated with warm ischemia time. CONCLUSIONS: Of 4 nephrometry scores the R.E.N.A.L. score correlated best with MIC achievement and quantitative perioperative outcomes of nephron sparing surgery.

Cost-effectiveness of robot-assisted partial nephrectomy for the prevention of perioperative complications.

PURPOSE: To evaluate the cost-effectiveness of robot-assisted partial nephrectomy (RAPN) and secondarily of laparoscopic PN (LPN) compared to the open procedure. METHODS: Model-based cost-effectiveness analysis: The model was structured as decision tree. The model was populated with published data. We measured intraoperative, postoperative complications, and inhospital deaths. We expressed costs in US dollars ($).The reference analysis calculated the mean cost and the mean number of each endpoint over 5000 iterations using a second-order Monte Carlo simulation. We conducted extensive sensitivity analyses. RESULTS: The mean inhospital costs were $13,186 for RAPN, $10,782 for LPN, and $12,539 for open partial nephrectomy (OPN), respectively. The incremental cost to prevent an inhospital event amounted to $5005 for RAPN compared to OPN. Lower RENAL scores were associated with lower incremental cost per avoided complications. Under assumption of 55 % higher costs in patients with complications, RAPN dominated OPN. LPN dominated OPN. We are aware of the following limitations: First, cost data for patients with and without complications were not available and we assumed the median cost for all cases, i.e., the analysis overestimated the cost associated with RAPN; second, we focused on inhospital estimates and did not apply a societal perspective. CONCLUSIONS: RAPN appears to be a cost-effective mean to avoid inhospital complications; however, these results might not apply to low-volume hospitals or to other health care systems.

Renal cell carcinoma with inferior vena cava involvement: Prognostic effect of tumor thrombus consistency on cancer specific survival.

BACKGROUND: Renal cell carcinoma forming a venous tumor thrombus (VTT) in the inferior vena cava (IVC) has a poor prognosis. Recent investigations have been focused on prognostic markers of survival. Thrombus consistency (TC) has been proposed to be of significant value but yet there are conflicting data. The aim of this study is to test the effect of IVC VTT consistency on cancer specific survival (CSS) in a multi-institutional cohort. METHODS: The records of 413 patients collected by the International Renal Cell Carcinoma-Venous Thrombus Consortium were retrospectively analyzed. All patients underwent radical nephrectomy and tumor thrombectomy. Kaplan-Meier estimate and Cox regression analyses investigated the impact of TC on CSS in addition to established clinicopathological predictors. RESULTS: VTT was solid in 225 patients and friable in 188 patients. Median CSS was 50 months in solid and 45 months in friable VTT. TC showed no significant association with metastatic spread, pT stage, perinephric fat invasion, and higher Fuhrman grade. Survival analysis and Cox regression rejected TC as prognostic marker for CSS. CONCLUSIONS: In the largest cohort published so far, TC seems not to be independently associated with survival in RCC patients and should therefore not be included in risk stratification models. J. Surg. Oncol. 2016;114:764-768. © 2016 Wiley Periodicals, Inc.

The management of the access tract after percutaneous nephrolithotomy.

PURPOSE: To describe the evolution of the current technique in percutaneous nephrolithotomy (PCNL) with a special focus on access tract closure techniques. METHODS: A systematic review of outcomes and complications of tubeless PCNL was conducted using the MEDLINE and Pubmed databases between 1976 and 2014. RESULTS: During the past decade, PCNL underwent fundamental modifications due to miniaturization of the instruments and advancements in technique. The routine use of the nephrostomy tube after PCNL has been subsequently questioned. Currently, the nephrostomy tube is increasingly omitted, and the access tract is usually sealed by haemostatic agents. An additionally ureteric stent is commonly inserted at the end of the procedure. However, the application of haemostatic sealants increases the immediate costs significantly. Still there are inconsistent data because of small study populations, lack of randomization, retrospective character and further more heterogeneous surgical techniques. CONCLUSION: The current body of literature does not provide high-level evidence for the preferred treatment of the access tract in PCNL. However, most authors agree that a tract sealing can be omitted without increasing the risk of complication in uncomplicated procedures.

Is there an anti-androgen withdrawal syndrome for enzalutamide?

