Predictors of symptomatic relief in water vapor thermal therapy for prostatic hyperplasia: 36-month prospective study.

PURPOSE: Existing literature lacks an analysis of factors predicting the achievement of minimum clinically important differences (MCID) after water vapor thermal therapy (WVTT) for prostatic hyperplasia. This study aims to identify these predictors over a 36-month post-WVTT period. METHODS: This prospective single surgeon case series assessed male patients receiving WVTT. Eligibility criteria included being at least 45 years old, having an estimated prostate volume (EPV) of 30-80 cc, an International Prostate Symptom Score (IPSS) of 12 points or more, and a maximum urinary flow rate (Qmax) under 16 mL/sec. MCID, representing the smallest symptomatic improvement perceived by patients, was calculated using the distribution-based method, considering half a standard deviation of baseline IPSS scores. Correlation and linear regression analyses assessed MCID attainment. Multivariable logistic regression evaluated MCID achievement, considering multicollinearity, heteroskedasticity, and normality. RESULTS: Of 206 men with a median 29.1-month follow-up (Range: 24-36), 13.6% didn't achieve MCID for IPSS, and 7.2% for QoL scores. Significant hindrances to MCID attainment for IPSS were a large median lobe (> 10 mm protrusion) (OR = 3.01, 95% CI: 2.3-3.72), increased median lobe treatments (OR = 1.73, 95% CI: 1.23-2.35), and high preoperative irritative IPSS scores (OR = 1.25, 95% CI: 1.13-1.38). Factors for QoL MCID non-achievement included age over 75 (OR = 1.25, 95% CI: 1.13-1.38), a large median lobe (OR = 1.87, 95% CI: 1.62-2.01), and EPV over 60 cc (OR = 1.55, 95% CI: 1.16-1.97). A 6.3% surgical re-intervention rate was noted. CONCLUSIONS: The characteristics of the median lobe as well as the severity of lower urinary tract symptoms are crucial for treatment success. These should be integral to preoperative assessments and patient discussions on treatment options.

Artificial Intelligence in Urology: Application of a Machine Learning Model to Predict the Risk of Urolithiasis in a General Population.

This research presents our application of artificial intelligence (AI) in predicting urolithiasis risk. Previous applications, including AI for stone disease, have focused on stone composition and aiding diagnostic imaging. AI applications centered around patient-specific characteristics, lifestyle considerations, and diet have been limited. Our study comprised a robust sample size of 976 Chilean participants, with meticulously analyzed demographic, lifestyle, and health data through a comprehensive questionnaire. We developed a predictive model using various classifiers, including logistic regression, decision trees, random forests, and extra trees, reaching high accuracy (88%) in identifying individuals at risk of kidney stone formation. Key protective factors highlighted by the algorithm include the pivotal role of hydration, physical activity, and dietary patterns that played a crucial role, emphasizing the protective nature of higher fruit and vegetable intake, balanced dairy consumption, and the nuanced impact of specific protein sources on kidney stone risk. In contrast, identified risk factors encompassed gender disparities with males found to be 2.31 times more likely to develop kidney stones than females. Thirst and self-perceived dark urine color emerged as strong predictors, with a significant increase in the likelihood of stone formation. The development of predictive tools with AI, in urolithiasis management signifies a paradigm shift toward more precise and personalized health care. The algorithm's ability to process extensive datasets, including dietary habits, heralds a new era of data-driven medical practice. This research underscores the transformative impact of AI in medical diagnostics and prevention, paving the way for a future where health care interventions are not only more effective but also tailored to individual patient needs. In this case, AI is an important tool that can help patients stay healthy, prevent diseases, and make informed decisions about their overall well-being.

Differences in cancer presentation, treatment, and mortality between rural and urban patients diagnosed with kidney cancer in the United States.

