Examination of nutritional factors associated with urolithiasis risk in plant based meat alternatives marketed to children and infants.

INTRODUCTION: The global prevalence of pediatric nephrolithiasis continues to rise amidst increased sodium and animal protein intake. Plant-based meat alternatives (PBMAs) have recently gained popularity due to health benefits, environmental sustainability, and increased retail availability. PBMAs have the potential to reduce the adverse metabolic impact of animal protein on kidney stone formation. We analyzed PBMAs targeted to children to characterize potential lithogenic risk vs animal protein. METHODS: We performed a dietary assessment using a sample of PBMAs marketed to or commonly consumed by children and commercially available at national retailers. Nutrient profiles for PBMAs were compiled from US Department of Agriculture databases and compared to animal protein sources using standardized serving sizes. We also analyzed nutrient profiles for plant-based infant formulas against typical dairy protein-based formulas. Primary protein sources were identified using verified ingredient lists. Oxalate content was extrapolated from dietary data sources. RESULTS: A total of 41 PBMAs were analyzed: chicken (N = 18), hot dogs (N = 3), meatballs (N = 5), fish (N = 10), and infant formula (N = 5). Most products (76%) contained a high-oxalate ingredient as the primary protein source (soy, wheat, or almond). Average oxalate content per serving was substantially higher in these products (soy 11.6 mg, wheat 3.8 mg, almond 10.2 mg) vs animal protein (negligible oxalate). PBMAs containing pea protein (24%) had lower average oxalate (0.11 mg). Most PBMAs averaged up to six times more calcium and three times more sodium per serving compared to their respective animal proteins. Protein content was similar for most categories. CONCLUSIONS: Three-quarters of the examined plant-based meat products for children and infants contain high-oxalate protein sources. Coupled with higher per-serving sodium and calcium amounts, our findings raise questions about possible lithogenic risk in some PBMAs, and further studies are needed to assess the relationship between PBMAs and nephrolithiasis.

Healthcare system contact following ureteroscopy: does discharge instruction readability matter?

INTRODUCTION: We aimed to assess the impact of discharge instruction (DCI) readability on 30-day postoperative contact with the healthcare system. MATERIALS AND METHODS: Utilizing a multidisciplinary team, DCI were modified for patients undergoing cystoscopy, retrograde pyelogram, ureteroscopy, laser lithotripsy, and stent placement (CRULLS) from a 13th grade to a 7th grade reading level. We retrospectively reviewed 100 patients including 50 consecutive patients with original DCI (oDCI) and 50 consecutive patients with improved readability DCI (irDCI). Clinical and demographic data collected including healthcare system contact (communications [phone or electronic message], emergency department [ED], and unplanned clinic visits) within 30 days of surgery. Uni/multivariate logistic regression analyses used to identify factors, including DCI-type, associated with increased healthcare system contact. Findings reported as odds ratios with 95% confidence intervals and p values (< 0.05 significant). RESULTS: There were 105 contacts to the healthcare system within 30 days of surgery: 78 communications, 14 ED visits and 13 clinic visits. There were no significant differences between cohorts in the proportion of patients with communications (p = 0.16), ED visits (p =1.0) or clinic visits (p = 0.37). On multivariable analysis, older age and psychiatric diagnosis were associated with significantly increased odds of overall healthcare contact (p = 0.03 and p = 0.04) and communications (p = 0.02 and p = 0.03). Prior psychiatric diagnosis was also associated with significantly increased odds of unplanned clinic visits (p = 0.003). Overall, irDCI were not significantly associated with the endpoints of interest. CONCLUSIONS: Increasing age and prior psychiatric diagnosis, but not irDCI, were significantly associated with an increased rate of healthcare system contact following CRULLS.

