Using artificial intelligence to generate medical literature for urology patients: a comparison of three different large language models.

PURPOSE: Large language models (LLMs) are a form of artificial intelligence (AI) that uses deep learning techniques to understand, summarize and generate content. The potential benefits of LLMs in healthcare is predicted to be immense. The objective of this study was to examine the quality of patient information leaflets (PILs) produced by 3 LLMs on urological topics. METHODS: Prompts were created to generate PILs from 3 LLMs: ChatGPT-4, PaLM 2 (Google Bard) and Llama 2 (Meta) across four urology topics (circumcision, nephrectomy, overactive bladder syndrome, and transurethral resection of the prostate). PILs were evaluated using a quality assessment checklist. PIL readability was assessed by the Average Reading Level Consensus Calculator. RESULTS: PILs generated by PaLM 2 had the highest overall average quality score (3.58), followed by Llama 2 (3.34) and ChatGPT-4 (3.08). PaLM 2 generated PILs were of the highest quality in all topics except TURP and was the only LLM to include images. Medical inaccuracies were present in all generated content including instances of significant error. Readability analysis identified PaLM 2 generated PILs as the simplest (age 14-15 average reading level). Llama 2 PILs were the most difficult (age 16-17 average). CONCLUSION: While LLMs can generate PILs that may help reduce healthcare professional workload, generated content requires clinician input for accuracy and inclusion of health literacy aids, such as images. LLM-generated PILs were above the average reading level for adults, necessitating improvement in LLM algorithms and/or prompt design. How satisfied patients are to LLM-generated PILs remains to be evaluated.

The decline in transurethral resection of the prostate gland in Irish public hospitals between 2005 and 2021.

BACKGROUND: Lower urinary tract symptoms due to an enlarged prostate is a common condition. Transurethral resection of the prostate gland (TURP) has been the gold standard treatment. The objective of this study was to assess the trends in the prevalence of TURP procedures in Irish public hospitals within the period of 2005-2021. In addition, we explore the attitudes and practices of urologist in Ireland on this topic. METHODS: An analysis using the Hospital In-Patient Enquiry (HIPE) system using code 37203-00 was undertaken. 16,176 discharges contained the code of interest and had undergone a TURP procedure. The data from this cohort was further analysed. In addition, members of the Irish Society of Urology undertook a bespoke questionnaire to understand the TURP surgery practices. RESULTS: There has been a substantial decline in the prevalence of TURP procedures in Irish public hospitals from 2005 to 2021. The number of patients discharged from Irish hospitals with a TURP procedure was 66% less in 2021 compared to 2005. 75% (n = 36) of urologist surveyed felt that the declining TURP numbers were due to lack of resources, access to theatre/inpatient beds and outsourcing. 91.5% (n = 43) felt that the declining TURP numbers would result in a lack of training opportunities for trainees, 83% (39) felt this has increased morbidity for patients. CONCLUSIONS: TURP procedures in Irish public hospitals has declined over the 16-year period studied. This decline is a concern for patient morbidity and urology training.

The impact of a novel surgical forum, 'Virtual Surgical Speed Dating', on career perception for medical students: a pilot study.

BACKGROUND: The SARS-CoV-2 pandemic limited medical student's exposure to surgical specialities, potentially affecting their understanding of specialties and limiting access to mentorship. AIMS: To develop a novel online 'round table' session to increase medical student's exposure to surgical careers, and to assess the value of the event as an educational tool. METHOD: A virtual education session was held, with questionnaires being completed before and after the virtual event. The event began with an introduction to surgical training. Participants rotated every 10 min in groups, with two specialties represented by a specialist registrar at each station. Data were analysed using a 5-point Likert scale, and a Student Evaluation of Educational Quality (SEEQ) questionnaire was completed. RESULTS: Of the 19 students involved, 14 (73.7%) were female, and 16 (84.2%) were undergraduate. The specialty attendees were most interested in before and after the event were neurosurgery (21.1%, n = 4) and cardiothoracic surgery (26.3%, n = 5), respectively. Five (26.3%) students changed the subspecialty they were most interested in after the event. Attendees' knowledge of surgical training in Ireland improved from 52.6% prior to the educational session to 69.5% after (p < 0.001). The session resulted in an increase in the perceived importance of research (4 [IQR 2-4] versus 4 [IQR 4-5], p = 0.0021). CONCLUSIONS: This 'Virtual Surgical Speed Dating' event offered medical students an opportunity to interact with various surgical specialties despite the SARS-CoV-2 pandemic. The novel approach increased medical students' exposure to surgical trainees, improved knowledge of training pathways and altered student values influencing career decision-making.