INTRODUCTION: Rural-urban discrepancies in care and outcomes for kidney cancer (KCa) in the United States remains poorly understood. Our study aims to improve our understanding of the influence of rurality on KCa outcomes in the United States by analyzing differences in presentation, treatment, and mortality between urban areas (UAs) and rural areas (RAs) in the Surveillance, Epidemiology, and End Results (SEERs) database. METHODS: SEERs data was queried from 2000 to 2019 for KCa patients. Patient counties were classified as UAs, rural adjacent areas (RAAs), or rural nonadjacent areas (RNAs) using Rural Urban Continuum Codes. Demographic, tumor characteristics, and treatment variables were compared. Propensity score matching was performed to create matched UA-RAA and UA-RNA cohorts. Multivariate regression evaluated rural-urban status as a predictor of treatment selection. Multivariate cox regression assessed the predictive value of rural-urban status for overall survival (OS) and cancer-specific survival (CSS). Kaplan-Meier analysis was used to generate survival curves for OS and CSS. RESULTS: 179,509 KCa patients were identified (UA = 87.0%, RAA = 7.7%, RNA = 5.3%). Patients in RAs were more likely to present with tumors of higher grade and stage than UAs. Following multivariate analysis, rural residency predicted undergoing nephrectomy (RAA: OR = 1.177, RNA: OR = 1.210) but was a negative predictor of receiving partial nephrectomy (RAA: OR = 0.744, RNA: OR = 0.717), all P < 0.001. Multivariate cox regression demonstrated that RAA or RNA residency was predictive of overall and cause-specific mortality. After matching, median OS was 151, 124, and 118 months for UA, RAA, and RNA cohorts respectively; mean CSS was 152, 147, and 144 months for UA, RAA, and RNA cohorts, respectively, all P < 0.001. Stage-specific analysis of CSS demonstrated significantly poorer CSS among RNA patients for localized, regionalized, and distant KCa after matching. Only RAA patients with localized KCa experienced significantly lower CSS than UA patients. CONCLUSIONS: Patients in RAs are more likely to present with advanced KCa at diagnosis compared to those in UAs and may also experience different treatment options including a lesser likelihood of undergoing partial nephrectomy. Rural patients with KCa also demonstrated significantly worse OS and CSS compared to their urban counterparts. Further patient-level studies are required to better understand the discrepancy in CSS between urban and rural patients diagnosed with KCa.

Initial Experience in Urological Surgery with a Novel Robotic Technology: Magnetic-Assisted Robotic Surgery in Urology.

Introduction and objective: Magnetic-assisted robotic surgery (MARS) has been developed to maximize patient benefits of minimally invasive surgery while enhancing surgeon control and visualization. MARS platform (Levita Magnetics) comprises two robotic arms that provide control to an external magnetic controller and an off-the-shelf laparoscopic camera. Our aim was to evaluate the safety and efficacy of the MARS platform in laparoscopic renal and adrenal procedure for the first time. Methods: This is a prospective, single-arm, open-label study (Clinical Trials Identifier: NCT05353777) including patients with renal or adrenal pathology analysis, submitted to laparoscopic procedure between April and June 2022. Patients were followed up to 30 days postoperatively. Preoperative, intraoperative, and postoperative data were recorded. Polynomial regression was used to determine the learning curve for docking time. Results: Fifteen cases were performed using the MARS platform (three partial nephrectomies, five total nephrectomies for benign pathology analysis, four radical nephrectomies, and three adrenalectomies) corresponding to 10 women and 5 men (mean age, 55 years [18-77]; average body mass index, 29 cm/m2 [22-39]). No cases required conversion to open procedure and all patients were discharged on the first or second postoperative day. No complications or re-admissions were reported within the first 30 days. All oncologic cases had negative margins. Learning curve was achieved by the fourth case, diminishing docking time from 5.22 (2.6-11.5) to 2.68 minutes (2.1-3.8) (p = 0.002). The learning curve was fitted to a cubic regression (R2 = 0.714). Conclusion: This is the first clinical study demonstrating the safety and versatility of the MARS platform in urologic procedures. The robot was especially useful for tissue retraction, avoiding additional incisions and the need for a surgical assistant while increasing surgeon control and visualization. The learning curve was rapid, achieving a short docking time. MARS is a promising new technology that could be successfully evaluated in other surgeries.

Transurethral Resection of Bladder Tumor Outcomes Are Predicted by a 5-Item Frailty Index.