The effects of continuing aspirin on blood loss and postoperative outcomes in percutaneous nephrolithotomy.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is an effective surgery for complex kidney stones yet with inherent bleeding risks. It remains unclear whether aspirin should be discontinued prior to PCNL. We aimed to further substantiate the safety of continuing aspirin during PCNL surgery and to determine whether aspirin status affects postoperative outcomes following PCNL. METHODS: We retrospectively queried our endourology database for patients who underwent PCNL from October 2017 to December 2022 at our high-volume tertiary referral center. The three groups were based on aspirin status at the time of PCNL: no aspirin (NA), discontinued aspirin (DA), and continued aspirin (CA). Data collected included demographics, preoperative characteristics, operative parameters, pre and postoperative lab values, transfusions, and complications. RESULTS: A total 648 patients were divided into these study groups: 525 NA patients (81.0%), 55 DA (8.5%), and 68 CA (10.5%). The DA and CA groups were of similar comorbidities, and both were more comorbid at baseline than NA. Postoperative change in lab values and complications did not differ significantly. Rates of postoperative blood transfusion were higher in the CA and DA groups compared to NA and approached statistical significance. There were no significant differences in any postoperative outcomes between the DA and CA groups alone. CONCLUSIONS: In patients on chronic aspirin therapy, continuing aspirin appears equally safe to discontinuing aspirin prior to PCNL. Most patients should not forego the benefits of continuous aspirin for the theoretical risk of bleeding. Patients on prolonged aspirin therapy may be more likely than those who are not on chronic aspirin therapy to require blood transfusions. However, regardless of whether aspirin use is stopped, this may be caused by patient comorbidities rather than higher rates of blood loss.

Dietary Assessment of Lithogenic Factors in Plant-Based Meat Products.

Introduction: Patients who form kidney stones are typically advised to limit intake of nondairy animal protein. Plant-based meat products may be a processed substitute protein source for these patients and have recently gained popularity because of health concerns, increased retail availability, decreased environmental impact, and meat supply shortages during the COVID-19 pandemic. Despite these perceived benefits and tangential association with whole food plant-based diets, the potential lithogenic risks associated with these products are not well characterized. Methods: The U.S. Department of Agriculture database was queried with a sample of plant-based meat products widely available to U.S. consumers. Nutrient profile data were compiled and compared with animal protein data using standardized serving sizes. Primary protein sources were identified using verified ingredient lists. Oxalate content was extrapolated based on dietary data sources. Results: A total 47 plant-based meat products (16 beef, 11 pork, 10 chicken, and 10 seafood) were analyzed. Compared with their respective animal protein, most products contained on average fewer calories (plant-based beef 77%, pork 94%, chicken 86%, and seafood 83%) and less protein (plant-based beef 68%, pork 96%, chicken 53%, and seafood 54%). Most products used soy protein as the primary protein source (55%). Soy-based beef contained the highest average oxalate content (18 mg per serving), whereas soy-based seafood contained the lowest (7 mg). The most common non-soy protein source was pea protein (30%), containing trace amounts of oxalate. Sodium content was higher in most plant-based products overall (72%) and in each category (plant-based beef 109%, pork 128%, chicken 100%, and seafood 148%). Calcium content was higher (plant-based beef 317%, pork 144%, chicken 291%, and seafood 295%) compared with animal protein. Conclusions: Most plant-based meat products consist of protein sources that are, relative to animal protein sources, higher in oxalate, sodium, and calcium. Stone-forming patients should be counseled about the potential lithogenic risk of these processed products.

The T-Tilt Position: A Novel Modified Patient Position to Improve Stone-Free Rates in Retrograde Intrarenal Surgery.

PURPOSE: Residual fragments following retrograde intrarenal surgery can lead to future stone episodes. The lower pole of the kidney presents a unique challenge as it is the most difficult location for retrograde intrarenal surgery. We investigated a modified patient position to increase stone-free rate by analyzing presence of residual fragments. We randomized patients into standard position and the T-Tilt position (15° Trendelenburg and 15° airplane away from the surgical side kidney). MATERIALS AND METHODS: In this prospective, randomized study, patients were randomized into the standard or T-Tilt position. Demographics, comorbidities and operative parameters were collected. Stone-free rate was determined with renal ultrasound and x-ray at 1-month followup. Postoperative complications were recorded up to 1 month. Variables were compared using Kruskal-Wallis test for continuous variables and chi-square test for categorical variables. RESULTS: A total of 138 patients were analyzed: 75 standard patients and 63 T-Tilt patients. The groups had similar patient and stone factors. The most common stone position was the lower pole (68.0% standard, 74.6% T-Tilt). Stone-free rates were significantly different: standard position was 76.7% and T-Tilt position was 92.1% (p=0.015). Stone-free rates for isolated lower pole stones were significantly different as well: standard position was 68.2% and T-Tilt position was 95.6% (p <0.001). Clavien-Dindo scores did not differ significantly (p=0.262). CONCLUSIONS: The T-Tilt patient position was associated with higher stone-free rates. It is an atraumatic, cost-effective technique. These results suggest that modifying patient positioning during retrograde intrarenal surgery improves stone-free rates.

Gender Differences in Incidence, Diagnosis, Treatments, and Outcomes in Clinically Localized Bladder and Renal Cancer.