Bilateral staghorn kidney stones in Megacalycosis: Non operative management of complex kidney stone disease.

What happens when kidney stone clearance is not feasible? We report the case of a 46-year-old male who presented for review with bilateral congenital non-obstructive calyceal dilatation (megacalycosis) and high volume bilateral renal calculi in the setting of stage four chronic kidney disease. Since complete stone clearance was deemed futile, thus a consensus was made between Urology and Nephrology, and treatment goals were focused on addressing symptoms, preserving renal function and preventing urinary tract infections until renal transplantation is needed. This case highlights that for some patients with severe complex kidney stone disease, an alternative management plan is needed.

Evaluation of the Impact of Ureteroscope, Access Sheath, and Irrigation System Selection on Intrarenal Pressures in a Porcine Kidney Model.

Introduction: Elevated intrarenal pressure (IRP) during flexible ureterorenoscopy (FURS) is a predictor of postoperative complications. The aim of this study is to evaluate IRP during FURS in a porcine kidney model to determine the safest combination of irrigation device, ureteral access sheath (UAS), and ureteroscope. Methods: Urinary tracts were harvested from Landrace pigs slaughtered for the food chain. Two flexible ureteroscopes, 8.7F and 9.5F, were evaluated. Irrigation systems evaluated included the following: TraxerFlow™ (Rocamed, France), SAPS™ single action pumping system (Boston Scientific), Pathfinder Plus™ (Utah Medical), and a manual "bag squeeze." This experiment was conducted with no UAS, followed by an 11/13F UAS and then a 12/14F UAS. IRPs were measured in the prepared porcine kidney during all possible combinations of scope, UAS, and irrigation system. Results: Pressures were significantly reduced when using 12/14F UAS compared with 11/13F UAS (16.45 ± 5.3 cmH2O vs 32.73 ± 35.66 cmH2O, p = 0.006), and when using 11/13F UAS compared with no UAS (32.73 ± 35.66 cmH2O vs 49.5 ± 29.36 cmH2O, p = 0.02). Pressures were significantly reduced with the 8.7F scope compared with the 9.5F scope (24.1 ± 21.24 cmH2O vs 41.68 ± 34.5 cmH2O, p = 0.001). SAPS generates significantly greater IRP than TraxerFlow, Pathfinder Plus, and a "bag squeeze" (p < 0.05). The most dangerous combination was using the SAPS, no UAS, and larger ureteroscope leading to an IRP of 100.6 ± 16.1 cmH2O. The safest combination was using Pathfinder Plus with a 12/14F UAS and smaller ureteroscope giving an IRP of 11.6 ± 3.65 cmH2O. Conclusion: IRPs are reduced by selecting larger UAS and a small ureteroscope. The SAPS generates significantly higher IRPs than other irrigation systems. To maintain safe IRPs during FURS, urologists should use large UAS, narrow ureteroscopes, and be cautious in the selection of an irrigation device.

Compliance in patients with dietary hyperoxaluria: A cohort study and systematic review.

OBJECTIVE: Hyperoxaluria leads to calcium oxalate crystal formation and subsequent urolithiasis. This study aims to analyse the effect of treatment compliance in hyperoxaluria, firstly by analysis of patients with non-primary hyperoxaluria and secondly via systematic review in patients with any hyperoxaluria. METHODS: In a retrospective cohort study, adults with non-primary hyperoxaluria managed with dietary counselling in 2013 were enrolled. Twenty-four-hour (24 h) urine collections initially and at 6 months were obtained. Compliance was assessed by self-reported dietary compliance and 24 h urinary volume >2 L. Patients were followed for 24 months. Primary outcomes were urinary oxalate and calcium 24 h load at 6 months, and urolithiasis-related procedural rates at 24 months. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compatible systematic review of compliance among hyperoxaluric patients was performed. RESULTS: In the cohort study, of 19 eligible patients (4 female) with median age 52 years, 10 (53%) were considered compliant. Compared with the non-compliant group, these patients had significantly increased subsequent 24 h urinary volume (2250 mL vs. 1600 mL; p = 0.008) and lower procedural rates (10% vs. 56%; p = 0.033). Subsequent 24 h urinary oxalate load was non-significantly lower in compliant patients. Systematic review regarding compliance in hyperoxaluric patients revealed five studies. Only one utilised dietary counselling or analysed compliant vs. non-compliant patients, finding no difference. None examined the effect of compliance on procedural rates. CONCLUSION: Hyperoxaluria is an important cause of recurrent urolithiasis. Increasing fluid intake and reducing dietary oxalate reduce the risk of operative intervention and remain fundamental to the treatment of hyperoxaluria.

