Survival following upfront chemotherapy for treatment-naïve metastatic prostate cancer: a real-world retrospective cohort study.

BACKGROUND: Upfront chemotherapy prolongs overall survival for men with metastatic, hormone-sensitive prostate cancer (mHSPC) based on data from clinical trials. We sought to assess the association between upfront chemotherapy and overall survival in men with mHSPC in a real-world cohort. METHODS: We performed a retrospective cohort study of men with de novo, treatment-naïve metastatic prostate cancer from a large, national cancer database in the United States (2014-2015). Men in the upfront chemotherapy group received chemotherapy within 4 months of diagnosis (n = 1033, 28%) versus no chemotherapy or chemotherapy later than 12 months after diagnosis (controls; n = 2704, 72%). Overall survival was assessed using Kaplan-Meier estimates and compared using multivariable Cox regression analysis. RESULTS: After a median follow-up of 23 months, median overall survival was 35.7 months in the upfront chemotherapy group and 32.5 months for controls (log-rank p < 0.001). After adjusting for patient and clinical variables, upfront chemotherapy was associated with longer overall survival (hazard ratio 0.78, 95% confidence interval 0.68-0.89, p < 0.001). In exploratory analyses, the association between upfront chemotherapy and overall survival did not differ by age groups, race, or number of comorbidities (all interaction p > 0.2). CONCLUSIONS: In this real-world cohort, upfront chemotherapy for mHSPC was associated with longer overall survival. These data support the continued use of chemotherapy for men with mHSPC regardless of race or age if they are fit for chemotherapy and underscore the importance of evaluating cancer therapeutics outside of clinical trials to demonstrate treatment efficacy in populations that may be underrepresented in clinical trials.

Predictors of use and overall survival for patients undergoing metastasectomy for bladder cancer in a national cohort.

OBJECTIVES: To determine the use of surgical resection of metastatic disease in a large national sample and its association with overall survival. METHODS: The National Cancer Database was queried for patients with metastatic bladder cancer (2004-2016). Overall survival was assessed using Kaplan-Meier and multivariable Cox analyses. The associations between covariates and use of metastasectomy were assessed with multivariable logistic regression. RESULTS: Of the 16 382 patients with metastatic bladder cancer included, 6.8% underwent metastasectomy. Its use increased over time (4.7% in 2004 to 6.6% in 2016; per year odds ratio 1.02, 95% confidence interval 1.00-1.04, P = 0.019). Median survival was 7.0 months for patients who received metastasectomy and 5.1 months for those who did not (hazard ratio 0.85, 95% confidence interval 0.79-0.91, P < 0.001). In subgroup analyses, metastasectomy predicted longer survival in patients with lung (hazard ratio 0.73, 95% confidence interval 0.61-0.88, P = 0.001) or brain metastases (hazard ratio 0.58, 95% confidence interval 0.35-0.96, P = 0.035) and in patients with variant histology (hazard ratio 0.80, 95% confidence interval 0.69-0.93, P = 0.003). CONCLUSIONS: In a national sample, the use of metastasectomy for bladder cancer is low. Furthermore, metastasectomy is associated with longer survival overall and in multiple subgroups. However, these results should be validated in future studies.

Marijuana, Lower Urinary Tract Symptoms, and Pain in the Urologic Patient.

OBJECTIVE: To describe marijuana's clinical role for urologic symptoms. METHODS: Studies related to marijuana, voiding dysfunction, lower urinary tract symptoms (LUTS), and pain through January 2019 from PubMed were evaluated for relevance and quality. RESULTS: Forty-eight studies were reviewed. Cannabinoids have mixed efficacy for neurogenic LUTS and little evidence for non-neurogenic LUTS, chronic non-cancer-related and perioperative pain. For cancer-related pain, high-level studies demonstrate cannabinoids are well-tolerated with unclear benefit. CONCLUSION: Cannabinoids appear well-tolerated in the short-term, but their efficacy and long-term impact is unproven and unknown in urologic discomfort. Cannabinoids for urologic symptoms should be further explored with well-designed randomized controlled trials.

