Geriatric Assessment Can Predict Outcomes of Endoscopic Surgery for Benign Prostatic Hyperplasia in Elderly Patients.

Ojectives: Surgical management of benign prostatic hyperplasia (BPH) in elderly patients is associated with higher morbidity and mortality rate. This raises the question of benefice and risk balance. We conducted a prospective observational study to evaluate the results of endoscopic surgery for BPH in elderly patients, according to geriatric assessment. PATIENTS AND METHODS: We included prospectively 60 patients older than 75 years, with an indwelling catheter for acute or chronic retention, who were candidates to endoscopic surgery for BPH. Patients underwent the brief geriatric assessment (BGA) and the comprehensive geriatric assessment (CGA) to classify them into three groups: "vigorous," "vulnerable," and "sick." Success was defined by the bladder catheter withdrawal after surgery. RESULTS: After geriatric assessment, 33 patients were classified in the "vigorous" group (55%), 25 in the "vulnerable" group (42%), and 2 in the "sick" group (3%). The success rate immediately after surgery was 85% and 41% in the "vigorous patient" group and the "vulnerable and sick" patient group, respectively (p < 0.05). The success rate at 3 months after surgery was 94% and 55% (p < 0.05). The morbidity was higher for the "vulnerable and sick" group (44%) compared with the "vigorous" group (15%) (p < 0.05). The BGA also allowed predicting a higher risk of failure in patients with a score ≥3 immediately after surgery (odds ratio 5.9, confidence interval [95% CI] 1.61, 29.9) and 3 months after surgery (odds ratio 6.9, 95% CI 1.31, 70.8). CONCLUSION: Geriatric assessment can predict the outcome of endoscopic surgery for BPH for patients in retention older than 75 years. "Vulnerable and sick" patients had a higher risk to keep their indwelling catheter after the surgery compared with "vigorous" patients. The complication rate is also higher. The BGA can although predict a poor result of surgery when its score is equal or above 3/6.

Impact of retrograde flexible ureteroscopy and intracorporeal lithotripsy on kidney functional outcomes.

OBJECTIVE: The aim of the study was to evaluate renal function and to identify factors associated with renal function deterioration after retrograde intrarenal surgery (RIRS) for kidney stones. MATERIALS AND METHODS: We retrospectively analyzed patients with renal stones treated by RIRS between January 2010 and June 2013 at a single institute. We used the National Kidney Foundation classification of chronic kidney disease (CKD) to classify Glomerular Filtration Rate (GFR) in 5 groups. The baseline creatinine level was systematically pre-operatively and post-operatively evaluated. All patients had a creatinine blood measurement in June 2013. A change toward a less or a more favorable GFR group following RIRS was considered significant. RESULTS: We included 163 patients. There were 86 males (52.8%) and 77 females (47.3%) with a mean age of 52.8±17 years. After a mean follow-up of 15.5±11.5 months, median GFR was not significantly changed from 84.3±26.2 to 84.9±24.5 mL/min (p=0.675). Significant renal function deterioration occurred in 8 cases (4.9%) and significant renal function amelioration occurred in 23 cases (14.1%). In univariate analysis, multiple procedures (p=0.023; HR: 5.4) and preoperative CKD (p=0.011; HR: 6.8) were associated with decreased renal function. In multivariate analysis these factors did not remain as predictive factors. CONCLUSION: Stone management with RIRS seems to have favorable outcomes on kidney function; however, special attention should be given to patients with multiple procedures and preoperative chronic kidney disease.

Impact of retrograde flexible ureteroscopy and intracorporeal lithotripsy on kidney functional outcomes

ABSTRACT Objective: The aim of the study was to evaluate renal function and to identify factors associated with renal function deterioration after retrograde intrarenal surgery (RIRS) for kidney stones. Materials and Methods: We retrospectively analyzed patients with renal stones treated by RIRS between January 2010 and June 2013 at a single institute. We used the National Kidney Foundation classification of chronic kidney disease (CKD) to classify Glomerular Filtration Rate (GFR) in 5 groups. The baseline creatinine level was systematically pre-operatively and post-operatively evaluated. All patients had a creatinine blood measurement in June 2013. A change toward a less or a more favorable GFR group following RIRS was considered significant. Results: We included 163 patients. There were 86 males (52.8%) and 77 females (47.3%) with a mean age of 52.8±17 years. After a mean follow-up of 15.5±11.5 months, median GFR was not significantly changed from 84.3±26.2 to 84.9±24.5 mL/min (p=0.675). Significant renal function deterioration occurred in 8 cases (4.9%) and significant renal function amelioration occurred in 23 cases (14.1%). In univariate analysis, multiple procedures (p=0.023; HR: 5.4) and preoperative CKD (p=0.011; HR: 6.8) were associated with decreased renal function. In multivariate analysis these factors did not remain as predictive factors. Conclusion: Stone management with RIRS seems to have favorable outcomes on kidney function; however, special attention should be given to patients with multiple procedures and preoperative chronic kidney disease.