The effect of appropriate bladder management on urinary tract infection rate in patients with a new spinal cord injury: a prospective observational study.

PURPOSE: This study aimed to determine the rate of urinary tract infection (UTI) in patients with a new spinal cord injury (SCI) and identify which bladder management technique is associated with the lowest rate of UTI. METHODS: Adults admitted to the Victorian Spinal Cord Service with a new SCI from 2012 to 2014 were enrolled. Data collected included patient characteristics, SCI level, bladder management and diagnosis of UTI. Bacteriuria (≥ 102 colony-forming organisms/mL) with clinical signs of infection was used to define a UTI. RESULTS: 143 patients were enrolled. 36 (25%) were female; the median age was 42 years. An indwelling urethral catheter (IUC) was placed in all the patients initially. 55 (38%) patients developed a UTI with an IUC, representing a UTI rate of 8.7/1000 inpatient days. Long-term bladder management strategies were initiated after a median of 58 days. IUC removal and initiation of any other alternative bladder management halved the UTI rate to 4.4/1000 inpatient days, p < 0.001. Intermittent self-catheterisation (ISC) and suprapubic catheter placement had lower UTI rates compared to IUC, 6.84 and 3.81 UTI/1000 inpatient days, p = 0.36 and p = 0.007, respectively. An IUC was re-inserted in 29 patients and resulted in a higher UTI rate of 8.33/1000 inpatient days. CONCLUSION: This study has identified a high UTI rate in new SCI patients with an IUC and reinforces the importance of early IUC removal and initiation of non-IUC bladder management in this cohort of patients.

Surgical management of chronic genital lymphoedema.

A 44-year-old man with a spinal cord injury was referred to a specialist urology service with a 7-year history of significant genital swelling. His condition had eluded diagnosis and was refractory to all previous treatments. The considerable swelling both impacted his quality of life and prevented the patient from adequately managing his neurogenic bladder. He was diagnosed with chronic idiopathic genital lymphoedema and underwent total scrotectomy, wide penile skin excision and split skin graft to the penile shaft. The patient made an excellent recovery. We present this unusual case with preoperative, intraoperative and postoperative images.

The impact of intra-operative cell salvage during open radical prostatectomy.

BACKGROUND: To examine the effect of intra-operative cell salvage (ICS) in open radical prostatectomy. METHODS: In this retrospective cohort study, all patients undergoing open radical prostatectomy for malignancy at our institution between 10/04/2013 and 10/04/2017 were enrolled. Patients were grouped and compared based on whether they received ICS. Primary outcomes were allogeneic transfusion rates, and disease recurrence. Secondary outcomes were complications and transfusion-related cost. RESULTS: Fifty-nine men were enrolled; 30 used no blood conservation technique, while 29 employed ICS. There were no significant differences between groups in age, pre- or post-operative haemoglobin, Charlson comorbidity index, operation duration or length of stay. Tumour characteristics were also similar between groups, including pre-operative prostate specific antigen, post-operative Gleason score, T-stage, nodal status and rates of margin positivity. Compared with controls, the ICS group had longer follow up (945 vs. 989 days; P=0.0016). The control and ICS groups were not significantly different in rates of tumour recurrence (6 vs. 3 patients; P=0.30) or complications (10 vs. 5 patients; P=0.16). While the proportion of patients receiving allogenic transfusion was similar (9 vs. 6 patients; P=0.41), fewer red blood products transfused (40 vs. 12 units) meant transfusion related costs were lower in ICS patients (AUD $47,666 vs. $37,429). CONCLUSIONS: ICS reduced transfusion related costs, without affecting allogeneic transfusion rates, tumour recurrence or complication rates. These findings extend the literature supporting ICS in oncological surgery. Prospective randomised studies are needed to confirm the existing level III evidence.