Trends in urinary calculi composition from 2005 to 2015: a single tertiary center study.

The goal of this study was to investigate recent changes in stone composition and patient demographics to identify factors influencing stone formation for the purpose of reducing the incidence of urolithiasis and preventing stone recurrence. This retrospective analysis includes patients who underwent percutaneous nephrolithotripsy or ureteroscopy at our institution from 2005 to 2015. Northwestern Medicine Enterprise Data Warehouse was used to retrieve demographic information and stone composition analyses. The composition of mixed stones containing uric acid (UA) and calcium oxalate monohydrate (COM) was analyzed further. Chi-squared tests were used for categorical variables and logistic regression was used to assess trends. From 2005 to 2015, 5268 stones were treated. COM was predominant in 42.2% and only 16.6% were pure. The male/female ratio decreased significantly from 1.8 to 1.08 and patient age increased (p < 0.001) with 45.6% of patients being 60 or older in 2015. Females formed more CO dihydrate (COD; p = 0.008) and struvite (p = 0.001) overall. The incidence of COM (p = 0.007) and UA (p < 0.001) rose significantly in men whereas both sexes saw a decrease in carbonate apatite (CA; p < 0.001). COM increased considerably from 12 to 75% amongst mixed stones with UA over the 11-year span. We concluded that stone formers have become older and more gender-equal. The increase in female patients parallels the increase in female obesity in the US. The rising predominance of COM, including when mixed with UA, and the scarcity of pure stones indicates it may be necessary to develop new approaches to managing and preventing urolithiasis.

Upper Pole Access for Prone Percutaneous Nephrolithotomy: Advantage or Risk?

OBJECTIVE: To analyze the outcomes of upper pole access during percutaneous nephrolithotomy (PCNL), an option pole often avoided due to the concern for pleural injury. METHODS: We retrospectively collected data on patients undergoing PCNL at our institution. Patients were divided into 3 groups according to access: supracostal upper calyx (group 1), subcostal upper calyx (group 2), and nonupper calyx (group 3). Preoperative imaging was reviewed to assess stone burden, Hounsfield units (HU), location, and Guy's Stone Score. Patients were considered stone-free if residual fragments were 3 mm or smaller on CT scan. RESULTS: We analyzed 329 PCNLs (left: 174; right: 155). Stones had a median size of 32 mm, 800 HU, and Guy's Stone Score of 2. Groups 1, 2, and 3 had 119, 108, and 102 patients, respectively. The 90-day complication rate was 20.4% (7.9% Clavien 3-4). Group 1 patients, with higher BMI and larger stones, had higher SFR than group 3 (89.9% vs 79.4%, P = .038), but with a significantly higher risk of complications (P = .001). Within group 1, left PCNL (7.0% vs 24.2%, P = .016) and BMI ≥30 (6.9% vs 25.0%, P = .013) carried a lower risk of chest tube insertion. There was no difference in complications between groups 2 and 3 (1.9% vs 2.9%). CONCLUSION: Upper pole access is safe and effective, particularly if done below the ribs. Supracostal access is an effective option to achieve higher stone-free rates in complex stones, while carrying a risk of significant hydrothorax, particularly on the right side and in nonobese patients.

Management of Recurrent Pelvic Fluid Collections in Adult Male Bladder Exstrophy Patients With Maintenance of Erectile Function.

