The role of preoperative immune cell metrics in renal cell carcinoma with a tumor thrombus.

INTRODUCTION: The objective of this study was to stratify preoperative immune cell counts by cancer specific outcomes in patients with renal cell carcinoma (RCC) and a tumor thrombus after radical nephrectomy with tumor thrombectomy. METHODS: Patients with a diagnosis of RCC with tumor thrombus that underwent radical nephrectomy with thrombectomy across an international consortium of seven institutions were included. Patients who were metastatic at diagnosis and those who received preoperative medical treatment were also included. Retrospective chart review was performed to collect demographic information, past medical history, preoperative lab work, surgical pathology, and follow up data. Neutrophil counts, lymphocyte counts, monocyte counts, neutrophil to lymphocyte ratios (NLR), lymphocyte to monocyte ratios (LMR), and neutrophil to monocyte ratios (NMR) were compared against cancer-specific outcomes using independent samples t-test, Pearson's bivariate correlation, and analysis of variance. RESULTS: One hundred forty-four patients were included in the study, including nine patients who were metastatic at the time of surgery. Absolute lymphocyte count preoperatively was greater in patients who died from RCC compared to those who did not (2 vs 1.4; p < 0.001). Patients with tumor pathology showing perirenal fat invasion had a greater neutrophil count compared to those who did not (7.5 vs 5.5; p = 0.010). Patients with metastatic RCC had a lower LMR compared to those without metastases after surgery (2.5 vs 3.2; p = 0.041). Tumor size, both preoperatively and on gross specimen, had an interaction with multiple immune cell metrics (p < 0.05). CONCLUSIONS: Preoperative immune metrics have clinical utility in predicting cancer-specific outcomes for patients with RCC and a tumor thrombus. Additional study is needed to determine the added value of preoperative serum immune cell data to established prognostic risk calculators for this patient population.

Bladder Stones in Renal Transplant Patients: Presentation, Management, and Follow-up.

INTRODUCTION: The study aim was to analyze the presentation, management, and follow-up of renal transplant patients developing bladder calculi. METHODS: Patients who underwent renal transplant with postoperative follow-up at our institution were retrospectively analyzed (1984-2023) to assess for the development of post-transplant bladder stones. All bladder stones were identified by computerized tomography (CT) imaging and stone size was measured using this imaging modality. RESULTS: The prevalence of bladder calculi post-renal transplantation during the study window was 0.22% (N=20/8835) with a median time to bladder stone diagnosis of 13 years post-transplant. Of all bladder stone patients, 6 (30%) received deceased donor and 14 (70%) living donor transplants. There were 11 patients with known bladder stone composition available; the most common being calcium oxalate (N=6). Eleven (55%) patients had clinical signs or symptoms (most commonly microhematuria). Fourteen of the bladder stone cohort patients (70%) underwent treatment including cystolitholapaxy in 12 subjects. Of these 14 patients, 9 (64%) were found to have non-absorbable suture used for their ureteroneocystotomy closure. CONCLUSIONS: The prevalence of bladder stones post-renal transplant is low. The utilization of non-absorbable suture for ureteral implantation was the main risk factor identified in our series. This technique is no longer used at our institution. Other factors contributing to bladder stone formation in this population warrant identification.

Risk factors for infection and acute urinary retention following transperineal prostate biopsy.