OBJECTIVE: To evaluate the mFI-5 as a predictor of postoperative outcomes following transurethral resection of bladder tumor (TURBT). METHODS: The National Surgical Quality Improvement Program database was queried for TURBT cases from 2015-2019. mFI-5 scores were calculated by assigning a point to chronic obstructive pulmonary disease, congestive heart failure, dependent functional status, hypertension, and diabetes. Patients were stratified by mFI-5 scores. Demographics and 30-day outcomes including Clavien-Dindo (CD) complications, mortality, and increased healthcare resource utilization (HCRU) were compared. HCRU outcomes included prolonged length of stay, unplanned readmission, and discharge to continued care. Multivariate regression assessed the predictive value of mFI-5 scores on outcomes. RESULTS: 40,278 TURBT cases were identified (mFI-5 =0: 12,400, mFI-5 =1: 17,328, mFI-5 =2: 9225, mFI-5 ≥3: 1416). Patients with higher mFI-5 scores were more likely to be older, male, White, and have larger tumors, all P < .05. Increasing mFI-5 scores resulted in increased frequency of all adverse outcomes, all P < .001. On multivariate analysis, mFI-5 ≥ 3 classification was a predictor of CD I/II (OR=1.280), CD IV (OR=2.539), mortality (OR=2.202), HCRU (OR=2.094), prolonged length of stay (OR=2.136), discharge to continued care (OR=3.401), and unplanned readmission (OR=1.705), all P < .05. A mFI-5 ≥ 3 demonstrated a sensitivity ranging from 6.0%-13.5% and a specificity ranging from 96.6%-97.0% for all outcomes. CONCLUSION: The mFI-5 is an easily ascertainable preoperative risk assessment tool that is a predictor of adverse clinical and HCRU outcomes following TURBT.

Comparison of Single-Port Robotic Donor Nephrectomy and Laparoscopic Donor Nephrectomy.

Purpose: To compare the intra- and postoperative outcomes of single-port robotic donor nephrectomies (SP RDNs) and laparoscopic donor nephrectomies (LDNs). Materials and Methods: We retrospectively reviewed our institutional database for patients who received LDN or SP RDN between September 2020 and December 2022. Donor baseline characteristics, intraoperative outcomes, postoperative outcomes, and recipient renal function were extracted and compared between LDN and SP RDN. SP RDN learning curve analysis based on operative time and graft extraction time was performed using cumulative sum analysis. Results: One hundred forty-four patients underwent LDN and 32 patients underwent SP RDN. LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 minutes, SP RDN: 194.5 ± 35.1 minutes, p = 0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 seconds, SP RDN: 204.1 ± 52.2 seconds, p < 0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 seconds, SP RDN: 275.4 ± 65.6 seconds, p < 0.0001). There were no differences in patient subjective pain scores, inpatient opioid usage, or Clavien-Dindo II+ complications. Short- and medium-term postoperative donor and recipient renal function were also similar between the groups. SP RDN graft extraction time and total operative time learning curves were achieved at case 27 and 13, respectively. Conclusion: SP RDN is a safe and feasible alternative to LDN that minimizes postoperative abdominal incisional scars and has a short learning curve. Future randomized prospective clinical trials are needed to confirm the findings of this study and to identify other potential benefits and drawbacks of SP RDNs.

Swiss LithoClast® Trilogy Lithotripter for Use in Robotic Pyelolithotomy.

Introduction: The Boston Scientific Swiss LithoClast® Trilogy lithotripter was intended for use in percutaneous nephrolithotomy. We performed, to our knowledge, the first two robotic pyelolithotomies using the Trilogy lithotripter for intracorporeal lithotripsy. Case Description: Two cases are presented involving a 65-year-old female with a complete left staghorn calculus and hydronephrosis secondary to a left ureteropelvic junction (UPJ) obstruction, and a 69-year-old male with a large left staghorn calculus and multiple large left sided simple renal cysts. In both cases, a robotic pyelolithotomy was scheduled for stone removal along with concurrent UPJ repair and cyst decortication respectively. Following pyeloplasty and cyst decortication respectively, and following stone visualization, the 2.4-mm Trilogy probe was inserted into the 12-mm assistant port and under direct visualization the stone was fragmented and removed using Trilogy's built-in mechanisms. Both patients were treated successfully without complications and were found to be stone-free on follow-up. Conclusion: The Trilogy lithotripter may be an effective tool for stone management when introduced during robotic pyelolithotomy and provides additional optionality when manual extraction poses challenges.

Open retropubic prostatectomy in a patient with bladder exstrophy for management of hematuria and urethral discharge - A case report.

Bladder exstrophy (BE) is a rare congenital disorder causing bladder and urethral malformation due to an abdominal wall embryological defect. Traditionally, BE had a poor life expectancy, but advances now offer a normal lifespan. A 57-year-old male with BE history and ureterosigmoidostomy repair presented with intractable hematuria, urethral discharge, and recurrent prostatic infections. He underwent retropubic subtotal prostatectomy without major complications, resolving urinary symptoms. Advances in BE management extend patient lifespans. This case demonstrates successful surgical management of hematuria and urethral discharge through radical prostatectomy in an adult with a history of BE.

