The effects of continuing aspirin on blood loss and postoperative outcomes in percutaneous nephrolithotomy.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is an effective surgery for complex kidney stones yet with inherent bleeding risks. It remains unclear whether aspirin should be discontinued prior to PCNL. We aimed to further substantiate the safety of continuing aspirin during PCNL surgery and to determine whether aspirin status affects postoperative outcomes following PCNL. METHODS: We retrospectively queried our endourology database for patients who underwent PCNL from October 2017 to December 2022 at our high-volume tertiary referral center. The three groups were based on aspirin status at the time of PCNL: no aspirin (NA), discontinued aspirin (DA), and continued aspirin (CA). Data collected included demographics, preoperative characteristics, operative parameters, pre and postoperative lab values, transfusions, and complications. RESULTS: A total 648 patients were divided into these study groups: 525 NA patients (81.0%), 55 DA (8.5%), and 68 CA (10.5%). The DA and CA groups were of similar comorbidities, and both were more comorbid at baseline than NA. Postoperative change in lab values and complications did not differ significantly. Rates of postoperative blood transfusion were higher in the CA and DA groups compared to NA and approached statistical significance. There were no significant differences in any postoperative outcomes between the DA and CA groups alone. CONCLUSIONS: In patients on chronic aspirin therapy, continuing aspirin appears equally safe to discontinuing aspirin prior to PCNL. Most patients should not forego the benefits of continuous aspirin for the theoretical risk of bleeding. Patients on prolonged aspirin therapy may be more likely than those who are not on chronic aspirin therapy to require blood transfusions. However, regardless of whether aspirin use is stopped, this may be caused by patient comorbidities rather than higher rates of blood loss.

The T-Tilt Position: A Novel Modified Patient Position to Improve Stone-Free Rates in Retrograde Intrarenal Surgery.

PURPOSE: Residual fragments following retrograde intrarenal surgery can lead to future stone episodes. The lower pole of the kidney presents a unique challenge as it is the most difficult location for retrograde intrarenal surgery. We investigated a modified patient position to increase stone-free rate by analyzing presence of residual fragments. We randomized patients into standard position and the T-Tilt position (15° Trendelenburg and 15° airplane away from the surgical side kidney). MATERIALS AND METHODS: In this prospective, randomized study, patients were randomized into the standard or T-Tilt position. Demographics, comorbidities and operative parameters were collected. Stone-free rate was determined with renal ultrasound and x-ray at 1-month followup. Postoperative complications were recorded up to 1 month. Variables were compared using Kruskal-Wallis test for continuous variables and chi-square test for categorical variables. RESULTS: A total of 138 patients were analyzed: 75 standard patients and 63 T-Tilt patients. The groups had similar patient and stone factors. The most common stone position was the lower pole (68.0% standard, 74.6% T-Tilt). Stone-free rates were significantly different: standard position was 76.7% and T-Tilt position was 92.1% (p=0.015). Stone-free rates for isolated lower pole stones were significantly different as well: standard position was 68.2% and T-Tilt position was 95.6% (p <0.001). Clavien-Dindo scores did not differ significantly (p=0.262). CONCLUSIONS: The T-Tilt patient position was associated with higher stone-free rates. It is an atraumatic, cost-effective technique. These results suggest that modifying patient positioning during retrograde intrarenal surgery improves stone-free rates.

Gender Differences in Incidence, Diagnosis, Treatments, and Outcomes in Clinically Localized Bladder and Renal Cancer.

OBJECTIVE: To review differences in bladder and renal cell cancer (RCC) incidence, diagnosis, treatment, and outcomes between men and women, and to summarize the evidence that explains these differences. METHODS: A review of the current literature was performed using PubMed and Google Scholar. RESULTS: The incidence of bladder cancer and RCC is higher in men. Historically higher smoking rates among men explain some but not all of the difference in incidence. Hormonal and genetic factors also contribute. In bladder cancer, the androgen receptor and estrogen receptor beta have been associated with gender and tumor characteristics. In RCC the relationships are less well defined. In both bladder cancer and RCC, differences in gene mutation patterns among men and women, particularly among genes located on the X-chromosome, have also been identified. Differences in the work-up and treatment of men and women with bladder cancer and RCC also contribute to gender disparities. CONCLUSION: Research to better delineate how the hormonal axis and genetics contribute to disparities in bladder cancer and RCC incidence and outcomes will allow for more individualized medicine. Appreciation of barriers to diagnosis and treatment will identify opportunities to improve patient care.