PURPOSE: To calculate the frequency of infection and acute urinary retention (AUR) following transperineal (TP) prostate biopsy at a single high-volume academic institution and determine risk factors for developing these post-biopsy conditions. METHODS: Men undergoing TP prostate biopsy from 2012 to 2022 at our institution were retrospectively identified and chart reviewed. TP biopsies were performed with TR ultrasound (TRUS) guidance with anesthesia using a brachytherapy grid template. TRUS volumes were recorded during the procedure, and magnetic resonance imaging (MRI) volumes were calculated using the ellipsoid formula. When available, MRI volume was used for all analysis, and when absent, TRUS volume was used. AUR was defined as requiring urinary catheter placement within 72 h post-biopsy for inability to urinate. Univariable analysis was performed and variables with p < 0.1 and/or established clinical relevance were included in a backward binary logistic regression to produce an optimized model that fit the data without collinearity between variables. RESULTS: A total of 767 TP biopsies were completed in the study window. The frequency of infection was 1.83% (N = 14/767). The total frequency of AUR was 5.48% (N = 42/767). On multivariable regression, patients who went into AUR were five times as likely to develop infection (p = 0.020). Patients with infection post-TP biopsy were four times as likely to develop AUR (p = 0.047) and with prostates > 61.21 cc were three times as likely (p = 0.019). CONCLUSION: According to our model, AUR is the greatest risk factor for infection post-TP biopsy. With regard to AUR risks, infection post-biopsy and prostate size > 61.21 cc are the greatest risk factors.

Robotic assisted radical nephrectomy with Inferior vena cava tumor thrombus

ABSTRACT Purpose: Surgery for renal cell carcinoma (RCC) with an inferior vena cava (IVC) tumor thrombus can be done via a robotic approach. While this approach is thought to minimize blood loss, it may still result in significant losses (1) and current publications indicate that it can require upwards of 3-day hospital stays (1, 2). However, innovative surgical techniques, such as the split and roll, may curtail this. The purpose of this video is to present the case and surgical technique of robotic assisted radical nephrectomy with IVC thrombectomy. Materials and Methods: The patient was a 77-year-old male found to have a right upper pole renal mass on CT urogram. On MRI (Figure 1), a renal mass and level II thrombus was seen. For this case, the Da Vinci Xi Intuitive robotic system was used, with four robotic 8-millimeter (mm) metallic trocars, two 5 mm assistant trocars, and one 12 mm air seal port. The split and roll technique were utilized to access the IVC and lumbar veins. This surgical method uses the adventitia of the IVC as a plane of dissection and safely identifies all branches/tributaries of the IVC to minimize the chance of vascular injury (3). Results: Robotic console time was 150 minutes. The patient had an excellent outcome, with all tumor thrombus removed, less than 50cc of blood loss, and was discharged within 24 hours of the operation. The tumor pathology came back as papillary, high grade, and was stage pT3bN1. Conclusions: The robotic approach with split and roll technique is a great surgical option for urologists to consider in patients with RCC and a level I or II thrombus, which can minimize blood loss and expedite discharge.

Less is more: single dose versus extended antibiotic prophylaxis for transperineal prostate biopsy.

INTRODUCTION: There is an ongoing debate as to the appropriate regimen of antibiotic prophylaxis with transperineal (TP) biopsy. The objective of this study was to report the rate of infection following TP biopsy at a high-volume institution and assess the impact of single dose antibiotics at the time of biopsy versus outpatient antibiotics in preventing postprocedural infections. MATERIALS AND METHODS: Records of men undergoing TP prostate biopsy from 2012 to 2022 were reviewed. Patients were divided into two groups, those who received single dose intravenous (IV) antibiotics at the time of biopsy (n = 440) and those who received both IV antibiotics at the time of biopsy and outpatient antibiotics before/after biopsy (n = 327). Post biopsy infection was defined as at least one of the following: fever (≥ 38.3°C) with/without symptoms of urinary tract infection or positive urine culture (> 105 colony forming units) within 72 hours post biopsy. The rates of infection were compared between the two groups. RESULTS: A total of 767 biopsies were included in the study. Infection rate post TP biopsy was 1.83% (n = 14). The infection rate for patients with single dose prophylaxis was 2.05% (n = 9) and 1.53% (n = 5) for those that received the extended antibiotic regimen. No significant difference in infection rates between the different antibiotic regimens was found (p = 0.597). CONCLUSIONS: Overall rates of infection after TP prostate biopsy are very low. Our data indicate that single dose and extended regimen of antibiotic prophylaxis show similar infection rates. These findings support antibiotic stewardship and encourage further research into the appropriate regimen of prophylaxis for TP prostate biopsy.

