Pancreatic metastasectomy of renal cell carcinoma: a single institution experience.

INTRODUCTION: Renal cell carcinoma (RCC) is the most common primary neoplasia that metastasizes to the pancreas. Pancreatic metastasis (PM) occur in asymptomatic older patients and are identified during follow up. If resectable, surgery is the treatment of choice for long term survival. Our goal is to analyze outcomes of patients with RCC-PM. MATERIAL AND METHODS: We reviewed all patients with metastatic RCC (mRCC) who underwent resection, from known primary RCC and RCC-PM. RESULTS: There were 16 patients (mean age of 67 ± 8 years, male 8 (50%), mean BMI 29 ± 5.36 kg/m2). Half of them were asymptomatic. Diagnosis was incidental in 56.25% with a median lesion size of 25 mm (12-80). Pancreatic resections performed were: pancreatoduodenectomy (31.25%), distal pancreatectomy (56.25%) and total pancreatectomy (12.5%). Median estimated blood loss was 225 mL (15-2,200), median operative time was 242 min (63-420). Median length of stay was 6 days (2-30). New-onset diabetes was 6.25%. The minor complication and reoperation rates, were 37.5% and 6.25%, respectively. The median number of harvested lymph nodes was 17 (4-31), all were negative. All had a R0 resection. Recurrence of disease was 18.75% with a median time after surgery of 3 years (2-6). The median follow up was 9 years (0-15). Thirteen (81.25%) patients are still alive, eight are disease free. Three (18.75%) died. CONCLUSIONS: Long term survival can be achieved with surgical resection of PM from RCC in selected patients in whom complete resection is possible.

Validation of new baseline renal function predictive model in robotic-assisted partial nephrectomy cohort.

OBJECTIVE: To validate a new baseline estimated glomerular filtration rate (NB-GFR) formula in a cohort of robotic-assisted partial nephrectomies (RAPN). METHODS: NB-GFR = 35 + preoperative GFR (× 0.65) - 18 (if radical nephrectomy) - age (× 0.25) + 3 (if tumor size >7 cm) - 2 (if diabetes). NB-GFR was calculated in 464 consecutive RAPN from a single surgeon cohort. 143 patients were excluded secondary to insufficient eGFR follow up. We analyzed NB-GFR accuracy utilizing the last observed eGFR 3-12 months post RAPN. Categorical variables were summarized with the frequency and percentage of patients. Numerical variables were summarized with the median, 25th percentile, and 75th percentile. RESULTS: The mean difference between observed and predicted NB-GFR was 4.6 ml/min/1.73m2 (95% CI -6.9 to 16.1 ml/min/1.73m2 ). There was a pattern of higher observed NB-GFRs being underestimated by the NB-GFR equation while lower observed NB-GFRs were overestimated by the NB-GFR equation. The NB-GFR formula had a high level of accuracy with 98.8% of predicted NB-GFRs falling within 30% of the observed NB-GFR (95% CI 86.8% to 99.5%). The median and interquartile range of the difference between observed and predicted NB-GFR was 3.9 ml/min/1.73m2 (IQR 0.7 to 8.2 ml/min/1.73m2 ). The sensitivity, specificity, positive predictive value, and negative predictive value for the ability of predicted NB-GFR to identify those with an observed NB-GFR <60 ml/min/1.73m2 after RAPN was 98%, 92%, 88%, and 99%, respectively. CONCLUSION: The NB-GFR equation developed with partial and radical nephrectomy cohorts is accurate in predicting post-operative eGFR 3-12 months following RAPN.

Independent external validation of a nomogram to define risk categories for a significant decline in estimated glomerular filtration rate after robotic-assisted partial nephrectomy.