Single-use disposable digital flexible ureteroscopes: an ex vivo assessment and cost analysis.

OBJECTIVE: To assess and measure the capability of a single-use disposable digital flexible ureteroscope, the LithoVue™ (Boston Scientific, Marlborough, MA, USA), and to assess if there is a benefit to switching to single-use scopes. PATIENTS AND METHODS: The LithoVue was compared to two commonly used reusable flexible ureteroscopes (Olympus URF-V [Olympus, Tokyo, Japan] and Karl Storz Flex-Xc [Karl Storz & Co. KG, Tuttlingen, Germany]) ex vivo. An analysis of reusable ureteroscope usage was performed to evaluate damage, durability, and maintenance costs. This was then compared to the projected costs of using single-use disposable scopes. RESULTS: Flexion, deflection and irrigation flow of the LithoVue was equivalent, if not better than the reusable flexible ureteroscopes. An analysis of 234 procedures with seven new Olympus URF-V scopes, revealed 15 scope damages. Staghorn stones and lower pole/mid-zone stones were significant risk factors for damage (P = 0.014). Once damage occurred it was likely to occur again. Total repair costs were $162 628 (Australian dollars) (£92 411 in Great British pounds), the mean cost per case was $695 (£395). Factoring in the purchase cost, cleaning and repair costs, the cumulative cost of 28 reusable flexible ureteroscopy procedures was ~$50 000 (£28 412). If the LithoVue was priced at $1 200 (£682), switching to a single-use scope would cost ~$35 000 (£19 888). CONCLUSION: The LithoVue is analogous to reusable flexible ureteroscopes in regard to standard technical metrics. Depending on its purchase cost it may also represent a cost saving for hospitals when compared to the cumulative costs of maintaining reusable scopes. Additionally, urologist may consider using the scope in cases in which reusable scope damage is anticipated.

Radiotherapy-related complications presenting to a urology department: a more common problem than previously thought?

OBJECTIVE: To quantify the burden of the side effects of radiotherapy on a tertiary referral urology department. PATIENTS AND METHODS: A prospective study of all urology admissions to a public urology department at a tertiary hospital in a 6-month period was performed. Patients admitted with complications attributable to radiotherapy were included in the study. Data obtained included patient demographics, radiotherapy details, complication type and management required. RESULTS: A total of 1198 patients were admitted; 921 (77%) were elective and 277 (23%) were emergency admissions. Thirteen out of the 921 (1.4%) elective admissions and 20 out of the 277 (7.2%) emergency admissions were attributable to radiotherapy complications. Radiotherapy complications was the fourth most common reason for emergency admission, ahead of acute urinary retention. These 33 admissions were accounted for by 21 patients. A total of 39 separate complications attributable to radiotherapy were diagnosed, with some patients having multiple complications. The median (interquartile range) time to onset of complications was 4 (1-9) years. The surgical intervention rate was 67%. The commonest procedures were washout with/without clot evacuation or diathermy in theatre (15.8%) and urethral dilatation/bladder neck incision (15.8%). Two urinary diversions and two cystoprostatectomies plus urinary diversion were performed. CONCLUSION: Radiotherapy complications are consequential and account for a substantial proportion of a tertiary urology department's emergency workload. These complications generally occur years after radiotherapy and frequently require surgical intervention.

Strategies for success: a multi-institutional study on robot-assisted partial nephrectomy for complex renal lesions.

OBJECTIVE: To describe our technique, illustrated with images and videos, of robot-assisted partial nephrectomy (RAPN) for challenging renal tumours. PATIENTS AND METHODS: A study of 249 patients who underwent RAPN in multiple institutions was performed. Patients were identified using prospective RAPN databases. Complex renal lesion were defined as those with a RENAL nephrometry score ≥10. Data were analysed and differences among groups examined. RESULTS: A total of 31 (12.4%) RAPNs were performed for complex renal tumours. The median (interquartile range [IQR]) patient age was 57 (50.5-70.5) years and 21 patients (67.7%) were men. The median (IQR) American Society of Anesthesiologists score was 2 (2-3). The median (IQR) operating time was 200 (50-265) min, warm ischaemia time was 23 (18.5-29) min, and estimated blood loss was 200 (50-265) mL. There were no intra-operative complications. Two patients (6.4%) had postoperative complications. One patient (3.2%) had a positive surgical margin. The median (IQR) length of stay was 3.5 (3-5) days and the median (IQR) follow-up was 12.5 (7-24) months. There were no recurrences. RAPN resulted in statistically significant changes in renal function 3 months after RAPN compared with preoperative renal function (P < 0.001). CONCLUSION: Our results showed that RAPN was a safe approach for selected patients with complex renal tumours and may facilitate tumour resection and renorrhaphy for challenging cases, offering a minimally invasive surgical option for patients who may otherwise require open surgery.