Postsurgery Opiate Use Is Significantly Lower in Patients With Interstitial Cystitis/Bladder Pain Syndrome Following Cystectomy With Urinary Diversion.

OBJECTIVE: To compare pre-and post-operative opiate use in a large cohort of interstitial cystitis/bladder pain syndrome (IC/BPS) patients who underwent cystectomy with urinary diversion (CWUD). METHODS: A retrospective analysis was completed using a database of IC/BPS patients who underwent CWUD at a single institution from 2014 to 2022. In addition to demographic information, bladder capacity and Hunner lesion status were documented for each patient. Opiate use (milligram morphine equivalents [MME]) was calculated for each patient and change in MME (ΔMME) was calculated by subtracting pre-CWUD MME from post-CWUD MME. Paired t test was used to compare ΔMME for all parameters except age, where a Pearson's correlation was used. RESULTS: The analysis included 82 patients (17 M; 65 F) that underwent CWUD as follows: 53 ileal conduit diversions, 11 neobladders, and 18 Indiana Pouches. Mean pre-CWUD MME use was 4509.57 and mean post-CWUD MME was 1788.48 with a ΔMME of - 2721.09 (P < .001). ΔMME was not significantly different based on gender (P = .597), bladder capacity (P = .754), age (P = .561), or Hunner lesion status (P = .085). CONCLUSION: IC/BPS patients using opiates primarily for relief of pain directly related to their condition show a significant decrease in opiate use following CWUD, which likely represents significant pain reduction and implicates the bladder as the primary source of that pain.

Robotic assisted radical nephrectomy with Inferior vena cava tumor thrombus.

PURPOSE: Surgery for renal cell carcinoma (RCC) with an inferior vena cava (IVC) tumor thrombus can be done via a robotic approach. While this approach is thought to minimize blood loss, it may still result in significant losses (1) and current publications indicate that it can require upwards of 3-day hospital stays (1, 2). However, innovative surgical techniques, such as the split and roll, may curtail this. The purpose of this video is to present the case and surgical technique of robotic assisted radical nephrectomy with IVC thrombectomy. MATERIALS AND METHODS: The patient was a 77-year-old male found to have a right upper pole renal mass on CT urogram. On MRI (Figure 1), a renal mass and level II thrombus was seen. For this case, the Da Vinci Xi Intuitive robotic system was used, with four robotic 8-millimeter (mm) metallic trocars, two 5 mm assistant trocars, and one 12 mm air seal port. The split and roll technique were utilized to access the IVC and lumbar veins. This surgical method uses the adventitia of the IVC as a plane of dissection and safely identifies all branches/tributaries of the IVC to minimize the chance of vascular injury (3). RESULTS: Robotic console time was 150 minutes. The patient had an excellent outcome, with all tumor thrombus removed, less than 50cc of blood loss, and was discharged within 24 hours of the operation. The tumor pathology came back as papillary, high grade, and was stage pT3bN1. CONCLUSIONS: The robotic approach with split and roll technique is a great surgical option for urologists to consider in patients with RCC and a level I or II thrombus, which can minimize blood loss and expedite discharge.

Comorbidities associated with cervical spine degenerative disc disease.

Determining important links between medical comorbidities and cervical spine degenerative disc disease (DDD) will help elucidate pathomechanisms of disc degeneration. Electronic medical records and magnetic resonance imaging were retrospectively reviewed to evaluate 799 patients assessed for cervical spine pathology. Bivariate analysis identified older age, diabetes, ASA class, cancer, COPD, depression, hypertension, hypothyroidism, Medicare status, peripheral vascular disease, history of previous cervical spine surgery, smoking, and lower median household income as having strong associations with increased cumulative grade of cervical spine DDD. This study provides evidence suggesting aging and accumulation of medical comorbidities influence severity of cervical spine DDD.