OBJECTIVE: "To describe management options for pelvic fluid collections in adult patients with classic bladder exstrophy." METHODS: A single institution retrospective chart review was performed of patients who presented between 1998 and 2016 with a history of bladder exstrophy and pelvic fluid collections and 3 patients were identified. Patients had been followed for a mean of 9.0 years (1-23). RESULTS: All 3 patients required urinary diversions at various intervals following their exstrophy repair as newborns. All initially presented with symptomatic fluid collections located inferior to the bladder visualized by cross-sectional imaging. Mean age at presentation was 32.3 years (26-38 years). Two patients underwent drainage and sclerosing of cystic fluid collections with durable symptomatic relief for 1 patient. The other had recurrence of the fluid collections so he underwent marsupialization of the fluid collection which failed to sufficiently alleviate his symptoms. Ultimately, he along with the last patient, underwent open excision of the presumed hypoplastic prostate leading to resolution of pain symptoms, though the last patient did have some persistence of the fluid collection. All patients maintained their erectile function subsequent to these interventions. CONCLUSION: Adult patients with bladder exstrophy can present with painful cystic fluid collections potentially due to secretions from presumed hypoplastic prostate tissue. Sclerosing of the cyst can be successful in a subset of these patients, though some may require removal of the presumed prostatic tissue, which is curative and can be achieved with preservation of erectile function.

Randomized Controlled Trial Comparing Three Different Modalities of Lithotrites for Intracorporeal Lithotripsy in Percutaneous Nephrolithotomy.

PURPOSE: To compare the efficiency (stone fragmentation and removal time) and complications of three models of intracorporeal lithotripters in percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: Prospective, randomized controlled trial at nine centers in North America from 2009 to 2016. Patients were randomized to one of three lithotripter devices: the Cyberwand, a dual-probe ultrasonic device; the Swiss Lithoclast Select, a combination pneumatic and ultrasonic device; and the StoneBreaker, a portable pneumatic device powered by CO2 cartridges. Since the StoneBreaker lacks an ultrasonic component, it was used with the LUS-II ultrasonic lithotripter to allow fair comparison with combination devices. RESULTS: Two hundred seventy patients were enrolled, 69 were excluded after randomization. Two hundred one patients completed the study: 71 in the Cyberwand group, 66 in the Lithoclast Select group, and 64 in the StoneBreaker group. The baseline patient characteristics of the three groups were similar. Mean stone surface area was smaller in the StoneBreaker group at 407.8 mm2 vs 577.5 mm2 (Lithoclast Select) and 627.9 mm2 (Cyberwand). The stone clearance rate was slowest in the StoneBreaker group at 24.0 mm2/min vs 28.9 mm2/min and 32.3 mm2/min in the Lithoclast Select and Cyberwand groups, respectively. After statistically adjusting for the smaller mean stone in the StoneBreaker group, there was no difference in the stone clearance rate among the three groups (p = 0.249). Secondary outcomes, including complications and stone-free rates, were similar between the groups. CONCLUSIONS: The Cyberwand, Lithoclast Select, and the StoneBreaker lithotripters have similar adjusted stone clearance rates in PCNL for stones >2 cm. The safety and efficacy of these devices are comparable.

Evaluation of targeted antimicrobial prophylaxis for transrectal ultrasound guided prostate biopsy: a prospective cohort trial.

BACKGROUND: We evaluated the effectiveness of targeted antimicrobial prophylaxis in transrectal ultrasound guided prostate biopsy (TRUSP). METHODS: A prospective, non-randomized cohort study was conducted. Rectal swab cultures plated on non-selective blood agar and on selective MacConkey agar supplemented with ciprofloxacin identified ciprofloxacin-susceptible and -resistant gram-negative bacteria (CS-GNB and CR-GNB). Patients with CS-GNB received ciprofloxacin while those with CR-GNB received directed prophylaxis. Infectious complications were defined clinically and microbiologically within 30 days after TRUSP. Data were derived at 7 and 30 days post procedure by questionnaires and electronic medical records. We hypothesized that there would be no difference in the infectious outcomes among the CS and CR groups. RESULTS: From November 1, 2012 to March 31, 2015, 510 men completed the study; 430 (84.3%) had CS-GNB and 80 (15.7%) had CR-GNB. 484 (94.9%) completed the study per protocol, while 26 (5.1%) had an intention-to-treat (ITT) analysis. Of the 484, 475 (98.1%) had no infections, nine (1.9%) had infections, six of which (1.2%) were culture-proven (CP). The nine infections were as follows: five (1.0%) uncomplicated UTIs, one (0.2%) complicated UTI, and three (0.6%) urosepsis. One case of uncomplicated UTI and two cases of urosepsis were not CP, but were diagnosed clinically. ITT outcomes were similar. The infection rates were not statistically different between the CS-and CR-GNB patients (p-value = 0.314; 95% CI 0.8-3.3). The four patients with complicated UTIs or sepsis were hospitalized for a mean of 2.6 days and discharged without sequelae. Of the nine infections, three were antimicrobial prophylaxis failures (two ciprofloxacin and one amikacin); three were likely due to failure of the collection or processing of the rectal swab or increasing bacterial resistance between the time of swab collection and biopsy, and three developed clinical infections with no isolate recovered. CONCLUSIONS: Targeted antimicrobial prophylaxis follows the principles of antimicrobial stewardship and achieved a low rate of infectious complications with limited morbidity and no sequelae. This individualized method of prophylaxis may be widely applied. Further studies are needed to explore reasons for targeted prophylaxis failure and to determine comparative efficacy of non-ciprofloxacin-containing targeted prophylaxis regimens. TRIAL REGISTRATION: ClinicalTrials.gov. NCT01659866 . Registered 9 July 2012. First patient enrolled 1 November 2012.

