Diabetes, Obesity, and Pathological Upstaging in Renal Cell Carcinoma: Results From a Large Multi-institutional Consortium.

PURPOSE: We sought to determine whether clinical risk factors and morphometric features on preoperative imaging can be utilized to identify those patients with cT1 tumors who are at higher risk of upstaging (pT3a). MATERIALS AND METHODS: We performed a retrospective international case-control study of consecutive patients treated surgically with radical or partial nephrectomy for nonmetastatic renal cell carcinoma (cT1 N0) conducted between January 2010 and December 2018. Multivariable logistic regression models were used to study associations of preoperative risk factors on pT3a pathological upstaging among all patients, as well as subsets with those with preoperative tumors ≤4 cm, renal nephrometry scores, tumors ≤4 cm with nephrometry scores, and clear cell histology. We also examined association with pT3a subsets (renal vein, sinus fat, perinephric fat). RESULTS: Among the 4,092 partial nephrectomy and 2,056 radical nephrectomy patients, pathological upstaging occurred in 4.9% and 23.3%, respectively. Among each group independent factors associated with pT3a upstaging were increasing preoperative tumor size, increasing age, and the presence of diabetes. Specifically, among partial nephrectomy subjects diabetes (OR=1.65; 95% CI 1.17, 2.29), male sex (OR=1.62; 95% CI 1.14, 2.33), and increasing BMI (OR=1.03; 95% CI 1.00, 1.05 per 1 unit BMI) were statistically associated with upstaging. Subset analyses identified hilar tumors as more likely to be upstaged (partial nephrectomy OR=1.91; 95% CI 1.12, 3.16; radical nephrectomy OR=2.16; 95% CI 1.44, 3.25). CONCLUSIONS: Diabetes and higher BMI were associated with pathological upstaging, as were preoperative tumor size, increased age, and male sex. Similarly, hilar tumors were frequently upstaged.

Volumetric Analysis of Renal Masses as Predictors of Partial Nephrectomy Outcomes.

Objective: To examine the role of endophytic tumor volume (TV) assessment (endophycity) on perioperative partial nephrectomy (PN) outcomes. Patients and Methods: Retrospective review of 212 consecutive laparoscopic and open partial nephrectomies from single institution using preoperative imaging and 1-year follow-up. Demographics, comorbidities, RENAL nephrometry scores, and all peri- and postoperative outcomes were recorded. Volumetric analysis performed using imaging software, independently assessed by two blinded radiologists. Univariate and multivariate statistical analysis were completed to assess predictive value of endophycity for all clinically meaningful outcomes. Results: Among those undergoing minimally invasive surgery (MIS), lower tumor endophycity was associated with higher likelihood of trifecta outcome (negative surgical margin, <10% decline in estimated glomerular filtration rate, the absence of complications) irrespective of max tumor size. For MIS, estimated blood loss increased with greater tumor endophycity regardless of tumor size. Among those who underwent open partial nephrectomy, lower tumor endophycity was associated with trifecta outcomes for tumors >4 cm only. On multivariate analysis with log-scaled odds ratios (OR), tumor endophycity and total kidney volume had the strongest correlation with tumor-related complications (OR = 3.23, 2.66). The analysis identified that tumor endophycity and TV on imaging were inversely correlated with of trifecta outcomes (OR = 0.53 for both covariates). Conclusions: Volumetric assessment of tumor endophycity performed well in identifying PN outcomes. As automated imaging software improves, volumetric analysis may prove to be a useful adjunct in preoperative planning and patient counseling.

Crowdfunding in urology: Canadian perspective.

INTRODUCTION: Crowdfunding is becoming an increasingly used resource for patients to cover costs related to medical care. These costs can be related directly to treatments or indirectly to loss of income or travel-related costs. Little is known as to the extent of which crowdfunding is used for urological disease here in Canada. This study offers a first look at the prevalence of crowdfunding for urological disease and the factors surrounding its use. METHODS: In January 2020, we queried the GoFundMe internal search engine for fundraising campaigns regarding urological ailments. Results were categorized according to the major organs of urological disease. RESULTS: Crowdfunding campaigns are very prevalent within several areas of urology. Prostate cancer and chronic kidney disease represent the most frequent reason for campaigns. Fundraising goals and actual funds raised for malignant disease were significantly more than for benign disease. Interestingly, there was a significant portion of crowdfunding campaigns to cover costs for non-conventional treatments and transplant tourism. CONCLUSION: Crowdfunding use to help cover direct and indirect costs of medical care is becoming increasingly apparent through several facets of medicine. This study shows that this statement holds true when looking at patients with urological disease in Canada. As urologists, we need to be aware of this trend, as it highlights the often-unforeseen financial burdens experienced by our patients.

