Postoperative urinary retention in men is common after carotid endarterectomy and is associated with advanced age and prior urinary tract infection.

OBJECTIVE: This study was undertaken to analyze the occurrence of postoperative urinary retention (POUR) after carotid endarterectomy (CEA) and determine whether there are any associated modifiable risk factors. CEA was chosen to minimize the confounding effects of known risk factors for POUR, including immobilization, regional and severe pain, and neuroaxial anesthesia. METHODS: This was a retrospective record review of 186 male patients undergoing CEA between 2007 and 2011. Demographic, comorbidities, and operative characteristics were compared. Continuous variables are reported as median and interquartile range (IQR) and categoric variables as frequencies and proportions. Pearson χ(2) or Mann-Whitney U tests compared categoric and continuous variables, respectively. Logistic regression was used to examine univariate and multivariate odds of POUR. Multivariate analysis controlled for known predictors of urinary retention. Association with other complications was examined with the Pearson correlation coefficient. RESULTS: POUR occurred in 34 patients (18.3%). Median age and history of urinary tract infection (UTI) were significantly associated with POUR: median age was 73.0 years (IQR, 67-80 years) for those with POUR vs 69.5 years (IQR, 63-76 years) for those without (P = .047); 17.6% of patients with a history of UTI developed POUR vs 5.9% without (P = .023). These findings persisted on multivariate analysis controlling for known predictors of POUR (body mass index, history of diabetes, benign prostate hyperplasia, and prior prostate surgery): median age (odds ratio, 1.05; 95% confidence interval, 1-1.1) and history of UTI (odds ratio, 4.16; 95% confidence interval, 1.23-14.05; P = .022). The occurrence of POUR was significantly correlated with postoperative UTI: 18.8% with POUR vs 0.7% without (Pearson r = 0.369; P < .001). CONCLUSIONS: POUR requiring bladder catheterization after CEA predisposes patients to postoperative UTI and is more common in older patients and those with a history of UTI. CEA patients lack inherent risk factors for POUR and would be a useful population for prospective studies involving POUR.

Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery.

OBJECTIVE: To evaluate the outcomes of robot-assisted partial nephrectomy RAPN after major prior abdominal surgery (PAS) using a large multicentre database. PATIENTS AND METHODS: We identified 1 686 RAPN from five academic centres between 2006 and 2014. In all, 216 patients had previously undergone major PAS, defined as having an open upper midline/ipsilateral incision. Perioperative outcomes were compared with those 1 470 patients who had had no major PAS. The chi-squared test and Mann-Whitney U-test were used for categorical and continuous variables, respectively. RESULTS: There was no statistically significant difference in Charlson comorbidity index, tumour size, R.E.N.A.L. nephrometry score or preoperative estimated glomerular filtration rate (eGFR) between the groups. Age and body mass index were higher in patients with PAS. The PAS group had a higher estimated blood loss (EBL) but this did not lead to a higher transfusion rate. A retroperitoneal approach was used more often in patients with major PAS (11.2 vs 5.4%), although this group did not have a higher percentage of posterior tumours (38.8 vs 43.3%, P = 0.286). Operative time, warm ischaemia time, length of stay, positive surgical margin, percentage change in eGFR, and perioperative complications were not significantly different between the groups. CONCLUSIONS: RAPN in patients with major PAS is safe and feasible, with increased EBL but no increased rate of transfusion. Patients with major PAS had almost twice the likelihood of having a retroperitoneal approach.

Evaluation of renal mass biopsy risk stratification algorithm for robotic partial nephrectomy--could a biopsy have guided management?