Retroperitoneal Laparoscopic Radical Nephrectomy Allows Continuation of Peritoneal Dialysis in Patients with End-Stage Renal Disease.

Patient outcomes for retroperitoneal laparoscopic radical nephrectomy (RLRN) in adults on peritoneal dialysis (PD) have not been described in the literature. This is the first series on the successful application of RLRN for renal cell carcinoma (RCC) among adults with end-stage renal disease (ESRD) on PD. In our series of 5 patients, all were able to promptly resume PD, no wound complications were noted at postoperative visits, and no evidence of recurrence was identified on surveillance imaging at follow-up. We propose that RLRN should be considered in PD patients as it allows immediate reinstitution of PD and prevents the morbidity and complications associated with interim hemodialysis.

Risks and Benefits of Postoperative Double-J Stent Placement After Ureteroscopy: Results from the Clinical Research Office of Endourological Society Ureteroscopy Global Study.

PURPOSE: Double-J stent placement after stone removal by ureteroscopy (URS) is common and recommended in many cases but debatable in others. In this study, the risks and benefits of postoperative Double-J stent placement in URS stone treatment procedures undertaken in current clinical practice are examined. MATERIALS AND METHODS: The Clinical Research Office of Endourological Society (CROES) URS is a prospective, observational, international multicenter study, in which patients are candidates for URS as primary treatment or after failure of prior treatment for ureteral and renal stones. Baseline, intraoperative, and postoperative data were collected. Predictors and outcomes of postoperative stent placement were analyzed by inverse probability-weighted regression adjustment of the relationship between a Double-J stent placement and outcomes (complications, readmission [including retreatment], and length of hospital stay). RESULTS: Significant predictors of postoperative Double-J stent placement in URS treatment of ureteral stones were intraoperative complications, impacted stones, operation time, stone burden, age, presence of a solitary kidney, and stone-free rate. In renal stone treatment, the predictors identified included operation time, age, preoperative stent placement, anticoagulant use, presence of a solitary kidney, and intraoperative complications. In both ureteral and renal stone treatment groups, postoperative placement of a Double-J stent resulted in significantly fewer postoperative complications (p < 0.001) compared with patients who did not receive a stent. CONCLUSIONS: Patient- and procedure-related variables were identified, which may enable an individualized approach to postoperative stenting, resulting in improved clinical outcomes in urologic stone treatment by URS.

Factors Associated with Compliance to Increased Fluid Intake and Urine Volume Following Dietary Counseling in First-Time Kidney Stone Patients.

