Nephroureterectomy vs. segmental ureterectomy of clinically localized, high-grade, urothelial carcinoma of the ureter: Practice patterns and outcomes.

BACKGROUND: Nephroureterectomy (NU) remains the gold-standard for upper-tract urothelial carcinoma (UTUC). However, nephron-sparing management (NSM), specifically segmental ureterectomy (SU) for urothelial tumors distal to the renal pelvis may offer decreased risk of renal insufficiency and equivalent cancer control. OBJECTIVES: To identify patient-specific and facility-related factors that are associated with the selection of SU vs. NU for patients with clinically localized, high-grade, ureteral UTUC. DESIGN, SETTING, PARTICIPANTS: We searched the National Cancer Database between 2004 and 2015 for patients with high-grade, clinically localized, primary ureteral UTUC managed by either NU or SU. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Univariate and multivariate analysis was performed to assess patient, disease-specific, facility and treatment-related factors associated with SU vs. NU. Since surgical approach was only indexed after 2010, separate multivariable logistic regressions were performed including and excluding surgical approach in order to capture patients treated between 2004 and 2009. Survival analysis utilized Kaplan-Meier methods and Cox proportional hazards regression. RESULTS AND LIMITATIONS: Multivariate analysis including surgical approach demonstrated that among other factors, higher clinical stage (P = 0.034), larger tumor size (P < 0.001), the addition of neoadjuvant chemotherapy (P = 0.002), and the utilization of minimally invasive surgery (P < 0.05) decreased the likelihood of patients receiving SU. In this same cohort, institutions with larger facility volumes (P = 0.038) and performing intraoperative lymph node dissection (P < 0.001) were associated with a higher probability of SU. Excluding surgical approach, once again more advanced clinical stage (P = 0.005), larger tumor size (P < 0.001), and neoadjuvant chemotherapy (P = 0.003) decreased the probability of patients receiving SU, while increasing age (P = 0.049) and intraoperative lymph node dissection (P < 0.001) were more closely associated with SU compared to NU. No differences were noted in pathological T stage (P > 0.05), 30-day readmission (P = 0.7), 30-day mortality (P = 0.09), and 90-day mortality (P = 0.157) on multivariate analysis between SU and NU. Additionally, no significant differences were seen in median overall survival between patients receiving SU or NU (53 vs. 50 months; P = 0.143). CONCLUSIONS: Comparable outcomes suggest segmental ureterectomy for high-grade ureteral UTUC is appropriate in well-selected patients. Practice patterns appear consistent with guideline recommendations (decreased tumor size and lower clinical stage favor SU), but treatment disparities may exist based on a multitude of patient, pathologic- and facility-related factors. Improved dissemination of knowledge regarding practice patterns and outcomes of SU for UTUC of the ureter has the potential to improve delivery of NSM in appropriate patients. PATIENT SUMMARY: In this study, we examined factors associated with different surgical procedures for cancer of the ureter. We found that smaller tumor sizes, a less advanced clinical stage, intraoperative lymph dissection higher facility volumes tended to favor kidney-sparing treatment, while survival outcomes appear comparable to renal extirpation.

Male-to-Female Gender Reassignment Surgery: An Institutional Analysis of Outcomes, Short-term Complications, and Risk Factors for 240 Patients Undergoing Penile-Inversion Vaginoplasty.

OBJECTIVE: To report outcomes, complications, and risk factors of a population cohort undergoing male-to-female gender affirmation surgery via penile-inversion vaginoplasty by a single surgeon at a large academic institution. As gender dysphoria awareness increases among the medical community, so does the population of patients seeking gender-affirmation surgery. MATERIALS AND METHODS: A prospectively maintained database of patients undergoing penile-inversion vaginoplasty was retrospectively queried for all available patients with at least 1 week of postoperative follow-up. Univariate and multivariate analyses were performed using Fisher's exact test and logistic regression, respectively, in order to evaluate relationship of risk factors to complications at 30, 60, and 90 days, as well as the likelihood of revision/reoperation. RESULTS: From November 2016 to April 2018, 240 penile-inversion vaginoplasties were performed. Median follow-up was 87 days. When accounting for competing risk factors, only noncompliance with postoperative dilation regimen and activity restriction was significantly associated with increased risk of complications or reoperation/revision. Overall incidence of reoperation/revision was 7.9% (n = 19). Reasons for reoperation included cosmesis (3.8%; n = 9), neovaginal stenosis (2.1%; n = 5), and wound dehiscence (0.8%; n = 2), with less than 0.5% (n = 1) reoperations for meatal stenosis, hematoma or rectovaginal fistula, respectively. Incidence of Clavien IIIa-b complications was 1.7% (n = 4). There were no Clavien IV-V complications. CONCLUSION: At short-term follow-up, gender-affirmation surgery is associated with low rates of reoperation and revision and few major complications when performed by an experienced, high-volume surgeon. Patient selection and compliance is imperative. Increased reporting among surgeons is necessary to continue to improve patient outcomes.

Acute pulmonary hemorrhage associated with metastatic testicular choriocarcinoma in a 46-year-old incarcerated male.

Pure testicular choriocarcinoma is a rare histological subtype of germ cell tumor (GCT) and typically presents with distant metastases and aggressive features leading to a generally poor prognosis. Unique to choriocarcinoma among GCT histological subtypes is the propensity of spontaneous hemorrhage into metastatic lesions. We report a case of pure testicular choriocarcinoma in a 46-year-old male with postoperative acute pulmonary hemorrhage secondary to tumor invasion of the lungs, and the subsequent management of his disease with a discussion of relevant literature.

A rare case of renal vein thrombosis secondary to Klebsiella pneumoniae pyelonephritis.

Renal vein thrombosis (RVT) is most often an implication of nephrotic syndrome. Pyelonephritis has been associated at a much lower rate, with the incidence of Klebsiella pneumoniae causation being extremely rare. In our case, a 35-year-old female patient presented with right-sided K. pneumoniae-positive acute pyelonephritis complicated by perinephric abscess and renal vein thrombosis. She was successfully treated with anticoagulation and extended antibiotic therapy. The possibility of RVT in patients with K. pneumoniae-induced pyelonephritis warrants consideration.