BACKGROUND: The anti-androgen withdrawal syndrome (AAWS) can be seen in one-third of patients after discontinuation of first-generation non-steroidal anti-androgen therapy. With the introduction of new agents for anti-androgen therapy as well as alternate mechanisms of action, new therapeutic options before and after docetaxel chemotherapy have arisen (Ohlmann et al. in World J Urol 30(4):495-503, 2012). The question regarding the occurrence of an enzalutamide withdrawal syndrome (EWS) has not been evaluated yet. In this study, we assess prostate-specific antigen (PSA) response after discontinuation of enzalutamide. METHODS: In total 31 patients with metastatic castration-resistant prostate cancer (mCRPC) underwent an enzalutamide withdrawal and were evaluated. Data were gathered from 6 centres in Germany. Patients with continuous oral administration of enzalutamide with rising serum PSA levels were evaluated, starting from enzalutamide withdrawal until subsequent therapy was initiated, follow-up ended or death of the patient occurred. Statistical evaluation was performed applying one-sided binomial testing using R-statistical software, version 3.0.1. RESULTS: Mean withdrawal follow-up was 6.5 weeks (range 1-26.1 weeks). None of the 31 patients showed a PSA decline. Mean relative PSA rise over all patients was 73.9 % (range 0.5-440.7 %) with a median of 44.9 %. CONCLUSIONS: If existent, an AAWS is at least very rare for enzalutamide in patients with mCRPC after taxane-based chemotherapy and does not play a clinical role in this setting. This may be attributed to the different pharmacodynamics of enzalutamide. Longer duration of therapy or a longer withdrawal interval may reveal a rare EWS in the future.

Structured reporting in radiology enables epidemiological analysis through data mining: urolithiasis as a use case.

PURPOSE: To investigate the epidemiology and distribution of disease characteristics of urolithiasis by data mining structured radiology reports. METHODS: The content of structured radiology reports of 2028 urolithiasis CTs was extracted from the department's structured reporting (SR) platform. The investigated cohort represented the full spectrum of a tertiary care center, including mostly symptomatic outpatients as well as inpatients. The prevalences of urolithiasis in general and of nephro- and ureterolithasis were calculated. The distributions of age, sex, calculus size, density and location, and the number of ureteral and renal calculi were calculated. For ureterolithiasis, the impact of calculus characteristics on the degree of possible obstructive uropathy was calculated. RESULTS: The prevalence of urolithiasis in the investigated cohort was 72%. Of those patients, 25% had nephrolithiasis, 40% ureterolithiasis, and 35% combined nephro- and ureterolithiasis. The sex distribution was 2.3:1 (M:F). The median patient age was 50 years (IQR 36-62). The median number of calculi per patient was 1. The median size of calculi was 4 mm, and the median density was 734 HU. Of the patients who suffered from ureterolithiasis, 81% showed obstructive uropathy, with 2nd-degree uropathy being the most common. Calculus characteristics showed no impact on the degree of obstructive uropathy. CONCLUSION: SR-based data mining is a simple method by which to obtain epidemiologic data and distributions of disease characteristics, for the investigated cohort of urolithiasis patients. The added information can be useful for multiple purposes, such as clinical quality assurance, radiation protection, and scientific or economic investigations. To benefit from these, the consistent use of SR is mandatory. However, in clinical routine SR usage can be elaborate and requires radiologists to adapt.

Understanding tumor localization in multiparametric MRI of the prostate-effectiveness of 3D printed models.

Introduction: Understanding tumor localization in multiparametric MRI (mpMRI) of the prostate is challenging for urologists but of great importance in mpMRI-fused prostate biopsy or radical prostatectomy. The aim was to evaluate the effectiveness of 3D printed models of the prostate to help urologists to locate tumors. Methods and Participants: 20 urologists from University Medical Center Mainz (Germany) were asked to plot the location of a cancer suspicious lesion (PI-RADS ≥ 4) on a total of 30 mpMRI on a prostate sector diagram. The following 3 groups (as matched triplets) were divided into: mpMRI only, mpMRI with radiological report and mpMRI with 3D printed model (scaled 1:1). Statistical analysis was performed using one-way and two-way ANOVA (with bonferroni post-test). Results: Overall, localization of the suspicious lesion was superior with the radiological report (median of max. 10 [IQR]: MRI 2 [IQR 1;5], MRI + report: 8 [6.3;9], MRI + 3D model 3 [1.3;5.8]; p < 0.001). Residents with <1 year of experience had a significantly higher detection rate using a 3D printed model [5 (5;5.8)] compared to mpMRI alone [1.5 (1;3.5)] (p < 0.05). Regarding the estimation of index lesion extension, the 3D model showed a significant benefit (mean percentage difference [95% CI]: MRI alone 234% [17.1;451.5], MRI + report 114% [78.5;149.6], MRI + 3D model 17% [-7.4;41.3] (p < 0.01). Conclusion: Urologists still need the written radiological report for a sufficient understanding of tumor localization. The effectiveness of the 3D printed model regarding tumor localization is particularly evident in young residents (<1 year) and leads to a better overall assessment of the tumor extension.