OBJECTIVE: Increasing fluid intake to achieve a urine volume (UV) of >2.5 L/day decreases stone events. We assessed compliance rates and demographic and clinical variables associated with increased fluid intake and UV in patients with urolithiasis following dietary counseling. MATERIALS AND METHODS: In a retrospective study, patients with a low baseline UV (<2.5 L/day) on an initial 24-hour urine collection during metabolic stone evaluation were identified between 2010 and 2015. Patients received detailed standardized dietary counseling, including increasing fluid intake to >3 L/day and titrating it to achieve UV >2.5 L/day. A follow-up 24-hour urine collection was performed at 6 months (FU1) and 18 months (FU2) to assess compliance (UV >2.5 L/day) and predictors associated with it. RESULTS: Our cohort contained 363 patients, 53.4% men and 46.6% women. The mean UV of baseline, FU1, and FU2 urine collections was 1.63, 2.52, and 2.48 L, respectively. The compliance rate of obtaining UV of >2.5 L was 50.1% at 6 months. On logistic regression, male sex (odds ratio [OR] 3.27, 95% confidence interval [CI] 1.94, 5.52, p < 0.001), urolithiasis-related procedures such as ureteroscopy (OR 2.31, 95% CI 1.20, 4.42, p = 0.01) or percutaneous nephrolithotomy (OR 3.48, 95% CI 1.58, 7.63, p = 0.002), and baseline 24-hour UV >1 L (OR 3.00, 95% CI 1.02, 8.76, p = 0.04) were associated with greater odds of compliance. Age >58 years (OR 0.39, 95% CI 0.20, 0.75, p = 0.005) and presence of lower urinary tract symptoms (OR 0.50, 95% CI 0.26, 0.95, p = 0.03) were associated with lower odds of compliance. Ethnicity, body mass index, renal function, marital status, renal stone burden, stone type, and household income were not associated with compliance. CONCLUSIONS: In stone formers, compliance to fluid intake recommendations as measured by 24-hour UV is roughly 50%. Understanding risk factors for noncompliance, especially in at risk patients, can be used for quality improvement initiatives and reducing stone events.

NCCN Guidelines Insights: Prostate Cancer Early Detection, Version 2.2016.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer Early Detection provide recommendations for prostate cancer screening in healthy men who have elected to participate in an early detection program. The NCCN Guidelines focus on minimizing unnecessary procedures and limiting the detection of indolent disease. These NCCN Guidelines Insights summarize the NCCN Prostate Cancer Early Detection Panel's most significant discussions for the 2016 guideline update, which included issues surrounding screening in high-risk populations (ie, African Americans, BRCA1/2 mutation carriers), approaches to refine patient selection for initial and repeat biopsies, and approaches to improve biopsy specificity.

Diagnostic Value of Guided Biopsies: Fusion and Cognitive-registration Magnetic Resonance Imaging Versus Conventional Ultrasound Biopsy of the Prostate.

OBJECTIVE: To better assess the increased utilization of multiparametric magnetic resonance imaging (mpMRI) and fusion biopsy of the prostate, we compared prostate cancer detection rates among (a) men undergoing MR-ultrasound (US) fusion biopsy, (b) mpMRI cognitive-registration biopsy, and (c) conventional transrectal US-guided biopsy for the detection of prostate cancer. MATERIALS AND METHODS: We present a retrospective review of consecutive patients undergoing mpMRI of the prostate with subsequent prostate biopsy from October 2013 to September 2015. Lesions concerning for prostate cancer visualized on mpMRI were targeted with cognitive-registration or MR-US fusion biopsies. A cohort of men undergoing conventional prostate biopsy was utilized for comparison. Rates of cancer detection were compared among the 3 cohorts. RESULTS: A total of 231 patients underwent mpMRI-targeted biopsy (81 fusion, 150 cognitive). There was no difference in prostate specific antigen, mpMRI-defined Prostate Imaging Reporting and Data System score or number of lesions, or history of prostate cancer among the cohorts. The overall detection rate of cancer was significantly higher in the fusion cohort (48.1%) compared with both the cognitive (34.6% P = .04) and conventional (32.0%, P = .03) cohorts. Cancer detection rates were comparable in the MRI-cognitive and transrectal prostate US biopsy groups (34.6% vs 32%). MR fusion detected significantly more Gleason ≥7 cancer (61.5 vs 37.5%, P = .04) and significantly less Gleason 6 cancer (38.5 vs 62.5%, P = .04) compared with conventional biopsy. CONCLUSION: Targeted biopsy of the prostate using MR-US fusion increased the cancer detection rate compared with both cognitive registration and conventional biopsy and was associated with detection of higher-grade cancer compared with conventional biopsy.