A Rare Neoplasm: Primary Adrenal Leiomyosarcoma.

Adrenal incidentalomas are common neoplasms and while they are often benign, they have the potential to be malignant. The American Urological Association guidelines state that adrenal incidentalomas should be surgically resected if they are large, metabolically active, or display malignant characteristics. Other groups have suggested that growth kinetics be factored in as well. We present a case of an adult woman with adrenal incidentaloma which was subsequently discovered to be a primary adrenal leiomyosarcoma, a rare subtype of soft tissue tumors.

Endoscopic Creation of a Neochimneycystotomy: A Case Report of a Ureteroileal Chimney Stricture.

Background: There are many nonmalignant complications after urinary reconstruction. Anastomotic strictures and redundancy of an ileal chimney are such. A patient with both issues might necessitate an open surgical approach; yet endoscopic techniques are more attractive for these older frail patients. Case Presentation: A 61-year-old woman with a history of bladder cancer who underwent radical cystectomy and neobladder creation now develops left hydronephrosis and a redundant ileal chimney with severe metabolic acidosis. She underwent endoscopic creation of a neochimneycystotomy. Conclusion: The refinement of endoscopic techniques moves the field of surgery away from open surgery, which is beneficial for patients. This endoscopic technique treated the anastomotic stricture as well as redundant ileal chimney in a novel way that has not been reported previously in the literature.

Robotic-Assisted Partial Nephrectomy and Adrenalectomy: Case of a Pheochromocytoma Invading into Renal Parenchyma.

Although upper pole renal masses and adrenal masses can usually be distinguished on cross-sectional imaging, large masses can obscure the boundaries between the kidney and adrenal gland. We describe a unique case of an adrenal pheochromocytoma in a 42-year-old female who was referred for robotic partial nephrectomy. During the procedure, the patient developed severe hypertension. The case was aborted, and the workup revealed pheochromocytoma. After appropriate pretreatment, the patient underwent a successful robotic adrenalectomy and partial nephrectomy. Therefore, we recommend screening patients with hypertension and large upper pole masses for pheochromocytoma to better direct preoperative management.

Clinical Complete Response after Neoadjuvant Chemotherapy for Muscle-invasive Bladder Cancer: A Call for Standardized Assessments and Definitions.

The ability to accurately determine a complete clinical response (cCR) to neoadjuvant chemotherapy (NAC) before cystectomy could have paradigm-shifting implications for the management of muscle-invasive bladder cancer. Level 1 evidence demonstrates that up to 40% of patients are downstaged to pT0 disease following NAC, presenting an intriguing opportunity to identify select patients who might be spared the morbidity of radical surgery. However, clinical investigations in this space are hindered by lack of a uniform approach to postchemotherapy restaging and a standardized definition of cCR. PATIENT SUMMARY: In this mini-review, we discuss the current limitations to restaging of muscle-invasive bladder cancer following neoadjuvant chemotherapy and their implications for personalized medicine and translational research. We conclude that there is an unmet need to optimize and standardize restaging evaluation and definitions of a complete clinical response.

Imaging Protocols for Active Surveillance in Renal Cell Carcinoma.

PURPOSE OF REVIEW: To review the growth kinetics of small renal masses and available imaging modalities for mass characterization and surveillance, highlight current organizational recommendations for the active surveillance of small renal masses, and discuss the most recently reported oncological outcomes of patients as they relate to various surveillance imaging protocols and progression to delayed intervention. RECENT FINDINGS: Overall, organizational guideline recommendations are broad and lack specifics regarding timing and modality for follow-up imaging of small renal masses. Additionally, despite general consensus in the literature about certain criteria to trigger delayed intervention, there exist no formal guidelines. Active surveillance of small renal masses is an acceptable management strategy for patients with prohibitive surgical risk; however, standardized imaging protocols for surveillance are lacking, as are randomized, prospective trials to evaluate the ideal follow-up protocol.