PURPOSE: We evaluated a published biopsy directed small renal mass management algorithm using a large cohort of patients who underwent robotic partial nephrectomy for tumors 4 cm or smaller. MATERIALS AND METHODS: A simplified algorithm of biopsy directed small renal mass management previously reported using risk stratified biopsies was applied to 1,175 robotic partial nephrectomy cases from 5 academic centers. A theoretical assumption was made of perfect biopsies that were feasible for all patients and had 100% concordance to final pathology. Pathology risk groups were benign, favorable, unfavorable and intermediate. The algorithm assigned favorable or intermediate tumors smaller than 2 cm to active surveillance and unfavorable or intermediate 2 to 4 cm tumors to treatment. Higher surgical risk patients were defined as ASA® 3 or greater and age 70 years or older. RESULTS: Patients were assigned to the pathology risk groups of benign (23%), favorable (13%), intermediate (51%) and unfavorable (12%). Patients were also assigned to the management groups of benign pathology (275, 23%), active surveillance (336, 29%) and treatment (564, 48%). Most of the 611 (52%) patients in the benign or active surveillance groups were low surgical risk and had safe treatment (2.6% high grade complications). A biopsy may not have been feasible or accurate in some tumors that were anterior (378, 32%), hilar (93, 7.9%) or less than 2 cm (379, 32%). Of 129 (11%) high surgical risk patients the biopsy algorithm assigned 70 (54%) to benign or active surveillance groups. CONCLUSIONS: The theoretical application of a biopsy driven, risk stratified small renal mass management algorithm to a large robotic partial nephrectomy database suggests that about half of the patients might have avoided surgery. Despite the obvious limitations of a theoretical assumption of all patients receiving a perfect biopsy, the data support the emerging role of renal mass biopsies to guide management, particularly in high surgical risk patients.

Emergency department visits in the United States for upper urinary tract stones: trends in hospitalization and charges.

PURPOSE: Using the Nationwide Emergency Department Sample (NEDS) we examined trends in visits, hospitalization and charges for patients with upper urinary tract stones who presented to the emergency department in the United States. MATERIALS AND METHODS: All visits with a primary diagnosis of kidney calculus (ICD-9-CM code 592.0), ureter calculus (592.1) or urinary calculus unspecified (592.9) were extracted from NEDS between 2006 and 2009. A weighted sample was used to calculate incidence rates. Temporal trends were quantified by the estimated annual percent change. Patient and hospital characteristics associated with hospitalization were evaluated using logistic regression models adjusted for clustering. RESULTS: Between 2006 and 2009 there were 3,635,054 emergency department visits for upper urinary tract stones. The incidence increased from 289 to 306/100,000 individuals. More men visited than women but women showed significant increases in visits (estimated annual percent change 2.85%, p = 0.018). Total monthly emergency department visits ranged from 5.8% in February to 8.4% in August. Overall 12.0% of patients were hospitalized and the hospitalization rate remained stable (estimated annual percent change -1.02%, p = 0.634). Patients were more likely to be hospitalized if they were female, more ill, seen at an urban teaching or low volume hospital, or had Medicaid or Medicare (each p <0.001). Sepsis was associated with the highest likelihood of hospital admission (OR 69.64, p <0.001). In 2009 charges for emergency department visits increased to $5 billion (estimated annual percent change 10.06%, p = 0.003). CONCLUSIONS: Women showed significant annual increases in emergency department visits for upper urinary tract stones. While emergency department charges increased substantially, hospitalization rates remained stable. Greater use of computerized tomography and medical expulsive therapy could be the reasons for this observation, which warrants further study.

Predictors of admission in patients presenting to the emergency department with urinary tract infection.

PURPOSE: Previous studies examining the management of urinary tract infections (UTI) showed marked variability in the economical burden of care, with a tenfold increase in costs when patients require admission to the hospital. We sought to examine the patient and emergency department (ED) characteristics associated with hospitalization in patients presenting to the ED with UTI. METHODS: An estimate of 10,798,343 patients with a primary diagnosis of UTI was presented to the ED from 2006 to 2009 and was abstracted from the Nationwide Emergency Department Sample. Univariable and multivariable analyses examined patient and hospital characteristics of those admitted with UTI. RESULTS: Between 2006 and 2009, 10.8 million patients presented to the ED in the United States for the treatment of UTI and 1.8 million patients (16.7 %) were admitted to the hospital for further management. Admitted patients were older, and a higher proportion had pyelonephritis, was male, and had Medicare. Admitted patients were also more likely to be seen at urban teaching hospitals, and/or treated at zip codes with higher median incomes. Following multivariable analysis, the independent predictors of admission included pyelonephritis (OR 5.29, 95 % CI 5.23-5.35), male gender (OR 1.58, 95 % CI 1.56-1.59), and advancing age (OR 1.037, 95 % CI 1.037-1.037). CONCLUSIONS: Expansion in ED utilization for the management of UTI has exceeded previous estimates. While the preponderance of patients presenting to the ED for UTI is discharged home, 16.7 % are admitted for further management. Predictors of inpatient admission on multivariable analyses included pyelonephritis, advancing age, and male gender.

Case report: Renal cell carcinoma with metastasis to the myometrium.