OBJECTIVE: To validate the Martini nomogram predicting the decline in estimated glomerular filtration rate after robotic-assisted partial nephrectomy. METHODS: Estimated glomerular filtration rate of 406 patients from a single surgeon series was calculated before robotic-assisted partial nephrectomy and at postoperative intervals. To determine the risk group, we calculated the total score and corresponding risk of significant estimated glomerular filtration rate reduction at 15 months using the Martini nomogram. The primary outcome was a reduction in estimated glomerular filtration rate of ≥25% from preoperative levels between 1 and 12 months after surgery. RESULTS: The median length of follow up for this study was 12 months (interquartile range 6-12 months). Overall, 134 (33%) patients were in the low-, 143 (35%) in the intermediate-, 119 (29%) in the high- and 10 (2%) in the very high-risk groups. The Kaplan-Meier estimates for the probability of significant estimated glomerular filtration rate reduction by 12 months after robotic-assisted partial nephrectomy was 12.9% in the low-risk group, 24.0% in the intermediate-risk group, 49.7% in the high-risk group and 40.0% in the very high-risk group. Harrell's C-index for discriminating between those with and without a significant reduction in estimated glomerular filtration rate 1-12 months after robotic-assisted partial nephrectomy was 0.73 (95% confidence interval 0.68-0.78). CONCLUSIONS: The risk groups proposed by the Martini nomogram are accurate in predicting those at higher risk for a >25% decline in postoperative estimated glomerular filtration rate after robotic-assisted partial nephrectomy at 12 months.

Mayo Adhesive Probability (MAP) score of non-donated kidney aids in predicting post-operative renal function following donor nephrectomy.

BACKGROUND: To examine the association of preoperative Mayo Adhesive Probability (MAP) scores in the donor (MAPd) and non-donor kidneys (MAPnd) with post-donation renal function. METHODS: Three hundred thirty-one patients undergoing hand assisted laparoscopic donor nephrectomy (HALDN) were reviewed. MAPd and MAPnd were obtained. Estimated glomerular filtration rate (eGFR) was recorded preoperatively and at 1 day, 1 month, and 6 months postoperatively. RESULTS: Two hundred females and 131 males were evaluated with median BMI 26.4 kg/m2 (range 17.1-39.6) and median age 45 years (range 19-78). MAPd score was 0 for 231 patients (69.8%) and > 0 for 100 patients (30.2%). MAPnd score was 0 for 234 patients (70.7%) and > 0 for 97 patients (29.3%). The median preoperative eGFR was 86.6 ml/min/1.73m2 (range 48.8-138.4). After adjusting for preoperative eGFR, BMI, ASA score, and kidney sidedness, postoperative eGFR was associated with MAP score in the non-donated kidney (p = 0.014) but not in the donated kidney (p = 0.24). Compared to donors with MAPnd = 0, donors with a MAPnd > 0, mean eGFR was - 2.33 ml/min/1.73m2 lower at postoperative day 1 (95% CI - 4.24 to - 0.41, p = 0.018), - 3.02 ml/min/1.73m2 lower at 1 month (95% CI - 5.11 to - 0.93, p = 0.005), and - 2.63 ml/min/1.73m2 lower at 6 months postoperatively (95% CI - 5.01 to - 0.26, p = 0.030). CONCLUSIONS: MAP score > 0 in the non-donated kidney is associated with worse renal function in the 6 months following HALDN.

Spontaneous extrusion of renal calculi presenting as a retroperitoneal abscess.

Spontaneous extrusion of a kidney stone is an extremely rare event with few reported cases. We present the unusual case of a 62-year-old female who presented with worsening of fever and flank pain over a 5 day period. Imaging revealed retroperitoneal and abdominal wall abscesses that upon evaluation of prior imaging were attributed to spontaneously extruded kidney stones. Prior reports suggest surgical exploration and extraction is the preferred treatment option for extruded renal calculi. Based on the experience presented here, conservative management may be an attractive first-line treatment option for patients with extruded renal stones and associated retroperitoneal abscesses.

Utility of the Aortic-Lesion-Attenuation-Difference (ALAD) and Peak Early-Phase Enhancement Ratio (PEER) to differentiate benign from malignant renal masses.