OBJECTIVE: To review differences in bladder and renal cell cancer (RCC) incidence, diagnosis, treatment, and outcomes between men and women, and to summarize the evidence that explains these differences. METHODS: A review of the current literature was performed using PubMed and Google Scholar. RESULTS: The incidence of bladder cancer and RCC is higher in men. Historically higher smoking rates among men explain some but not all of the difference in incidence. Hormonal and genetic factors also contribute. In bladder cancer, the androgen receptor and estrogen receptor beta have been associated with gender and tumor characteristics. In RCC the relationships are less well defined. In both bladder cancer and RCC, differences in gene mutation patterns among men and women, particularly among genes located on the X-chromosome, have also been identified. Differences in the work-up and treatment of men and women with bladder cancer and RCC also contribute to gender disparities. CONCLUSION: Research to better delineate how the hormonal axis and genetics contribute to disparities in bladder cancer and RCC incidence and outcomes will allow for more individualized medicine. Appreciation of barriers to diagnosis and treatment will identify opportunities to improve patient care.

A Rare Neoplasm: Primary Adrenal Leiomyosarcoma.

Adrenal incidentalomas are common neoplasms and while they are often benign, they have the potential to be malignant. The American Urological Association guidelines state that adrenal incidentalomas should be surgically resected if they are large, metabolically active, or display malignant characteristics. Other groups have suggested that growth kinetics be factored in as well. We present a case of an adult woman with adrenal incidentaloma which was subsequently discovered to be a primary adrenal leiomyosarcoma, a rare subtype of soft tissue tumors.

The effect of tumor location on overall survival for pT2-4 bladder and upper tract urothelial carcinoma following radical surgery.

INTRODUCTION: Historically, staging and treatment for upper tract urothelial carcinoma were extrapolated from bladder urothelial carcinoma literature. However, embryological, genetic, and anatomical differences exist between them. We sought to explore the relationship between location of urothelial cancer and overall survival (OS). METHODS: Data was culled from the National Cancer Database from 2004-2015. Patients with pT2-pT4 treated with definitive surgery were included; those with metastatic disease or who received neoadjuvant or adjuvant treatment were excluded. Patients were stratified by tumor location and pathological stage. The primary outcome was OS. Secondary outcomes were predictors of mortality in each pT stage stratum. RESULTS: A total of 11 330 patients with bladder, 954 patients with ureteral, and 1943 patients with renal pelvis urothelial carcinoma were analyzed. Mean followup was 43.3, 39.4, and 41.4 months for bladder, ureteral, and renal pelvis, respectively. On univariable analysis, ureteral pT2 was associated with worse OS compared to both bladder (61.3 vs. 80.4 months, p=0.007) and renal pelvis (61.3 vs. 80.5 months, p=0.014). Renal pelvis pT3 was associated with improved OS compared to both bladder (42.5 vs. 28.6 months, p=0.003) and ureteral (42.5 vs. 25.7 months, p<0.001). Renal pelvis pT4 had decreased survival compared to bladder (11.4 vs. 17.7 months, p<0.001). On multivariable Cox regression, only renal pelvis pT3 was associated with a 20% decreased risk of mortality compared to bladder pT3 (hazard ratio 0.80, 95% confidence interval 0.72-0.88, p<0.001). CONCLUSIONS: Renal pelvis pT3 is associated with lower mortality. Mutational and embryological differences may play a role in this disparity.

Endoscopic Creation of a Neochimneycystotomy: A Case Report of a Ureteroileal Chimney Stricture.

Background: There are many nonmalignant complications after urinary reconstruction. Anastomotic strictures and redundancy of an ileal chimney are such. A patient with both issues might necessitate an open surgical approach; yet endoscopic techniques are more attractive for these older frail patients. Case Presentation: A 61-year-old woman with a history of bladder cancer who underwent radical cystectomy and neobladder creation now develops left hydronephrosis and a redundant ileal chimney with severe metabolic acidosis. She underwent endoscopic creation of a neochimneycystotomy. Conclusion: The refinement of endoscopic techniques moves the field of surgery away from open surgery, which is beneficial for patients. This endoscopic technique treated the anastomotic stricture as well as redundant ileal chimney in a novel way that has not been reported previously in the literature.

Robotic-Assisted Partial Nephrectomy and Adrenalectomy: Case of a Pheochromocytoma Invading into Renal Parenchyma.