Impact of lower pole calculi in patients undergoing retrograde intrarenal surgery.

OBJECTIVE: To assess if the presence of a lower pole stone (LPS) decreases the stone-free (SF) rate following retrograde intrarenal surgery (RIRS). The second purpose was to assess the result of RIRS for LPS and to identify predictors of SF status. PATIENTS AND METHODS: We retrospectively analyzed 205 procedures in 162 patients with renal stones treated by RIRS between January 2010 and January 2013 at a single institute. The SF status was defined as no residual fragments. Independent-sample t-tests and Chi-square tests were used for comparisons of means and proportions, respectively, between patients with or without LPS. Logistic regression models were used to assess prognostic factors influencing SF status in cases of LPS. RESULTS: LPS were present in 89 (54.9%) patients. There were no differences between patients with or without LPS regarding the mean operative time (p=0.77), the surgeon's experience (p=0.522), the length of hospital stay (p=0.269), and the SF rate (p=0.224). SF status after RIRS in patients with or without LPS was 74.1% and 78% (p=0.224), respectively. In the case of LPS, the presence of multiple stones and a history of percutaneous nephrolithotomy (PCNL) were predictive factors for occurrence of residual fragments in univariate analysis (p=0.037 and p=0.015). In multivariable analysis, only the presence of multiple stones remained as a predictive factor (p=0.027; HR=3.2), whereas a trend was observed when there was a history of PCNL (p=0.07; HR=3). CONCLUSION: The presence of a LPS does not alter the SF rate of RIRS even in cases of early experience. RIRS for LPS appears to be an effective technique, but special attention should be given to patients with multiple stones and/or a history of PCNL.

Nephron-sparing surgery for renal tumors measuring more than 7 cm: morbidity, and functional and oncological outcomes.

BACKGROUND: The purpose of this study was to evaluate morbidity, functional, and oncological outcomes after NSS in renal tumors > 7 cm. MATERIALS AND METHODS: We retrospectively analyzed data from 168 patients with tumors > 7 cm who were treated using NSS between 1998 and 2012. RESULTS: Imperative and elective indications accounted for 76 (45.2%) and 92 (54.8%) patients, respectively. Major perioperative complications and renal function deterioration occurred in 33 (19.6%) and 51 patients (30.4%), respectively. In multivariate analysis, age older than 60 years (P = .001; hazard ratio [HR], 5) and tumor malignancy (P = .014; HR, 6.7) were prognostic factors for renal function deterioration whereas imperative indication was a risk factor for major postoperative complications (P = .0019; HR, 2.7). In 126 (75%) patients with malignant tumors, after a median follow-up of 30 months (range, 1-254 months), 25 patients (20.2%) died. In multivariate analysis, imperative indication (P = .023; HR, 4.2), positive surgical margin (P = .021; HR, 3.3), and Fuhrman grade > II (P = .013; HR, 3.7) were prognostic indicators for cancer-free survival (CFS). Imperative indication (P = .04; HR, 8.5) and Fuhrman grade > II (P = .04; HR, 3.9) were predictive factors of cancer-specific survival (CSS). In case of elective indication, positive surgical margin, local recurrence, and cancer-related death occurred in 4 (7.6%), 1 (1.1%), and 1 (1.1%) cases, respectively. For elective indication, 5-year estimates of CFS, CSS, and overall survival rates were: 85.7%, 98%, and 93.9%, respectively. CONCLUSION: In this selected population, imperative vs. elective indication status seems to play a critical role in oncologic outcomes. Oncologic results for elective indications are close to those reported with radical nephrectomy.

The oncologic impact of a delay between diagnosis and radical nephroureterectomy due to diagnostic ureteroscopy in upper urinary tract urothelial carcinomas: results from a large collaborative database.

OBJECTIVES: According to the current upper urinary tract urothelial carcinomas (UTUC) guidelines, ureteroscopic evaluation (URS) is recommended to improve diagnostic accuracy and obtain a grade (by biopsy or cytology). However, URS may delay radical surgery [e.g., nephroureterectomy (RNU)]. The objective of this study was to evaluate the influence of URS implementation before RNU on patient survival. METHODS: A French multicentre retrospective study including 512 patients with nonmetastatic UTUC was conducted between 1995 and 2011. Achievement of ureteroscopy (URS), treatment time (time between imaging diagnosis and RNU), tumour location, pT-pN stage, grade, lymphovascular invasion (LVI) and the presence of invaded surgical margins (R+) were evaluated as prognostic factors for survival using univariate and multivariate Cox regression analyses. Cancer-specific survival (CSS), recurrence-free survival (RFS) and metastasis-free survival (MFS) were calculated using the Kaplan-Meier method. RESULTS: A total of 170 patients underwent ureteroscopy prior to RNU (URS+ group), and 342 did not undergo URS (URS-). The median treatment time was significantly longer in the URS+ group (79.5 vs. 44.5 days, p = 0.04). Ureteroscopic evaluation was correlated with ureteral location and lower stage and tumour grade (p = 0.022, 0.005, 0.03, respectively). Tumour stage, LVI+ and R+ status were independently associated with CSS (p = 0.024, 0.049 and 0.006, respectively). The 5-year CSS, RFS and MFS did not differ between the two groups (p = 0.23, 0.89 and 0.35, respectively). These results were confirmed for muscle-invasive (MI) UTUC (p = 0.21, 0.44 and 0.67 for CSS, RFS and MFS, respectively). CONCLUSIONS: Despite the increased time to radical surgery, diagnostic ureteroscopy can be systematically performed for the appraisal of UTUC to refine the therapeutic strategy without significantly affecting oncological outcomes, even for MI lesions.

