Do Hounsfield Units have any significance in predicting intra- and postoperative outcomes in retrograde intrarenal surgery using Holmium and Thulium fiber laser? Results from the FLEXible ureteroscopy Outcomes Registry (FLEXOR).

PURPOSE: To evaluate outcomes of flexible ureteroscopy for renal stones by comparing hard versus soft stones based on their attenuation on computed tomography (Hounsfield Units-HU). METHODS: Patients were divided into two groups according to the type of laser employed [Holmium:YAG (HL) or Thulium fiber laser (TFL)]. Residual fragments (RF) were defined as > 2 mm. Multivariable logistic regression analysis was performed to evaluate factors associated with RF and RF needing further intervention. RESULTS: 4208 patients from 20 centers were included. In whole series, age, recurrent stones, stone size, lower pole stones (LPS), and multiple stones were predictors of RF at multivariable analysis and LPS and stone size with RF requiring further treatment. HU and TFL were associated with lesser RF and RF requiring an additional treatment. In HU < 1000 stones, recurrent stones, stone size, and LPS were predictors of RF at multivariable analysis, whereas TFL was less likely associated with RF. Recurrent stones, stone size, and multiple stones were predictors of RF requiring further treatment, while LPS and TFL were associated with lesser RF requiring further treatment. In HU ≥ 1000 stones, age, stone size, multiple stones, and LPS were predictors of RF at multivariable analysis, while TFL was less likely associated with RF. Stone size and LPS were predictors of RF requiring further treatment, whereas TFL was associated with RF requiring further treatment. CONCLUSION: Stone size, LPS, and use of HL are predictors of RF after RIRS for intrarenal stones regardless of stone density. HU should be considered an important parameter in predicting SFR.

Improved lower urinary tract symptoms after robot-assisted radical prostatectomy: implications for survivorship, treatment selection and patient counselling.

OBJECTIVE: To assess changes in lower urinary tract symptoms (LUTS) and quality of life (QoL) after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: A prospectively curated database of 1917 consecutive RARPs undertaken over an 8-year period from January 2009 to January 2017 was assessed. Preoperative information including age, prostate-specific antigen (PSA) level, body mass index (BMI), International Prostate Symptom Score (IPSS) and QoL score was collected, with IPSS and QoL score compared between baseline (preoperatively) and 12 months post-surgery. RESULTS: Of the 1917 patients who underwent RARP, 1470 with complete data were included in the analysis. Their mean ± sd age, prostate weight and BMI were 62 (±6.7) years, 51 (±17.6) g, and 28 kg/m2 , respectively. Overall, 57% of patients reported an improved IPSS score, whilst 76% reported an IPSS of ≤7 postoperatively. A total of 41% of patients reported an improved QoL and 90.3% of patients with severe preoperative LUTS (IPSS 20-35) demonstrated clinically improved LUTS at 1 year post RARP. The post-RARP mean IPSS in the present study was lower than those reported in the existing post-radiotherapy literature, especially in patients with moderate to severe baseline LUTS (IPSSs ≥ 8). CONCLUSIONS: At 12 months post RARP, most patients reported improved overall LUTS and QoL, with the greatest benefit seen in those patients with a high pre-RARP IPSS. This has implications for treatment selection and preoperative counselling in men being offered active treatment for their prostate cancer. Further analyses of specific IPSS domains and longer follow-up are needed.

Predictors of new-onset chronic kidney disease in patients managed surgically for T1a renal cell carcinoma: An Australian population-based analysis.

BACKGROUND: New-onset chronic kidney disease (CKD) following surgical management of kidney tumors is common. This study evaluated risk factors for new-onset CKD after nephrectomy for T1a renal cell carcinoma (RCC) in an Australian population-based cohort. METHODS: There were 551 RCC patients from the Australian states of Queensland and Victoria included in this study. The primary outcome was new-onset CKD (eGFR <60 mL/min per 1.73 m2 ) and the secondary outcome was new-onset moderate-severe CKD (<45 mL/min per 1.73 m2 ). Multivariable logistic regression was used to evaluate associations between patient, tumor and health-service characteristics and these outcomes. RESULTS: Forty percent (219/551) of patients developed new-onset CKD, and 12% (68/551) experienced new-onset moderate-severe CKD. Risk factors for new-onset CKD were age, lower preoperative eGFR, tumor size >20 mm, radical nephrectomy, lower hospital caseloads (<20 cases/year), and rural place of residence. The associations between rural place of residence and low center volume were a consequence of higher radical nephrectomy rates. CONCLUSION: Risk factors for CKD after nephrectomy generally relate to worse baseline health, or likelihood of undergoing radical nephrectomy. Surgeons in rural centres and hospitals with low caseloads may benefit from formalized integration with specialist centers for continued professional development and case-conferencing, to assist in management decisions.