Impact of bladder dysfunction in the management of post radical prostatectomy stress urinary incontinence-a review.

Bladder dysfunction is a relatively common urodynamic finding post radical prostatectomy (RP). It can be the sole cause of post prostatectomy incontinence (PPI) or may be found in association with stress urinary incontinence (SUI). The aim of this review is to provide a comprehensive review of the diagnosis and different treatments of post RP bladder dysfunction. A comprehensive literature review using medical search engines was performed. The search included a combination of the following terms, PPI, detrusor overactivity (DO), detrusor underactivity (DU), impaired compliance, anticholinergic, onabotulinumtoxinA (Botox®) and sacral neuromodulation (SNM). Definitions, general overview and management options were extracted from the relevant medical literature. DO, DU and impaired compliance are common and may occur alone or in combination with SUI. In some patients the conditions exist pre RP, in others they arise due to denervation and surgical changes. DO can be treated with anticholinergics, Botox® and SNM. DO may need to be treated before SUI surgery. DU may be a contraindication to male sling surgery as some patients may go into urinary retention. Severely impaired bladder compliance may be a contraindication to SUI surgery as the upper tracts may be at risk. Each individual dysfunction may affect the outcome of PPI treatments and clinicians should be alert to managing bladder dysfunction in PPI patients.

Implementation rates of uro-oncology multidisciplinary meeting decisions.

OBJECTIVES: To assess implementation rates of the consensus plans made at the uro-oncology multidisciplinary meeting (MDM) of an Australian tertiary centre, and analyse obstacles to implementation. METHODS: A retrospective review was performed of all patients discussed at the uro-oncology MDM at our institution between 1 January and 30 June 2015. Rates of referral for MDM discussion after a new histological diagnosis of malignancy, categorised by tumour type, were assessed. Patient records were interrogated to confirm MDM plan implementation, with the outcomes examined being completion of MDM plan within 3 months and factors preventing implementation. RESULTS: During the enrolment period, from 291 uro-oncological procedures, 240 yielded malignant histology of which 160 (67%) were discussed at the MDM. Overall, 202 patients, including 32 females, were discussed at the uro-oncology MDM. MDM consensus plans were implemented in 184 (91.1%) patients. Reasons for deviation from the MDM plan included delay in care, patient deterioration or comorbidities, patient preference, consultant decision, loss to follow-up, and change in patient scenario due to additional new information. CONCLUSION: The MDM is increasingly important in the care of uro-oncology patients, with about two-thirds of new diagnoses currently captured. There appear to be few barriers to the implementation of consensus plans, with nearly all patients undergoing the recommended management.

Mini PCNL for renal calculi: does size matter?

OBJECTIVE: To evaluate the minimally invasive percutaneous nephrolithotomy (MIP) system for renal calculi. PATIENTS AND METHODS: Consecutive patients undergoing mini-percutaneous nephrolithotomy (mPCNL) procedures with the MIP system were enrolled. Patient position, American Society of Anesthesiologists classification, puncture location, stone clearance, postoperative drainage and complications were recorded, and features unique to MIP were noted. RESULTS: In all, 30 patients underwent 32 mPCNL procedures. The mean stone size was 17 (10.75-21.25) mm and the mean number of stones was 1 (1-2). The median stone clearance rate was 96.5 (95-100)%. The complication rate was 9.3%. No patient required a transfusion. In addition to these outcomes, we noted that the MIP system has many advantages over conventional PCNL (cPCNL). It is easy to learn and can be performed in both supine and prone positions. It is safe for supracostal puncture, provides excellent access to nearly all calyces and upper ureter, has multiple stone treatment options, can be used as an adjunct to cPCNL, and can be performed as a tubeless procedure. CONCLUSION: Our experience with the MIP system has shown several advantages over cPCNL. mPCNL with the MIP system has several features that suggest it should be considered as an alternative or adjunct to cPCNL, ureteroscopy and extracorporeal shockwave lithotripsy.