The impact of lymph node status and features on oncological outcomes in urothelial carcinoma of the upper urinary tract (UTUC) treated by nephroureterectomy.

PURPOSE: Prognostic impact of lymphadenectomy during radical nephroureterectomy (RNU) for urothelial carcinoma of the upper urinary tract (UTUC) is controversial. Our aim was to assess the impact of lymph node status (LNS) on survival in patients treated by RNU. METHODS: In our multi-institutional, retrospective database, 714 patients with non-metastatic UTUC had undergone RNU between 1995 and 2010. LNS was tested as prognostic factor for survivals through univariate and multivariable Cox regression analysis. RESULTS: Median age was 70 years [interquartile range (IQR), 60-75] with median follow-up of 27 months (IQR, 10-50). Overall, lymphadenectomy was performed in 254 patients (35.5 %). Among these patients, 204 (80 %) had negative lymph nodes (pN0) and 50 (20 %) had positive lymph nodes (pN1/2). The 5-year cancer-specific survival (CSS) was 81 % [95 % confidence interval (CI), 73-88 %] for pN0 patients, 85 % (95 % CI, 80-90 %) for pNx patients and 47 % (95 % CI, 24-69 %) for pN1/2 patients (p < 0.001). Metastasis-free survival (MFS) and overall survival (OS) rates were significantly lower in pN1/2 patients than in pN0 and pNx patients (p < 0.05). On multivariable analysis, LNS did not appear as an independent prognostic factor for CSS, OS or MFS (p > 0.05). In case of lymph node involvement, extra-nodal extension was marginally associated with worse CSS (log rank p = 0.07). The retrospective design was the main limitation. CONCLUSION: LNS is helpful for survival stratification in patients treated with RNU for UTUC. However, LNS did not appear as an independent predictor of survival in this retrospective series and needs to be investigated in a large multicentre, prospective evaluation.

Ureteral and multifocal tumours have worse prognosis than renal pelvic tumours in urothelial carcinoma of the upper urinary tract treated by nephroureterectomy.

BACKGROUND: It is not known whether the primary tumour location of upper urinary tract urothelial carcinoma (UUT-UC) is associated with prognosis. OBJECTIVE: To evaluate the impact of initial primary tumour location on survival in patients who had undergone radical nephroureterectomy (RNU). DESIGN, SETTING, AND PARTICIPANTS: Using a multi-institutional, retrospective database, we identified 609 patients with UUT-UC who had undergone RNU between 1995 and 2010. Tumour location was categorised as renal pelvis, ureter, or multifocal. INTERVENTION: All patients had undergone RNU. MEASUREMENTS: Tumour location was tested as a prognostic factor for survival through univariate and multivariable Cox regression analysis. RESULTS AND LIMITATIONS: Tumour location was renal pelvis in 317 cases (52%), ureter in 185 cases (30%), and multifocal in 107 cases (18%). Compared to renal pelvic and ureteral tumours, multifocal tumours were more likely to be associated with advanced stages (pT3/pT4; 39%, 30%, and 54%, respectively; p<0.001) and high-grade disease (53%, 56%, and 76%, respectively; p<0.001). On multivariable analysis, tumour location was an independent prognostic factor for cancer-specific death, disease recurrence, and metastasis (p<0.05). The 5-yr cancer-specific death-free survival probability was 86.8% for renal pelvic tumours, 68.9% for ureteral tumours, and 56.8% for multifocal tumours (p<0.001). The retrospective design of this study was its main limitation. CONCLUSIONS: Ureteral and multifocal tumours had a worse prognosis than renal pelvic tumours. These findings are not in line with recently published data and should be investigated in a prospective assessment to obtain a definitive statement regarding this matter.

Hazard analysis and critical control point (HACCP) for an ultrasound food processing operation.

Emerging technologies, such as ultrasound (US), used for food and drink production often cause hazards for product safety. Classical quality control methods are inadequate to control these hazards. Hazard analysis of critical control points (HACCP) is the most secure and cost-effective method for controlling possible product contamination or cross-contamination, due to physical or chemical hazard during production. The following case study on the application of HACCP to an US food-processing operation demonstrates how the hazards at the critical control points of the process are effectively controlled through the implementation of HACCP.