The impact of COVID-19 on the Canadian Kidney Paired Donation program: an opportunity for universal implementation of kidney shipping.

SUMMARY: "Never let a good crisis go to waste." - Sir Winston Churchill.The value of Canada's Kidney Paired Donation program to the population cannot be overstated. Its greatest challenge as a national program, however, is the geographic separation of recipient and matched donor. Representatives from every transplant program in the country have been working toward increased use of kidney shipping in order to diminish the disincentive of donor travel. With transplantation program and travel restrictions in place to minimize the risk of coronavirus disease 2019 (COVID-19), the time to make a full transition from donor travel to the shipment of donor kidneys has clearly arrived.

Quality and Quantity in Kidney Cancer Surgery: The Role of Nonneoplastic Kidney and Kidney Volumetrics in Predicting Postoperative Renal Function.

Objectives: To model renal function 2 years following radical nephrectomy with quantitative analyses using clinical, histopathologic, and renal composite cortical volumes (CCV). Methods: This retrospective study involved an assessment of the nonneoplastic kidney tissue by three blinded nephropathologists using modified Banff 1997 criteria for renal allograft pathology. Volumetric image acquisition was obtained by three independent radiologists using preoperative imaging. A 2-year estimated glomerular filtration (eGFR) calculator was created. Results: Among the 126 patients, median age was 60 years; median CCV, 398.1 cm3; preoperative eGFR, 77 mL/min/1.73 m2; and 2-year postoperative eGFR, 54 mL/min/1.73 m2. Of the subjects, 64% had hypertension, 26% diabetes, and 37% were smokers. Increasing age, glomerulopathy/sclerosis, tubulointerstitial scarring, and arteriosclerosis were statistically significantly and adversely associated with eGFR. Conversely, increasing CCV was associated with a higher eGFR. Conclusions: Quantitative analysis of the nephrectomized kidney in conjunction with patient age can accurately predict renal function at 2 years.

Long-term results of protocol kidney biopsy directing steroid withdrawal in simultaneous pancreas-kidney transplant patients.

INTRODUCTION: We sought to determine whether protocol biopsies could be used to guide treatment and improve outcomes in simultaneous pancreas-kidney (SPK) patients. METHODS: Between 2004 and 2013, protocol biopsies were performed on SPK patients at 3-6 months and one year post-transplant. Maintenance immunosuppression consisted of a calcineurin inhibitor, anti-proliferative agent, and corticosteroid. Corticosteroid was withdrawn in negative early biopsies, maintained in subclinical/ borderline biopsies, and increased if Banff IB or greater rejection was identified. Endpoints included presence of interstitial fibrosis and tubular atrophy on biopsy at one year (IF/TA), rejection episodes, and renal and pancreas function at five years' followup. RESULTS: Forty-one SPK transplant patients were reviewed and a total of 75 protocol biopsies were identified. On early biopsy, 51% had negative biopsies, 44% had borderline rejection, and 5% had subclinical rejection. Renal and pancreas function were not significantly different at one, two, and five years post-transplant between negative vs. borderline early biopsy patients. No difference in the degree of IF/TA was found between these two groups. CONCLUSIONS: To our knowledge, this is the first study to evaluate protocol biopsies as an investigative tool prior to steroid withdrawal in SPK patients. Our study suggests that there are no detrimental functional or histological effects at five years post-transplant, despite weaning steroids in the negative biopsy group.

CanMEDS scholars: A national survey on urology residents' attitudes towards research during training.