Sacral neuromodulation for detrusor hyperactivity with impaired contractility.

INTRODUCTION: Detrusor hyperactivity with impaired contractility (DHIC) is a challenging condition to manage. Sacral neuromodulation (SNM) is a proven treatment modality for both the individual aspects of DHIC. To date, data reporting the outcome of SNM for DHIC are lacking. MATERIALS AND METHODS: Consecutive patients undergoing SNM for DHIC were followed prospectively, from April 2013 to October 2016. Patient demographics, bladder diaries, subjective response rates, ICIQ-OAB, and PGI-I scores were recorded. Success was defined as greater than 50% improvement in storage symptoms and a 50% improvement in voided volume or reduction of post-void residual volumes. RESULTS: Twenty patients underwent stage 1 trial of SNM for DHIC. Median age was 68.5, IQR (54.25-76.25). Thirteen (65%) patients were female. A total of 14/20 (70%) of patients had a significant treatment response, 9/20 had a response to both elements of DHIC, 4/20 patients had a response to the detrusor overactivity (DO) alone, and 1/20 had a response to the voiding component alone. A total of 12/20 (60%) patients proceeded to insertion of an IPG. At mean follow-up of 17 months, IQR (1.5-35), 11/12 (91.7%) of patients are still using the SNM for DHIC. Median PGI score is 2, IQR (2-4). SNM for DHIC resulted in statistically significant improvements in voided volume (P = 0.016), PVR (P = 0.0296), ICIQ-OAB score (P < 0.0001), and ICIQ-OAB bother score (P = 0.016) CONCLUSION: This is the first study we know of to report the results of SNM for DHIC. SNM is associated with satisfactory success rates, treating both the detrusor hyperactivity, and impaired contractility components of this condition.

Risk factors for surgical site infection following colorectal resection: a multi-institutional study.

INTRODUCTION: Surgical site infection (SSI) is an infection occurring in an incisional wound within 30 days of surgery and significantly affects patients undergoing colorectal surgery. This study examined a multi-institutional dataset to determine risk factors for SSI following colorectal resection. METHODS: Data on 386 patients who underwent colorectal resection in three institutions were accrued. Patients were identified using a prospective SSI database and hospital records. Data are presented as median (interquartile range), and logistic regression analysis was used to identify risk factors. RESULTS: Patients (21.5%) developed a postoperative SSI. The median time to the development of SSI was 7 days (5-10). Of all infections, 67.5% were superficial, 22.9% were deep and 9.6% were organ space. In univariate analysis, an ASA grade of II (RR 0.6, CI 0.3-0.9, P = 0.019), having an elective procedure (RR 0.4, CI 0.2-0.6, P < 0.001), using a laparoscopic approach (RR 0.5, CI 0.3-0.9, P = 0.019), having a daytime procedure (RR 0.3, CI 0.1-0.7, P = 0.006) and having a clean/contaminated wound (RR 0.4, CI 0.2-0.7, P = 0.001) were associated with reduced risk of SSI. In multivariate analysis, an ASA grade of IV (RR 3.9, CI 1.1-13.7, P = 0.034), a procedure duration over 3 h (RR 4.3, CI 2.3-8.2, P < 0.001) and undergoing a panproctocolectomy (RR 6.5, CI 1.0-40.9, P = 0.044) were independent risk factors for SSI. Those who developed an SSI had a longer duration of inpatient stay (22 days [16-31] vs 15 days [10-26], P < 0.001). CONCLUSIONS: Patients who develop an SSI have a longer duration of inpatient stay. Independent risk factors for SSI following colorectal resection include being ASA grade IV, having a procedure duration over 3 h, and undergoing a panproctocolectomy.

Mixed collecting duct and renal cell carcinoma presenting with spinal cord compression.

Collecting duct carcinoma (CDC) is a rare renal malignancy thought to develop from the collecting duct epithelium of the kidney. CDC tends to have a more aggressive clinical course than conventional renal cell carcinoma (RCC), with early metastases. The occurrence of a mixed CDC and conventional RCC is infrequently reported in the literature. We report the first case of a metastatic mixed CDC and RCC presenting as back pain in a young adult. In addition we discuss the epidemiology of and current adjuvant therapies for CDC.