INTRODUCTION: To evaluate the utility of the Aorta-Lesion-Attenuation-Difference (ALAD) and Peak Early-phase Enhancement Ratio (PEER) on contrast-enhanced computed tomography (CT) to differentiate between the appearances of chromophobe renal cell carcinoma, clear cell renal cell carcinoma, and oncocytoma. MATERIAL AND METHODS: ALAD and PEER values were retrospectively measured by a reviewer from 119 patients with surgically resected renal masses (chromophobe renal cell carcinoma n = 29, clear cell renal cell carcinoma n = 28, and oncocytoma n = 62). The ALAD value is expressed as: ALAD = Hounsfield Units aorta - Hounsfield Units mass. PEER is expressed as (Hounsfield Units contrast tumor - Hounsfield Units non-contrast tumor):( Hounsfield Units contrast cortex - Hounsfield Units non-contrast cortex). RESULTS: The ALAD median was 27.6 for oncocytomas, 68.5 for chromophobe renal cell carcinoma, and 55.4 for clear cell renal cell carcinoma. A significant difference between ALAD values of oncocytoma and chromophobe renal cell carcinoma was observed in the nephrographic (area under the ROC curve 0.92) and excretory phases (area under the ROC curve 0.95). The PEER median was 0.74 for oncocytomas and 0.37 for chromophobe renal cell carcinoma. The PEER values significantly differed while comparing oncocytomas and chromophobe renal cell carcinoma in the nephrographic and excretory phases. CONCLUSIONS: Preoperative contrast-enhanced CT ALAD and PEER values both significantly differentiate between chromophobe renal cell carcinoma and oncocytoma. PEER may be more effective in contrast-enhanced CT scans lacking distinct phases.

Factors associated with prolonged length of stay following robotic-assisted partial nephrectomy.

INTRODUCTION: To prospectively analyze the association of clinical and operative variables on patient length of hospital stay (LOS) following robotic-assisted partial nephrectomy (RAPN) and develop an accurate clinical-based scoring system to predict prolonged LOS following RAPN. MATERIALS AND METHODS: We analyzed 304 consecutive RAPNs performed by a single surgeon. Prolonged LOS was defined as greater than 3 days of hospitalization postoperatively. Preoperative clinical factors and operative variables were analyzed for association with LOS. After adjusting for multiple testing, p ≤ 0.004 was considered statistically significant. RESULTS: LOS was 1 day in 17 (5.6%) patients, 2 days in 136 (44.7%) patients, 3 days in 89 (29.3%) patients, and more than 3 days in 62 (20.4%) patients. Lower preoperative hemoglobin (p = 0.004), total operative time (p < 0.001), estimated blood loss (EBL) (p < 0.001), intraoperative complications or conversion (p < 0.001), and renal mass size (p < 0.001) were associated with prolonged LOS. EBL and total operative time were most predictive of prolonged LOS and were used to create the BLOT (blood loss and operative time) predictive scoring system. Blot scores ranged from 0 to 5, to predict prolonged LOS. We observed prolonged LOS in 4.3%, 9.6%, 25.6%, 47.1%, 50.0%, and 100% of patients with scores of 0, 1, 2, 3, 4, and 5, respectively. CONCLUSIONS: Operative time and estimated blood loss are most predictive of prolonged LOS following RAPN. Using these variables, the BLOT score accurately predicts prolonged LOS following RAPN.

Prospective evaluation of the effect of adherent perinephric fat on outcomes of robotic assisted partial nephrectomy following elimination of the learning curve.

PURPOSE: To prospectively evaluate the association of adherent perinephric fat (APF) on perioperative outcomes of robotic-assisted partial nephrectomy (RAPN) following elimination of the surgical learning curve. MATERIALS AND METHODS: 305 consecutive RAPNs performed by a single experienced surgeon were analyzed. The fi rst 100 RAPNs were considered the learning curve and therefore excluded. APF was defined as the necessity of subcapsular renal dissection to mobilize the tumor from surrounding perinephric fat. Perioperative outcomes were evaluated including operative time, warm ischemia time (WIT), postoperative complications, length of stay, margins, ischemia, and complications score (MIC), estimated blood loss (EBL), and change in pre-operative to postoperative day 1 (POD 1) laboratory values. After correction for multiple comparisons, P values ≤0.0045 were considered statistically signifi cant but associations with P values ≤0.05 were also mentioned in the study results. RESULTS: Fifty-eight (28.3%) patients had APF. Patients with APF had longer operative times compared to those without APF (median, 213 vs. 192 minutes, P <0.001). There was some evidence of higher increase in change in creatinine from preoperative to POD 1 among those with APF compared to those without APF, although this was not statistically signifi cant (median, 0.2 vs. 0.1mg/dL, P=0.03). There were no other statistically significant associations between presence of APF and perioperative outcomes. CONCLUSIONS: APF is associated with increased operative time but no change in other perioperative outcomes. Surgeon experience does not affect perioperative outcomes associated with APF.