Change in Splenic Volume as a Surrogate Marker for Immunotherapy Response in Patients with Advanced Urothelial and Renal Cell Carcinoma-Evaluation of a Novel Approach of Fully Automated Artificial Intelligence Based Splenic Segmentation.

BACKGROUND: In the treatment of advanced urothelial (aUC) and renal cell carcinoma (aRCC), biomarkers such as PD-1 and PD-L1 are not robust prognostic markers for immunotherapy (IO) response. Previously, a significant association between IO and a change in splenic volume (SV) was described for several tumour entities. To the best of our knowledge, this study presents the first correlation of SV to IO in aUC and aRCC. METHODS: All patients with aUC (05/2017-10/2021) and aRCC (01/2012-05/2022) treated with IO at our academic centre were included. SV was measured at baseline, 3 and 9 months after initiation of IO using an in-house developed convolutional neural network-based spleen segmentation method. Uni- and multivariate Cox regression models for overall survival (OS) and progression-free survival (PFS) were used. RESULTS: In total, 35 patients with aUC and 30 patients with aRCC were included in the analysis. Lower SV at the three-month follow-up was significantly associated with improved OS in the aRCC group. CONCLUSIONS: We describe a new, innovative artificial intelligence-based approach of a radiological surrogate marker for IO response in aUC and aRCC which presents a promising new predictive imaging marker. The data presented implicate improved OS with lower follow-up SV in patients with aRCC.

Comparative assessment of multiple-tract vs single-tract percutaneous nephrolithotomy.

INTRODUCTION: To investigate the efficacy and safety of multi-tract percutaneous nephrolithotomy (PNL) against the benchmark of the single-tract approach. METHODS: A retrospective analysis of 391 consecutive PNL procedures was conducted in our tertiary referral center between April 2016 and March 2020. Clinical outcome parameters such as stone-free rate, operation time, postoperative complications according to Clavien-Dindo, length of hospital stay and time to ipsilateral recurrence resulting in active treatment were assessed. RESULTS: Multi-tract PNL and single-tract PNL were performed in 37 (9%) and 354 (91%) cases respectively. At baseline, compared to single-tract PNL, multi-tract PNL cases were characterized by significantly larger stone burden (2.62 vs 0.97 cm3 , P < .00), lower Hounsfield units (HU) (751 vs 1017 HU, P < .01), a more complex S.T.O.N.E. (size, tract length, obstruction, number of calyces, essence) score (P < .00) and a higher rate of high-risk stone formers (59 vs 19%, P < .00). Analysis of outcome revealed shorter operation time and length of hospital stay for single-tract PNL compared to multi-tract PNL (P < .01). However, the difference in terms of stone-free rates (92% vs 88%), complication rates (43% vs 28%) and time to active retreatment due to ipsilateral recurrence was not statistically significant (P > .05). CONCLUSION: In this retrospective single-center analysis, a multi-tract PNL has been proved to be an efficient and safe expansion of single-tract PNL for large stone burden and complex kidney stone disease. Future prospective research should focus on the procedure's potential effectiveness in reducing the number of interventions until stone-free status in patients with massive stone disease.

Outcomes for Geriatric Urolithiasis Patients aged ≥80 Years Compared to Patients in Their Seventies.