Changing trends in surgical management of renal tumours from 2000 to 2016: a nationwide study of Medicare claims data.

BACKGROUND: Guidelines recommend nephron sparing surgery where possible for patients with T1 renal tumours. The trends of nephron sparing surgery outside the USA are limited, particularly since the introduction of robotic-assisted partial nephrectomy (RAPN). The aim of this study was to describe contemporary surgical management patterns of renal tumours in Australia according to Medicare claims data. METHODS: Claims data according to the Medicare Benefits Schedule on surgical management of renal tumours in adult Australians between January 2000 and December 2016 was collated. Analysis of absolute number, population-adjusted rate and renal cancer-adjusted rate of interventions according to age and gender were performed, as well as proportion of RAPN. RESULTS: Between 2000 and 2016, the rate of partial nephrectomy (PN) increased while radical nephrectomy (RN) remained stable (PN: 0.87-4.16, RN: 6.52-6.70 per 100 000 population). Since 2015, PN has become more common than RN in patients aged 25 to 44 years (0.98 versus 0.95 procedures per 100 000 population). Renal cancer-adjusted rate exhibited a trend towards increasing utilization of PN and reduced RN across all age groups. An increase in overall surgical treatment was observed (25%-41%), mainly due to increased treatment of patients older than 75 years. The proportion of RAPN was seen to rapidly increase (4.7% in 2010 to 58% in 2016). CONCLUSIONS: Treatment utilization for renal masses has markedly changed in Australia according to Medicare claims. PN is increasingly replacing RN in younger patients, and older patients are receiving more surgical treatment. The impact of increased RAPN utilization is yet to be determined.

A Review of Prostate-Specific Membrane Antigen (PSMA) Positron Emission Tomography (PET) in Renal Cell Carcinoma (RCC).

Metastatic renal cell carcinoma (mRCC) is a disease that portends poor prognosis despite an increasing number of novel systemic treatment options including new targeted therapies and immunotherapy. Ablative intervention directed at oligometastatic RCC has demonstrated survival benefit. Consequently, developing techniques for improved staging of mRCC on contemporary imaging modalities including X-ray computed tomography (CT), magnetic resonance imaging (MRI) and/or bone scan (BS) is a clinical priority. This is relevant for metastatic deposits too small to characterize or lymph nodes within physiological normality. Prostate-specific membrane antigen (PSMA) is a type II transmembrane glycoprotein highly expressed on prostate cancer epithelial cells. Recently, small molecules targeting the PSMA receptor, linked to radioactive isotopes have been developed for use with positron emission tomography (PET). Despite its nomenclature, PSMA has also been found to be expressed in the neovasculature of non-prostate cancers such as renal cell carcinoma (RCC) and hence PSMA PET/CT imaging has been proposed as an alternative staging modality. Preliminary small studies involving the use of PSMA PET/CT imaging in mRCC have been encouraging with evidence of improved staging sensitivity which has directly led to change in management in some cases. Given these early encouraging reports, we performed a comprehensive narrative review on the available evidence, including the scientific basis for PSMA expression in RCC, the role of PSMA PET/CT imaging with potential clinical implications in mRCC, its limitations and future opportunities.

Changing etiology and management patterns for spontaneous renal hemorrhage: a systematic review of contemporary series.