Contemporary Attitudes and Practice Patterns of North American Urologists in Investigating Stone-Forming Patients-A Survey of Endourological Society Members.

INTRODUCTION: Recent evidence would suggest a low rate of metabolic assessment in stone formers, even in those deemed as high risk. We wished to assess the attitudes and practice patterns of metabolic work up in North American members of the Endourological Society as part of the management of stone-forming patients. METHODS: A 12-question online multiple-choice questionnaire (using Survey Monkey(®)) was distributed to all members of the Endourological Society through e-mail. Descriptive analyses were performed. RESULTS: A total of 124 North American members of the Endourological Society responded (90% endourologists, 65% fellowship trained). Ninety-seven percent perform metabolic assessments without referring to a consultant. Eighty-three percent use a commercial analysis company and 17% request serum or urine parameters individually. Ninety-seven percent believe that 24-48-hour urine collection is a better way of assessing patients for metabolic abnormalities than a "basic analysis." Many respondents (37%) would be more likely to metabolically assess if results were easier to interpret, and 35% would like assistance/advice in the interpretation of results. At initial investigation of a first-time stone former, 87% of respondents use serum chemistry, 48% use 24-hour urine, 26% use 48-hour urine (two consecutive 24-hour urine collections), 54% send stone for analysis, and 7% do not investigate. On recurrent stone formers, 69% use serum chemistry, 73% use 24/48-hour urine, and 23% send stone for analysis. On routine follow-up, 36% check serum chemistry, 55% use 24-hour urine, 2% use 48-hour urine, and 29% do not metabolically evaluate. The majority agree that pharmacologic therapy plays a strong role in preventing recurrence (90%). After initiating pharmacologic therapy, 59% reassess using serum chemistry and 84% and 7% use 24/48-hour urine collection, respectively. Physicians re-evaluate patients after 1 month (7%), 1-2 months (10%), 2-4 months (44%), 4-6 months (30%), or after 6-12 months (7%). CONCLUSION: This snapshot assessment of Endourological Society members' practices in the metabolic investigation of stone-forming patients demonstrates wide testing variations. Many physicians expressed interest in assistance/advice in the interpretation of the metabolic assessment results.

Radiofrequency Ablation-Assisted Zero-Ischemia Robotic Laparoscopic Partial Nephrectomy: Oncologic and Functional Outcomes in 49 Patients.

Introduction and Objectives. Robotic partial nephrectomy with peritumoral radiofrequency ablation (RFA-RPN) is a novel clampless technique. We describe oncologic and functional outcomes in a prospective cohort. Methods. From May, 2007, to December, 2009, 49 consecutive patients with renal masses <7 cm underwent RFA-RPN. During this period, only the RFA-RPN technique was utilized for all cases of partial nephrectomy. Pre- and postoperative data were analyzed and compared to 36 consecutive patients who underwent LPN. Results. In total, 49 tumors were treated in the RFA-RPN group and 36 tumors in the comparison group. Mean operative time was longer in the RFA-RPN group (370 min versus 293 min, p < 0.001). There were no significant differences in mean EBL (231 cc versus 250 cc, p = 0.42), transfusion rate (8.2% versus 11.1%, p = 0.7), or hospital stay (3.9 versus 4.4 days, p = 0.2). Two patients in the RFA-RPN (4.1%) and 1 (2.7%) patient in the comparison group had a positive surgical margin (p = 0.75). 17 (34.7%) patients had a postoperative urine leak in the RFA-RPN group versus 2 (5.6%) patients in the comparison group (p = 0.001). Mean follow-up was 54 months versus 68.4 months in the comparison group. There was no significant difference between the two groups regarding change in GFR (p = 0.67). There were 3 recurrences (6.1%) in the RFA-RPN group and 0 recurrences in the RPN group (p = 0.23). There were 3 deaths (6.1%) in the RFA-RPN group (one cancer specific) and 4 deaths (11.1%) in the RPN group (non-cancer specific) over the follow-up period (p = 0.44). Conclusions. Our data suggests that this technique is associated with a similar degree of renal preservation but higher rates of postoperative urine leak and possibly higher rates of recurrence.