INTRODUCTION: Participation in scholarly activity is an important tenet of residency training and is firmly entrenched in Canada since the introduction of CanMEDS roles by the Royal College of Physicians and Surgeons. As Canadian residency programs transition to competency-based training, it will remain important to understand how to best implement and encourage scholarly pursuits among resident trainees. The objective of this study was to understand the experiences, attitudes, and barriers that surgical residents face when pursuing research during their training. METHODS: An anonymous, cross-sectional, self-report questionnaire was administered to chief residents of all English-speaking urology programs in Canada in 2015. Questions were open- and close-ended, including an agreement score based on a five-point Likert scale. Questions addressed residents' involvement in and attitudes towards research, as well as their perceptions of the utility of research involvement during training. The residents were also asked about the support they received and potential areas to improve the attainment of this competency. Descriptive and correlative statistics were used to analyze the responses. RESULTS: There was a 100% overall response rate to the questionnaire. This study revealed that Canadian urology residents have a high rate of participation in scholarly work, with the vast majority (94%) publishing at least one manuscript with a mean of four papers. Despite this, there appeared to be significant variation in the respondent's experiences, including protected time for research. Furthermore, many residents appeared unconvinced of the importance of research involvement, with only 51% agreement that participation was important to their overall training. As well, a significant number of residents reported largely external, rather than internal, motivations for research participation, such as attaining a preferred fellowship (66% agreement). While the majority of respondents felt (66% agreement) that the scholar role was important in residency training, it would appear that significant barriers, including time and mentorship, limited the effectiveness of research participation to gain those competencies. CONCLUSIONS: The results of this self-report survey outline the significant differences in attitudes and experience towards mandatory research as a component of scholarship in Canadian urology training programs. As postgraduate medical education evolves, particularly with the uptake of competency-based medical education, programs and residents will need to address the motives and barriers to better foster academic pursuits during urology training.

Vascular control during laparoscopic kidney donation.

SUMMARY: Laparoscopic donor nephrectomy (LDN) is the gold standard for kidney donation. Recent literature has led to considerable debate regarding the safest route to provide vascular control during this procedure. The most common devices used for vascular control during LDN are staplers and surgical clips. Opinions regarding the safety of these devices vary, as both are prone to dysfunction. Certain clips have already been contraindicated for use on the donor artery owing to reports of catastrophic complications of falling off. Donor safety is paramount to the continued success of renal transplantation in Canada. A review of existing practice at each institution may be called for to ensure the safest standards possible are in place. An appendix to this commentary is available at canjsurg.ca.

Hilar control during laparoscopic donor nephrectomy: Practice patterns in Canada.

INTRODUCTION: In recent years, the method of vascular control during laparoscopic donor nephrectomy (LDN) has come under scrutiny due to catastrophic consequences of a device failure. This study sought to examine the surgical preferences of Canadian donor surgeons with regards to vascular control and their perception on the safety of these modalities. We also surveyed the experience with device malfunction and their subsequent management during LDN. METHODS: An online survey was sent out to donor surgeons registered with the Canadian Society of Transplantation. Surveys were anonymous and voluntary. Descriptive statistics were used to analyze the collected responses. Recollection of the sequelae and outcomes from device malfunction were also queried. RESULTS: Twenty-eight of 37 surgeons (76% response rate) responded to the survey. At least one surgeon from every institution in Canada performing LDN responded to the survey. Laparoscopic stapler is the most commonly used device for securing the renal artery (61%) and renal vein (67%). Overall, surgeons felt the stapler was the safest method of securing the renal artery. Stapler misfire and clip slippage were reported by eight (28.5%) and 12 (43%) surgeons, respectively. Most cases were salvageable: laparoscopically (30%), open conversion (30%), and by hand port (5%). Slippage of a plastic locking clip resulted in one emergent laparotomy on POD#1 and one stapler misfire was converted to open resulting in donor death. CONCLUSIONS: Although rare, hemorrhagic complications can occur from device malfunction resulting in poor outcomes for healthy volunteers undergoing LDN. Surgeons need to remain vigilant when selecting the appropriate modality for vascular control.

Expanding living kidney donor criteria with ex-vivo surgery for renal anomalies.