Alcohol consumption, variability in alcohol dehydrogenase genes and risk of renal cell carcinoma.

Alcohol consumption has been associated inversely with renal cell carcinoma (RCC) risk; however, no study has examined effect modification by germline variation in alcohol-metabolizing genes. We investigated whether the association between alcohol intake and RCC risk is modulated by germline variants in alcohol dehydrogenase genes in a large case-control study. Data from 652 RCC cases and 1,366 non-cancer controls were analyzed. Alcohol intake was assessed using a standardized risk factor questionnaire. Three previously genotyped polymorphisms in ADH6 and ADH7 with the TaqMan assay were examined. Odds ratios (ORs) and 95% confidence interval (CI) were calculated using logistic regression, adjusting for covariates. Compared to non-drinkers, ever consumption of alcohol was associated with lower RCC risk (OR = 0.52, 95% CI = 0.42-0.65). Analysis with cubic spline regression curve showed a "J-shaped" relationship between alcohol drinks/day and RCC risk, such that there was no added benefit against RCC for consumption of more than two drinks/day. We observed effect modification by variation in rs1154454 (ADH7) (pinteraction = 0.007); a per unit increase in alcohol drink/day was associated with 35% lower RCC risk among non-minor allele carriers, a 27% lower risk among those who carry one copy of the minor allele, but no association was observed among those with two copies of the minor allele. These findings indicate that alcohol consumption is associated with lower RCC risk. Consuming more than two drinks a day does not confer additional protection against RCC. The association between alcohol intake and RCC risk appears to be modulated by inter-individual germline variation in alcohol-metabolizing genes.

Coffee consumption and risk of renal cell carcinoma.

BACKGROUND: Studies have suggested an inverse association between coffee consumption and risk of renal cell carcinoma (RCC); however, data regarding decaffeinated coffee are limited. METHODS: We conducted a case-control study of 669 incident RCC cases and 1,001 frequency-matched controls. Participants completed identical risk factor questionnaires that solicited information about usual coffee consumption habits. The study participants were categorized as non-coffee, caffeinated coffee, decaffeinated coffee, or both caffeinated and decaffeinated coffee drinkers. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression, adjusting for multiple risk factors for RCC. RESULTS: Compared with no coffee consumption, we found an inverse association between caffeinated coffee consumption and RCC risk (OR 0.74; 95% CI 0.57-0.99), whereas we observed a trend toward increased risk of RCC for consumption of decaffeinated coffee (OR 1.47; 95% CI 0.98-2.19). Decaffeinated coffee consumption was associated also with increased risk of the clear cell RCC (ccRCC) subtype, particularly the aggressive form of ccRCC (OR 1.80; 95% CI 1.01-3.22). CONCLUSIONS: Consumption of caffeinated coffee is associated with reduced risk of RCC, while decaffeinated coffee consumption is associated with an increase in risk of aggressive ccRCC. Further inquiry is warranted in large prospective studies and should include assessment of dose-response associations.

'Pseudo' pseudoaneurysm following robotic assisted partial nephrectomy.

A 65-year-old female presented to clinic requesting follow up for a history of right robotic partial nephrectomy done at an outside institution 2 years prior. Initial pathology demonstrated a grade 2/4 3.4 cm clear cell renal cell carcinoma with negative margins. There was no tumor necrosis, sarcomatoid differentiation, or lymphovascular invasion. High quality follow up imaging initially revealed a pseudoaneurysm in the central portion of the right kidney. The patient was sent to interventional radiology for angioembolization. Angiography identified the abnormality to be a recurrent or residual mass in the renal hilum. MRI confirmed these findings, and the patient ultimately required a laparoscopic radical nephrectomy for definitive treatment. Final pathology showed grade 2/4 clear cell renal cell carcinoma with negative margins and no tumor necrosis or sarcomatoid differentiation. The tumor did involve sinus fat and sinus vessels, but not perinephric fat.