BACKGROUND: Demographic changes are leading to an increase in geriatric urolithiasis patients aged ≥70 yr. Published data regarding their management remain sparse. In particular, for the subgroup of patients aged ≥80 yr there is a lack of evidence supporting the hypothesis that stone-removing treatment is effective, safe, and beneficial. OBJECTIVE: To examine the efficiency and safety of stone-removing treatment in geriatric urolithiasis patients aged ≥80 yr compared to their younger geriatric counterparts aged 70-79 yr against the background of their respective life expectancy. DESIGN, SETTING, AND PARTICIPANTS: Data for the study cohort were extracted from an institutional review board-approved retrospective database with 325 patients aged ≥70 yr (70-79 yr: n = 241; ≥80 yr: n = 84) consecutively admitted to hospital because of symptomatic urolithiasis from 2013 to 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Baseline characteristics, outcome and follow-up data, and survival were compared using Wilcoxon-Mann-Whitney U tests, χ2 tests, Kaplan-Meier estimation, log-rank tests, and Cox regression. RESULTS AND LIMITATIONS: At baseline, the incidence of infected hydronephrosis was greater among patients aged ≥80 yr (p < 0.05), whereas the median stone burden and Charlson comorbidity index did not differ between the groups. Outcome analysis revealed no significant differences in terms of complication, stone-free, and 6-mo readmission rates (p > 0.05). Survival analysis for the two groups demonstrated a 2-yr overall survival (OS) rate of 0.91 (95% confidence interval [CI] 0.75-1) for patients aged ≥80 yr and 0.97 (95% CI 0.88-1), for those aged 70-79 yr (p < 0.01). Multivariable Cox analysis revealed age ≥80 yr (hazard ratio [HR] 3.3, 95% CI 1.3-8.5) and infected hydronephrosis (HR 2.8, 95% CI 1.0-7.8) as predictors of all-cause mortality (p < 0.05). The study is limited by its retrospective design. CONCLUSIONS: Stone-removing treatment for patients aged ≥80 yr proved to be as effective and safe as for patients in their seventies. Although characterized by shorter remaining life expectancy, excellent 2-yr OS for patients aged ≥80 yr supports the hypothesis of equal benefit from stone-removing treatment when compared to septuagenarians. PATIENT SUMMARY: There is a lack of evidence supporting the benefit of urinary stone-removing treatment for patients older than 80 yr. Our study included geriatric patients older than 70 yr with symptomatic urinary stone disease for which urinary drainage or stone removal is indicated. We compared treatment outcomes and survival between two age groups: patients aged 70-79 yr and those aged 80 yr or older. We found equivalent outcomes for the two groups and excellent 2-yr overall survival of 91% for those older than 80 yr. The study strengthens the evidence that active stone-removing therapy is safe and beneficial for these patients.

Impact of Blood Loss on Renal Function and Interaction with Ischemia Duration after Nephron-Sparing Surgery.

OBJECTIVES: Nephron-sparing surgery (NSS) exposes the kidney to ischemia-reperfusion injury. Blood loss and hypotension are also associated with kidney injury. We aimed to test the hypothesis that, during NSS, both ischemia duration and blood loss significantly affect postoperative renal function and that their effects interact. METHODS: Consecutive patients undergoing NSS were enrolled. The primary endpoint was renal function expressed as the absolute delta between preoperative and postoperative peak creatinine. We developed a generalized linear model with the ischemia duration and absolute hemoglobin difference as independent variables, their interaction term, and the RENAL score. The model was than expanded to include a history of hypertension (as a proxy for hypotension susceptibility) and related interaction terms. Further, we described the perioperative and mid-term oncological outcomes. RESULTS: A total of 478 patients underwent NSS, and 209 (43.7%) required ischemia for a mean of 10.9 min (SD 8). Both the ischemia duration (partial eta 0.842, p = 0.006) and hemoglobin difference (partial eta 0.933, p = 0.029) significantly affected postoperative renal function, albeit without evidence of a significant interaction (p = 0.525). The RENAL score also significantly influenced postoperative renal function (p = 0.023). After the addition of a previous history of hypertension, the effects persisted, with a significant interaction between blood loss and a history of hypertension (p = 0.02). CONCLUSIONS: Ischemia duration and blood loss had a similar impact on postoperative renal function, albeit without potentiating each other. While the surgical technique and ischemia minimization remain crucial to postoperative kidney function, increased awareness of conscious hemodynamic management appears warranted.

Shikonin Inhibits Cell Growth of Sunitinib-Resistant Renal Cell Carcinoma by Activating the Necrosome Complex and Inhibiting the AKT/mTOR Signaling Pathway.

Therapy resistance remains a major challenge in treating advanced renal cell carcinoma (RCC), making more effective treatment strategies crucial. Shikonin (SHI) from traditional Chinese medicine has exhibited antitumor properties in several tumor entities. We, therefore, currently investigated SHI's impact on progressive growth and metastatic behavior in therapy-sensitive (parental) and therapy-resistant Caki-1, 786-O, KTCTL-26, and A498 RCC cells. Tumor cell growth, proliferation, clonogenic capacity, cell cycle phase distribution, induction of cell death (apoptosis and necroptosis), and the expression and activity of regulating and signaling proteins were evaluated. Moreover, the adhesion and chemotactic activity of the RCC cells after exposure to SHI were investigated. SHI significantly inhibited the growth, proliferation, and clone formation in parental and sunitinib-resistant RCC cells by G2/M phase arrest through down-regulation of cell cycle activating proteins. Furthermore, SHI induced apoptosis and necroptosis by activating necrosome complex proteins. Concomitantly, SHI impaired the AKT/mTOR pathway. Adhesion and motility were cell line specifically affected by SHI. Thus, SHI may hold promise as an additive option in treating patients with advanced and therapy-resistant RCC.