OBJECTIVE: To conduct a systematic literature review on spontaneous renal hemorrhage (SRH) in a contemporary cohort describing patterns in etiology and treatment. METHODS: A systematic search of MEDLINE and CENTRAL databases was conducted to include articles, including case reports and case series on SRH published from 2000 to 2016. Full-text manuscripts were reviewed for clinical parameters which were collated and analyzed with univariate methods. RESULTS: Seventy-nine publications met inclusion criteria, reporting on 102 cases. Renal neoplasms (56.9%) and polyarteritis nodosa (PAN) (11.8%) remained as the most common overall and vascular causes of SRH, respectively. Angiomyolipoma (AML) was the most common causative renal neoplasm (74.1%), and patients were more likely to be female and present with macroscopic hematuria than those with vasculitis, while malignant neoplasms were more common in men. Proportions of SRH due to malignant neoplasms (specifically renal cell carcinoma, RCC) were reported less than PAN. Among this contemporary series, transarterial embolization (TAE) was most commonly used for acute SRH (42.2%). CONCLUSIONS: Renal neoplasms remain as the most common cause of SRH, of which AML predominates, while PAN is currently the second most common etiology in acute SRH, replacing RCC. Minimally invasive approaches, such as TAE and conservative/medical management, were preferred to initial surgery. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number CRD42017069222.

Geospatial patterns in human papillomavirus vaccination uptake: evidence from uninsured and publicly insured children in North Carolina.

BACKGROUND: Human papillomavirus (HPV) vaccination coverage is far below the national objective set by Healthy People 2020. This paper explores spatial patterns in HPV vaccination uptake. METHODS: Secondary data for publicly funded HPV vaccinations among age-eligible children from 2008 through 2013 from the North Carolina Immunization Registry (NCIR) were used in 2014 in an ecological analysis at the ZIP code tabulation area (ZCTA) level. We tested for spatial autocorrelation in unadjusted HPV vaccination rates using choropleth maps and Moran's I. We estimated nonspatial and spatial negative binomial models with spatially correlated random effects adjusted for demographic, economic, and healthcare variables drawn from the 2010 U.S. Census Bureau, 2008-2012 American Community Survey, 2010 ZIP Business Patterns, and the 2012-2013 Area Resource File. RESULTS: The NCIR revealed areas of especially low rates in publicly funded HPV vaccinations among uninsured and means-tested, publicly insured children. For boys, but not girls, ZCTAs tended to have HPV vaccination rates that were similar to their neighbors. This result was partially explained by included ZCTA characteristics, but not wholly. CONCLUSIONS: To the extent that the geospatial clustering of vaccination rates is due to causal influences from one ZCTA to another (e.g., through information networks), targeting interventions to increase HPV vaccination in one area could also lead to increases in neighboring areas. IMPACT: Spatial targeting of HPV vaccination, especially in clusters of low vaccination areas, could be an effective strategy to reduce the spread of HPV and related cancers. Cancer Epidemiol Biomarkers Prev; 24(3); 595-602. ©2015 AACR.

Geospatial patterns in influenza vaccination: evidence from uninsured and publicly insured children in North Carolina.

BACKGROUND: The purpose of this study was to explore geospatial patterns in influenza vaccination. METHODS: We conducted an ecological analysis of publicly funded influenza vaccinations at the ZIP code tabulation area (ZCTA) level using secondary data for publicly funded influenza vaccinations among eligible school-aged children (age range, 5-17 years) for the 2010-2011 and 2011-2012 influenza seasons from the North Carolina Immunization Registry (NCIR). NCIR data were merged by ZCTA with other publicly available data. We tested for spatial autocorrelation in unadjusted influenza vaccination rates using choropleth maps and Moran's I. We estimated nonspatial and spatial negative binomial models with spatially correlated random effects adjusted for demographic, economic, and health care variables. The study was conducted at the University of North Carolina at Chapel Hill in the spring of 2014. RESULTS: The NCIR demonstrated spatial autocorrelation in publicly funded influenza vaccinations among uninsured and means-tested, publicly insured school-aged children; ZCTAs tended to have influenza vaccination rates that were similar to their neighbors. This result was partially explained by included ZCTA characteristics, but not wholly. CONCLUSION: To the extent that the geospatial clustering of vaccination rates is the result of social influences, targeting interventions to increase influenza vaccination among school-aged children in one area could also lead to increases in neighboring areas.