Timing interval from peri-prostatic block to biopsy impacts procedural pain.

INTRODUCTION: To compare visual analog scale (VAS) pain scores between patients with a 2-minute versus 10-minute delay of peri-prostatic lidocaine injection prior to transrectal ultrasound-guided prostate biopsies (TRUS-bx). MATERIALS AND METHODS: Eighty patients who underwent standard 12-core TRUS-bx by a single surgeon were prospectively randomized into four different treatment arms: bibasilar injection with a 2-minute delay, bibasilar injection plus a single apical injection with a 2-minute delay, bibasilar injection with a 10-minute delay, and bibasilar injection plus a single apical injection with a 10-minute delay. Patients were asked to report their level of pain on the VAS (0-10, with 10 indicating unbearable pain) at the following intervals: probe insertion (baseline), after each core, and post-procedure. The primary outcome measure was mean VAS score across all 12 cores minus baseline VAS score, which we refer to baseline-adjusted mean VAS score. RESULTS: Baseline-adjusted mean VAS score was significantly higher for the 2-minute delay group compared to the 10-minute delay group (mean: -0.7 versus -1.6, p = 0.025). Subset analysis of biopsies 1-3, 4-6, 7-9 and 10-12 also demonstrated higher baseline-adjusted mean VAS scores in the 2-minute delay group (all p ≤ 0.043). CONCLUSIONS: Lower TRUS-bx VAS scores can be achieved by extending the time from lidocaine injection to onset of prostate biopsy from 2 to 10 minutes.

Salvage autologous fascial sling after failed synthetic midurethral sling: Greater than 3-year outcomes.

OBJECTIVE: To determine long-term surgical outcomes of salvage autologous fascial sling placement after a failed synthetic midurethral sling. METHODS: Women who had undergone autologous fascial sling placement without concomitant pelvic surgery for a failed synthetic midurethral sling utilizing mesh with a minimum follow up of 36 months were identified. Charts were reviewed, and patients were contacted by telephone. Success was determined by the Patient Global Impression of Improvement. Secondary measures included the Incontinence Severity Index questionnaire, patient recommendation of the autologous fascial sling and need for further incontinence surgery. RESULTS: A total of 35 patients met the criteria, and 21 were successfully contacted. Of those contacted, the median age at surgery was 67 years (range 53-81 years) and at the time of the survey was 75 years (range 63-84 years) with median follow up of 74 months (range 36-127 years). Preoperatively, 12 patients (57.1%) had urethral hypermobility and 13 patients (61.9%) had mixed urinary incontinence. Eight patients (38.1%) had concomitant sling excision with five of those combined with urethrolysis at the time of the salvage operation. Patient Global Impression of Improvement success was noted in 16 patients (76.2%). A total of 11 patients (52.4%) were dry or had slight incontinence by the Incontinence Severity Index. One patient required additional anti-incontinence surgery (4.8%). A total of 18 patients (85.7%) recommended the autologous fascial sling. No statistical impact was noted with sling excision (P = 0.62), mixed urinary incontinence (P = 0.61), age at surgery (P = 0.23), age at follow up (P = 0.15), length of follow up (P = 0.71) or first surgery type (transobturator tape vs retropubic; P = 1.00). CONCLUSIONS: Autologous fascial sling provides reasonable long-term success as a salvage operation for failed midurethral slings.

Baseline and follow-up association of the MAX-PC in Men with newly diagnosed prostate cancer.