Although upper pole renal masses and adrenal masses can usually be distinguished on cross-sectional imaging, large masses can obscure the boundaries between the kidney and adrenal gland. We describe a unique case of an adrenal pheochromocytoma in a 42-year-old female who was referred for robotic partial nephrectomy. During the procedure, the patient developed severe hypertension. The case was aborted, and the workup revealed pheochromocytoma. After appropriate pretreatment, the patient underwent a successful robotic adrenalectomy and partial nephrectomy. Therefore, we recommend screening patients with hypertension and large upper pole masses for pheochromocytoma to better direct preoperative management.

Clinical Complete Response after Neoadjuvant Chemotherapy for Muscle-invasive Bladder Cancer: A Call for Standardized Assessments and Definitions.

The ability to accurately determine a complete clinical response (cCR) to neoadjuvant chemotherapy (NAC) before cystectomy could have paradigm-shifting implications for the management of muscle-invasive bladder cancer. Level 1 evidence demonstrates that up to 40% of patients are downstaged to pT0 disease following NAC, presenting an intriguing opportunity to identify select patients who might be spared the morbidity of radical surgery. However, clinical investigations in this space are hindered by lack of a uniform approach to postchemotherapy restaging and a standardized definition of cCR. PATIENT SUMMARY: In this mini-review, we discuss the current limitations to restaging of muscle-invasive bladder cancer following neoadjuvant chemotherapy and their implications for personalized medicine and translational research. We conclude that there is an unmet need to optimize and standardize restaging evaluation and definitions of a complete clinical response.

Imaging Protocols for Active Surveillance in Renal Cell Carcinoma.

PURPOSE OF REVIEW: To review the growth kinetics of small renal masses and available imaging modalities for mass characterization and surveillance, highlight current organizational recommendations for the active surveillance of small renal masses, and discuss the most recently reported oncological outcomes of patients as they relate to various surveillance imaging protocols and progression to delayed intervention. RECENT FINDINGS: Overall, organizational guideline recommendations are broad and lack specifics regarding timing and modality for follow-up imaging of small renal masses. Additionally, despite general consensus in the literature about certain criteria to trigger delayed intervention, there exist no formal guidelines. Active surveillance of small renal masses is an acceptable management strategy for patients with prohibitive surgical risk; however, standardized imaging protocols for surveillance are lacking, as are randomized, prospective trials to evaluate the ideal follow-up protocol.

An Extubation Protocol for Angioedema.

Angioedema-nonpitting edema of the mucous membranes and skin-most commonly occurs as a complication from the use of angiotensin-converting enzyme inhibitors. At our institution, the otolaryngology department has incorporated the use of the endotracheal tube cuff-leak test and bedside direct laryngoscopy to aid in timing for extubation of angioedema patients. Prospective data collection of patients presenting to the emergency department with angioedema was performed. Of 76 patients with angioedema, 9 required fiberoptic intubation. Intubation was performed at a median of 73 hours (range, 44-118). An endotracheal tube cuff-leak test was performed in 7 patients prior to extubation, and bedside direct laryngoscopy was also performed in 3 of these 7 patients to document resolution of laryngeal edema. The use of the endotracheal tube cuff-leak test and bedside direct laryngoscopy is an easy and inexpensive method to help determine eligibility for extubation in patients intubated for angioedema.

The prevalence of sleep-disordered breathing in children with asthma and its behavioral effects.

OBJECTIVES: To determine the prevalence of sleep-disordered breathing (SDB) in children with asthma compared to non-asthmatic children and to determine if behavior problems are associated with asthma and SDB. STUDY DESIGN: Cross-Sectional. METHODS: Parents of 263 children with asthma and 266 controls ages 2 to 15 years attending routine pediatric office visits completed the Pediatric Sleep Questionnaire (PSQ) and the Child Behavior Checklist. Asthma severity was classified based on NIH guidelines. RESULTS: The prevalence of snoring was significantly higher in asthmatic children (35.5%) than controls (15.7%) and the prevalence of a positive PSQ was significantly higher in asthmatic children (25.9%) than controls (10.6%) (P < 0.001 for both). The effect of asthma was "dose-dependent" as children with more severe asthma had increased odds ratios for snoring and a positive PSQ. On multivariate analysis, there were significant interactions of gender with asthma and age with gender. A positive modified PSQ along with measures of socioeconomic status and age were the only independent predictors of abnormal Child Behavior Checklist scores and score classifications. CONCLUSIONS: There was a higher prevalence of SDB in asthmatic children compared to non-asthmatic children and the prevalence of SDB increased with increasing asthma severity. In multivariate analysis the role of asthma was much less clear as it predicted a positive PSQ in girls but not boys. SDB, but not asthma, was an independent predictor of behavioral problems.