Renal cell carcinoma (RCC) is well known for its ability to metastasize to different organs, but the involvement of gynecological organs is rare. Our case represents the first case of bilateral RCC with metastasis to the myometrium. The patient was a 60-year-old woman who underwent bilateral robotic partial nephrectomy surgeries for clear cell RCC, low-grade, low-stage with negative margins. Her 1-year postoperative computed tomography scan showed an enlarging necrotic uterine mass. She underwent a debulking excision, including hysterectomy, with pathology showing metastatic RCC to the uterus. The patient developed widespread metastatic disease, and died months later of metastatic RCC.

Trends in Prostate-Specific Antigen Screening Since the Implementation of the 2012 US Preventive Services Task Force Recommendations.

In 2012, the US Preventive Services Task Force recommended against prostate-specific antigen (PSA) screening. Following the initial decrease in PSA screening rate, there appears to be no further decrease in screening rate from 2013 to 2015. In addition, the screening rate did not differ by age or race.

Use of the Satinsky clamp for hilar clamping during robotic partial nephrectomy: indications, technique, and multi-center outcomes.

A Satinsky clamp may be a backup option for hilar clamping during robotic partial nephrectomy (RPN) if there are challenges with application of bulldog clamps, but there are potential safety concerns. We evaluate outcomes of RPN using Satinsky vs. bulldog clamps, and provide tips for safe use of the Satinsky as a backup option. Using a multi-center database, we identified 1073 patients who underwent RPN between 2006 and 2013, and had information available about method of hilar clamping (bulldog clamp vs. Satinsky clamp). Patient baseline characteristics, tumor features, and perioperative outcomes were compared between the Satinsky and bulldog clamp groups. A Satinsky clamp was used for hilar clamping in 94 (8.8 %) RPN cases, and bulldog clamps were used in 979 (91.2 %) cases. The use of a Satinsky clamp was associated with greater operative time (198 vs. 175 min, p < 0.001), estimated blood loss (EBL, 200 vs. 100 ml, p < 0.001), warm ischemia time (WIT, 20 vs. 19 min, p = 0.036), transfusion rate (12.8 vs. 4.8 %, p = 0.001), and hospital stay (3 vs. 2 days, p < 0.001). Tumor characteristics and number of renal vessels were similar between groups. There were six intraoperative complications in the Satinsky clamp group, but none were directly related to the Satinsky clamp. On multivariable analysis, the use of the Satinsky clamp was not associated with increase in intraoperative or Clavien ≥3 postoperative complications, positive surgical margin rate or percentage change in estimated glomerular filtration rate. A Satinsky clamp can be a backup option for hilar clamping during challenging RPN cases, but requires careful technique, and was rarely necessary.

Preoperative predictors of malignancy and unfavorable pathology for clinical T1a tumors treated with partial nephrectomy: a multi-institutional analysis.

PURPOSE: To determine preoperative predictors associated with renal cell carcinoma (RCC) and unfavorable pathology in small renal masses treated with partial nephrectomy (PN). MATERIALS AND METHODS: PN records from 5 centers were retrospectively queried for patients with a clinically localized single tumor <4 cm on imaging (clinical T1a). Between 2007 and 2013, 1,009 patients met the inclusion criteria. Unfavorable pathology was defined as any grade III or IV RCC or tumors upstaged to pathologic T3a disease. Logistic regression models were used to determine preoperative characteristics associated with RCC and with unfavorable pathology. RESULTS: A total of 771 (76.4%) patients were found to have RCC and 198 (19.6%) had unfavorable pathology. On multivariate, bootstrap-adjusted logistic regression analysis, factors associated with the presence of malignancy were imaging tumor size ≥ 3 cm (odds ratio [OR] = 1.46; P = 0.040), male sex (OR = 1.88; P<0.0001), and nephrometry score ≥ 8 (OR = 1.64; P = 0.005). These same factors were independently associated with risk of unfavorable pathology: size ≥ 3 cm (OR = 1.46; P = 0.021), male sex (OR = 2.35; P<0.0001), and nephrometry score ≥ 8 (OR = 1.49; P = 0.015). The c statistic was 0.62 for the predicting malignancy and 0.63 for unfavorable pathology. CONCLUSIONS: In this multi-institutional cohort, male sex, imaging tumor size ≥ 3 cm, and nephrometry score ≥ 8 were predictors of RCC and adverse pathology following PN. These factors may assist in risk stratification and selective renal mass biopsy before decision making. Further studies are necessary to validate these findings.