Evaluating the safety of same-day discharge following pediatric pyeloplasty and ureteral reimplantation; A NSQIP analysis 2012-2020.

INTRODUCTION: Same-day discharge (SDD) is a safe option for several adult urologic surgeries, benefiting patients and hospitals. By decreasing length of stay while maintaining patient safety, SDD is in-line with recent goals to provide high value care while minimizing costs. Literature on SDD in the pediatric population, however, is scarce, and no study has identified the efficacy of SDD for pediatric pyeloplasty (PP) and ureteral reimplantation (UR). OBJECTIVE: The aim of this study was to identify trends in the usage of SDD as well as its efficacy and safety based on surgical outcomes for pediatric PP and UR. STUDY DESIGN: The 2012-2020 files of the American College of Surgeon's National Surgical Quality Improvement Project pediatric database were queried for PP and UR. Patients were stratified as SDD or standard-length discharge (SLD). Trends in SDD usage, differences in baseline characteristics, surgical approach, and surgical outcomes including 30-day readmission, complication, and reoperation rates were analyzed between SDD and SLD groups. RESULTS: 8213 PP (SDD: 202 [2.46%]) and 10,866 UR (469 [4.32%]) were included in analysis. There were no significant changes in SDD rates between 2012 and 2020, averaging 2.39% (PP), and 4.39% (UR). For both procedures, SDD was associated with higher rates of open versus minimally invasive (MIS) surgical approach and with shorter operative and anesthesia durations. For PP, there were no differences in readmission, complication, or reoperation rates in the SDD group. For UR, there was a 1.69% increase in CD I/II complications in those receiving SDD, correlating to 1.96-fold higher odds of CD I/II in all SDD patients compared to SLD patients. DISCUSSION: These results suggest that while the rate of SDD has not increased in recent years, the current screening methods for SDD have been generally effective in maintaining the safety of SDD for pediatric procedures. Though SDD for UR did show a very small increase in minor complications, this may be due to less strict screening protocols, and may be alleviated via MIS surgical approach. While this is the first paper to investigate SDD for pediatric urology procedures, these results are similar to those found for adult procedures. This study is limited by the lack of clinical data reported in the database. CONCLUSION: SDD is a generally safe option for pediatric PP and UR, and further research should identify proper screening protocols to continue to allow for safe SDD.

The Role of Experience: How Case Volume and Endourology-Fellowship Training Impact Surgical Outcomes for Ureteroscopy.

Introduction: Surgical experience is associated with superior outcomes in complex urologic cases, such as prostatectomy, nephrectomy, and cystectomy. The question remains whether experience is predictive of outcomes for less complex procedures, such as ureteroscopy (URS). Our study examined how case volume and endourology-fellowship training impacts URS outcomes. Methods: We retrospectively reviewed URS cases from 2017 to 2019 by high ureteroscopy volume urologists (HV), low ureteroscopy volume urologists (LV), endourology-fellowship trained (FT), and non-endourology FT (NFT) urologists. Surgical outcomes including stone-free rate (SFR), complication and reoperation rates, and postoperative imaging follow-up were analyzed between groups. Results: One thousand fifty-seven cases were reviewed across 23 urologists: 6 HV, 17 LV, 3 FT, and 20 NFT. Both FT and HV operated on more complex cases with lower rates of pre-stented patients. HV also operated on patients with higher rates of renal stones, lower pole involvement, and prior failed procedures. Despite this, FT and HV showed between 11.7% and 14.4% higher SFR, representing 2.7- to 3.6-fold greater odds of stone-free outcomes for primary and secondary stones. Additionally, HV and FT had a 4.9% to 7.8% lower rate of postoperative complications and a 3.3% to 4.3% lower rate of reoperations, representing 1.9- to 4.0-fold lower odds of complications. Finally, their patients had a 1.6- to 2.1-fold higher odds of postoperative imaging follow-up with a greater proportion receiving postoperative imaging within the recommended 3-month postoperative period. Conclusions: More experienced urologists, as defined by higher case volume and endourology-fellowship training, had higher SFR, lower complication and reoperation rates, and better postoperative imaging follow-up compared with less experienced urologists. Although less experienced urologists had outcomes in-line with clinical and literature standards, continued training and experience may be a predictor of better outcomes across multiple URS modalities.