OBJECTIVE: The objective of this paper is to conduct a prospective, longitudinal study employing the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) to examine the baseline and follow-up association of prostate cancer (PCa)-specific anxiety, health-related quality of life (HRQOL), and PCa aggressiveness in men with newly-diagnosed PCa undergoing prostatectomy at our institution. METHODS: From our prospective PCa registry, we identified a total of 350 men with newly-diagnosed PCa who completed the MAX-PC and the Expanded Prostate Cancer Index Composite (EPIC) at baseline and one-year following surgery. Scores on both measures were compared with clinical measure and demographics using the Wilcoxon Rank Sum, Fisher's exact, and Cochran-Armitage Trend tests. Spearman test was used to assess correlation at between the MAX-PC and EPIC at baseline and one-year. RESULTS: Baseline overall MAX-PC measures were correlated with measures at one-year (r=0.5479, p<0.001). Those reporting high anxiety at one-year were more likely to have Gleason score>6 (p=0.004), T-Stage ≥ 2C disease (p=0.004), and a postoperative prostate-specific antigen (PSA)>0.1 (p=0.002); however, this did not apply to all anxious patients. Baseline EPIC sexual function scores were predictive of follow-up EPIC sexual function scores as well (r=0.5790, p<0.001). Depression was noted as a problem in 16% of patients at follow-up. CONCLUSIONS: Our data suggests that the MAX-PC could be used at baseline as a tool to determine who may benefit from psychological intervention pre-PCa and post-PCa treatment. In terms of individualized medicine, behavioral therapy may be the most beneficial in improving HRQOL for younger patients, those with advanced stage disease, and more specifically those whose anxiety outweighs their actual prognosis.

Comparison of patient-reported quality of life outcome questionnaire response rates between patients treated surgically for renal cell carcinoma and prostate carcinoma.

BACKGROUND: We sought to examine differences in response rates to quality of life (QoL) surveys in patients treated surgically for renal cell carcinoma (RCC) and prostate cancer (PCa) and to analyze factors associated with non-response of the surveys. METHODS: Patients who underwent surgery for RCC or PCa between 2006 and 2012 were offered enrollment in respective prospective cancer registries that included baseline and annual QoL assessments. We identified 201 RCC patients and 616 PCa patients who completed a baseline QoL survey and were mailed annual QoL surveys [RCC: SF-36, FACT-G (73 questions), PCa: EPIC, IIEF, Max-PC (80 questions)]. We compared patient characteristics between responders and non-responders using a Wilcoxon rank-sum test for continuous variables and a Fisher's Exact test for categorical variables. RESULTS: The overall response rates for the PCa and RCC groups were 63 and 48% (p < 0.001), respectively. This difference in response rates remained when we limited analysis to only those with early stage disease (pT2 for PCa and pT1 RCC, 62% vs. 52%; p = 0.03). PCa characteristics associated with response included older age (64.1 vs 62.6 years, p = 0.032) and robotic versus open surgery (56% vs 44%; p = 0.009). There were no characteristics that were associated with response in RCC patients. CONCLUSIONS: Surgically treated PCa patients have higher QoL mail-based survey response rates compared to patients treated surgically for RCC. This difference holds true for clinically localized cancers as well.

Retroperitoneal hematoma secondary to inferior adrenal artery spontaneous hemorrhage.

Spontaneous retroperitoneal hematoma (SRH) is a rare, potentially lethal entity that can arise from a variety of etiologies. We present a case of SRH secondary to hemorrhage from the right inferior adrenal artery in a 22-year-old woman. The patient presented to the emergency room with significant right flank pain, and computed tomography (CT) demonstrated a large, right-sided retroperitoneal hematoma with no identifiable etiology. Renal angiography revealed active extravasation from the right inferior adrenal artery. The patient was definitively treated with endovascular coiling of the ruptured artery, and long term follow up demonstrated resolution of the retroperitoneal hematoma.

Prospective evaluation of 24-hour urine profiles following bariatric surgery in a modern comprehensive care bariatric clinic.