Update on the Diagnosis and Management of Renal Angiomyolipoma.

PURPOSE: Advances in minimally invasive therapies and novel targeted chemotherapeutics have provided a breadth of options for the management of renal masses. Management of renal angiomyolipoma has not been reviewed in a comprehensive fashion in more than a decade. We provide an updated review of the current diagnosis and management strategies for renal angiomyolipoma. MATERIALS AND METHODS: We conducted a PubMed(®) search of all available literature for renal or kidney angiomyolipoma. Further sources were identified in the reference lists of identified articles. We specifically reviewed case series of partial nephrectomy, selective arterial embolization and ablative therapies as well as trials of mTOR inhibitors for angiomyolipoma from 1999 to 2014. RESULTS: Renal angiomyolipoma is an uncommon benign renal tumor. Although associated with tuberous sclerosis complex, these tumors occur sporadically. Risk of life threatening hemorrhage is the main clinical concern. Due to the fat content, angiomyolipomas are generally readily identifiable on computerized tomography and magnetic resonance imaging. However, fat poor angiomyolipoma can present a diagnostic challenge. Novel research suggests that various strategies using magnetic resonance imaging, including chemical shift magnetic resonance imaging, have the potential to differentiate fat poor angiomyolipoma from renal cell carcinoma. Active surveillance is the accepted management for small asymptomatic masses. Generally, symptomatic masses and masses greater than 4 cm should be treated. However, other relative indications may apply. Options for treatment have traditionally included radical and partial nephrectomy, selective arterial embolization and ablative therapies, including cryoablation and radio frequency ablation, all of which we review and update. We also review recent advances in the medical treatment of patients with tuberous sclerosis complex associated angiomyolipomas with mTOR inhibitors. Specifically trials of everolimus for patients with tuberous sclerosis complex suggest that this agent may be safe and effective in treating angiomyolipoma tumor burden. A schema for the suggested management of renal angiomyolipoma is provided. CONCLUSIONS: Appropriately selected cases of renal angiomyolipoma can be managed by active surveillance. For those patients requiring treatment nephron sparing approaches, including partial nephrectomy and selective arterial embolization, are preferred options. For those with tuberous sclerosis complex mTOR inhibitors may represent a viable approach to control tumor burden while conserving renal parenchyma.

NCCN Clinical Practice Guidelines Prostate Cancer Early Detection, Version 2.2015.

Prostate cancer represents a spectrum of disease that ranges from nonaggressive, slow-growing disease that may not require treatment to aggressive, fast-growing disease that does. The NCCN Guidelines for Prostate Cancer Early Detection provide a set of sequential recommendations detailing a screening and evaluation strategy for maximizing the detection of prostate cancer that is potentially curable and that, if left undetected, represents a risk to the patient. The guidelines were developed for healthy men who have elected to participate in the early detection of prostate cancer, and they focus on minimizing unnecessary procedures and limiting the detection of indolent disease.

Modern Guidelines for Bowel Preparation and Antimicrobial Prophylaxis for Open and Laparoscopic Urologic Surgery.

Mechanical bowel preparation (MBP) and antibiotics (oral and/or intravenous) have historically been used to decrease infectious complications in surgeries that involve manipulation of bowel or potential risk of injury. The use of MBP has recently been challenged in the colorectal surgery literature, thus inspiring similar critical evaluation of our practices in urology. This review gives a brief overview of the history of mechanical and oral antibiotic bowel preparation, as well as the evolution of the practice trends in colorectal surgery and urology. We also examine contemporary guidelines in skin preparation as well as antimicrobial prophylaxis before surgery.