INTRODUCTION: Renal transplantation remains the gold standard treatment for end-stage renal disease, with living donor kidneys providing the best outcomes in terms of allograft survival. As the number of patients on the waitlist continues to grow, solutions to expand the donor pool are ongoing. A paradigm shift in the eligibility of donors with renal anomalies has been looked at as a potential source to expand the living donor pool. We sought to determine how many patients presented with anatomic renal anomalies at our transplant centre and describe the ex-vivo surgical techniques used to render these kidneys suitable for transplantation. METHODS: A retrospective review was performed of all patients referred for surgical suitability to undergo laparoscopic donor nephrectomy between January 2011 and January 2015. Patient charts were analyzed for demographic information, perioperative variables, urological histories, and postoperative outcomes. RESULTS: 96 referrals were identified, of which 81 patients underwent laparoscopic donor nephrectomy. Of these patients, 11 (13.6%) were identified as having a renal anomaly that could potentially exclude them from the donation process. These anomalies included five patients with unilateral nephrolithiasis, four patients with large renal cysts (>4 cm diameter), one patient with an angiomyolipoma (AML) and one patient with a calyceal diverticulum filled with stones. A description of the ex-vivo surgical techniques used to correct these renal anomalies is provided. CONCLUSIONS: We have shown here that ex-vivo surgical techniques can safely and effectively help correct some of these renal anomalies to render these kidneys transplantable, helping to expand the living donor pool.

Retained Urethral Catheter Secondary to Placement in Proximal Ureter.

We present an unusual complication secondary to indwelling urethral catheter placement. Routine catheter placement by the obstetrics team in a postpartum female leads to retention of the catheter and inability of its removal by both the obstetrics and urology teams. Although a retained urinary catheter is relatively common, inability to remove a catheter secondary to placement inadvertently into a ureter is extremely rare. In this paper we will discuss the options in removing a retained catheter and present our case of a retained catheter secondary to placement within the right proximal ureter.

Hypothermic machine perfusion improves Doppler ultrasonography resistive indices and long-term allograft function after renal transplantation: a single-centre analysis.

OBJECTIVES: To evaluate whether hypothermic machine perfusion (HMP) of transplanted kidneys can improve long-term renal allograft function compared with static cold storage (CS). METHODS: We evaluated whether graft Doppler ultrasonography resistive indices improved with the use of HMP compared with CS preservation, and examined whether these improvements were predictive of long-term graft function. A total of 30 kidney transplants (15 pairs) were examined. One of the kidney pairs was placed on CS and transplanted first (CS group, n = 15). The other kidney of each pair was placed on HMP and transplanted after the CS group (HMP group, n = 15). Doppler ultrasonography was performed on days 1 and 7 after transplantation and resistive indices were evaluated. The estimated glomerular filtration rate (eGFR) was monitored for 24 months after transplantation. RESULTS: Despite longer cold ischaemia times, kidneys maintained with HMP had lower resistive indices (P = 0.005) with correspondingly higher eGFR throughout the follow-up. Subgroup analysis showed that the HMP-induced improvement in postoperative eGFR was greatest in kidneys obtained from donation after cardiac death (DCD), even at 2 years after transplantation (P = 0.008). CONCLUSIONS: HMP of transplant kidneys appears to improve vascular resistance after transplantation and has a positive impact on long-term allograft function compared with CS in the population of recipients of DCD kidneys.

The value of a core clinical rotation in urology for medical students.

INTRODUCTION: In 2013, our institution underwent a change to the undergraduate medical curriculum whereby a clinical urology rotation became mandatory. In this paper, we evaluated the perceived utility and value of this change in the core curriculum. METHODS: Third year medical students, required to complete a mandatory 1-week clinical urology rotation, were asked to complete a survey before and after their rotation. Fourth year medical students, not required to complete this rotation, were also asked to complete a questionnaire. Chi-squared and Fisher's exact test were used for data analysis. RESULTS: In total, 108 third year students rotated through urology during the study period. Of these, 66 (61%) completed the pre-rotation survey and 54 (50%) completed the post-rotation survey. In total, there were 110 fourth year students. Of these, 44 (40%) completed the questionnaire. After completing their mandatory rotations, students felt more comfortable managing and investigating common urological problems, such as hematuria and renal colic. Students felt they had a better understanding of how to insert a Foley catheter and felt comfortable independently inserting a Foley catheter. Importantly, students felt they knew when to consult urology and were also more likely to consider a career in urology. Compared to fourth year students, third year students felt urology was an important component to a family medicine practice and felt they had a better understanding of when to consult urology. CONCLUSION: The introduction of a mandatory urology rotation for undergraduate medical students leads to a perceived improvement in fundamental urological knowledge and skill set of rotating students. This mandatory rotation provides a valuable experience that validates its inclusion.