AIMS: To prospectively examine the effect of modern bariatric surgery on 24-hour urine parameters in a comprehensive care bariatric practice (CCBP). MATERIALS AND METHODS: 47 consecutive patients in our CCBP underwent serum and 24-hour urine analysis pre-operatively, and 30 returned at 12 months for repeat testing. Paired comparisons for serum metabolite and 24-hour urine measures were performed using a Wilcoxon signed-rank test for continuous variables and McNemar's test for categorical variables. Statistical tests were two-sided, with threshold of significance set at p = 0.05. RESULTS: All 30 patients with pre-operative and 12-month follow-up analysis were free of stone events. 20 (67%) had Roux-en-Y gastric bypass (RYGB), 6 (20%) had laparoscopic gastric banding (LGB), and 4 (13%)h ad laparoscopic sleeve gastrectomy (LSG). 24-hour urinary parameters were available for 27 patients. Median urine oxalate (mmol) was 0.29 pre-operatively and 0.21 at 12 months (p = 0.048). Median urine calcium (mg) was 143 pre-operatively and 180 at 12 months (p = 0.11). Median citrate excretion was 527 pre-operatively and 782 at 12 months (p = 0.22). Median serum creatinine was 0.7 pre-operatively and 0.8 at 12 months (p < 0.001). These trends were preserved with the exclusion of LGB and LSG patients. CONCLUSIONS: Modern bariatric surgery (RYGB, LGB, and LSG) as part of a CCBP can still demonstrate alterations of select urinary parameters (particularly oxalate and citrate) in select patients associated with an increased risk of urolithiasis at 1 year follow-up.

Case series demonstrating the clinical utility of dual energy computed tomography in patients requiring stents for urinary calculi.

Dual energy computed tomography (DECT) utilizes the material change in attenuation when imaged at two different energies to determine the composition of urinary calculi as uric acid or non-uric acid. We discuss a series of case reports illustrating DECT's ability to provide immediate determination of uric acid versus non-uric acid calculi and facilitate more informed clinical decision-making. Further, these cases demonstrate a unique population of patients with ureteral stents and percutaneous nephrostomy tubes that benefit from DECT's ability to create a virtual color contrast between an indwelling device and the stone material and thereby significantly impacting patient morbidity.

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy.

Objective: We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre- and peri-operative variables associated with length of stay (LOS) greater than 3 days and readmission within 30 days. Methods: Records from 2008 to 2018 for "laparoscopy, surgical; partial nephrectomy" for prolonged LOS and readmission cohorts were compiled. Univariate analysis with Chi-square, t-tests, and multivariable logistic regression analysis with odds ratios (ORs), p-values, and 95% confidence intervals assessed statistical associations. Results: Totally, 20 306 records for LOS greater than 3 days and 15 854 for readmission within 30 days were available. Univariate and multivariable analysis exhibited similar results. For LOS greater than 3 days, undergoing non-elective surgery (OR=5.247), transfusion of greater than four units within 72 h prior to surgery (OR=5.072), pre-operative renal failure or dialysis (OR=2.941), and poor pre-operative functional status (OR=2.540) exhibited the strongest statistically significant associations. For hospital readmission within 30 days, loss in body weight greater than 10% in 6 months prior to surgery (OR=2.227) and bleeding disorders (OR=2.081) exhibited strongest statistically significant associations. Conclusion: Multiple pre- and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data. Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection, optimization strategies, and patient education.

Disposable Cystoscopes Do Not Decrease Post Renal Transplant Stent Removal Symptomatic Infection Rates.

OBJECTIVE: To evaluate the effect of disposable cystoscopes on the rate of symptomatic urinary tract infections (UTI) following post-renal transplant cystoscopic stent removal. METHODS: We performed a retrospective study of post-renal transplant cystoscopic stent removals in our outpatient clinic from March 2019 to March 2022. Our clinic converted to disposable cystoscopes in October 2021. All outpatient, phone, and portal encounters were reviewed for 30 days following the procedure. The primary outcome was the number of post-procedural symptomatic UTI within 30 days of the procedure. Symptomatic UTI was defined as fever, dysuria, or hematuria accompanied by a positive urine culture. RESULTS: A total of 323 patients had post-transplant stent removals including 123 with reusable scopes and 200 with disposable scopes. Around 1.6% (2/123) of patients with a reusable cystoscope experienced symptomatic UTI's. They had positive urine cultures for Escherichia coli and Klebsiella. 2.0% (4/200) of patients with a disposable cystoscopy had a symptomatic UTI. The 3 types of positive urine cultures they experienced were E Coli, Klebsiella, and Enterococcus. CONCLUSION: The conversion from reusable to disposable cystoscopes did not decrease symptomatic UTI following renal transplant stent removal.