Totally tubeless outpatient percutaneous nephrolithotomy: initial case report.

We report the first case of totally tubeless outpatient percutaneous nephrolithotomy (PCNL). Our patient was discharged home safely less than 4 hours following uncomplicated PCNL with no nephrostomy tube, ureteral stent, or urethral catheter. Follow-up the next day in clinic confirmed that the procedure was successful, as the patient was clinically well and stone free. To our knowledge, this is the first case report of totally tubeless (no nephrostomy, no ureteral stent) PCNL performed on a truly outpatient basis.

Pathologic and physiologic phimosis: approach to the phimotic foreskin.

OBJECTIVE: To review the differences between physiologic and pathologic phimosis, review proper foreskin care, and discuss when it is appropriate to seek consultation regarding a phimotic foreskin. SOURCES OF INFORMATION: This paper is based on selected findings from a MEDLINE search for literature on phimosis and circumcision referrals and on our experience at the Children's Hospital of Eastern Ontario Urology Clinic. MeSH headings used in our MEDLINE search included "phimosis," "referral and consultation," and "circumcision." Most of the available articles about phimosis and foreskin referrals were retrospective reviews and cohort studies (levels II and III evidence). MAIN MESSAGE: Phimosis is defined as the inability to retract the foreskin. Differentiating between physiologic and pathologic phimosis is important, as the former is managed conservatively and the latter requires surgical intervention. Great anxiety exists among patients and parents regarding non-retractile foreskins. Most phimosis referrals seen in pediatric urology clinics are normal physiologically phimotic foreskins. Referrals of patients with physiologic phimosis to urology clinics can create anxiety about the need for surgery among patients and parents, while unnecessarily expanding the waiting list for specialty assessment. Uncircumcised penises require no special care. With normal washing, using soap and water, and gentle retraction during urination and bathing, most foreskins will become retractile over time. CONCLUSION: Physiologic phimosis is often seen by family physicians. These patients and their parents require reassurance of normalcy and reinforcement of proper preputial hygiene. Consultation should be sought when evidence of pathologic phimosis is present, as this requires surgical management.

Phimosis--a diagnostic dilemma?

INTRODUCTION: Phimosis is defined as the inability to retract the foreskin. Differentiating between physiological phimosis and pathological phimosis is important, as the former is managed conservatively and the latter requires surgical intervention. Referrals of patients with physiological phimosis to urology clinics may create anxiety regarding the need for surgery amongst patients and parents, while unnecessarily expanding the waiting list for specialty assessment. OBJECTIVES: To determine the ability of referring physicians to differentiate physiological from pathological phimosis, and to see whether there is any difference in this ability between generalists versus specialists. MATERIALS AND METHODS: A retrospective chart review of 284 consecutive referrals for phimosis to the Children's Hospital of Eastern Ontario (CHEO) Urology Clinic during November 2000 - April 2003 was conducted. Referral sources included family physicians (FP), pediatricians (PD), emergency physicians (ER), and other subspecialists (SS). Data for this study were obtained from the original referral letters and cross-referenced with the impressions of the pediatric urologist following the initial patient encounter. The accuracy in diagnosing phimosis was evaluated among the various types of referring physicians. RESULTS: A total of 284 phimosis referrals were reviewed of patients ranging from 2 months to 16 years of age (mean = 6.6 years). The referral sources consisted of 222-GP, 33-PD, 23-ER, and 6-SS. The majority of referred cases were diagnosed by the attending pediatric urologist as physiological phimosis across all referral sources, with the exception of subspecialists (FP = 75.2%, PD = 81.8%, ER = 56.5%, SS = 33.3%). Second to this was the diagnosis of pathological phimosis across all referral sources except SS (FP = 14.9%, PD = 12%, ER = 34.8%, SS = 50%). Overall, the circumcision rate for the 284 phimosis referrals reviewed was 14.4%. CONCLUSIONS: Our findings reveal that many physicians continue to face difficulties in distinguishing physiological phimosis from the pathological. As a result, many unnecessary referrals are made for phimosis . We suggest the implementation of improved educational measures regarding preputial pathophysiology in the medical curriculum. Such measures would serve two purposes: first, to reduce the number of unnecessary specialty referrals and secondly, to aid primary care physicians in recognizing the presence of physiological phimosis so that patients and families may be reassured of normalcy.