Prospective Randomized Trial Comparing the Safety and Clarity of Water Versus Saline Irrigant in Ureteroscopy.

BACKGROUND: Water irrigant is discouraged in ureteroscopy due to risks demonstrated in more invasive endoscopic procedures. However, water is not well studied in ureteroscopy and may provide better visualization than standard saline. OBJECTIVE: To determine whether water irrigant increases the risk of hyponatremia compared with saline and provides better visualization in ureteroscopy. DESIGN, SETTING, AND PARTICIPANTS: A randomized, prospective, double-blinded trial was conducted. In 2017, eligible adult ureteroscopy patients at a university hospital were recruited for the study. INTERVENTION: Participants randomized to water or saline irrigant in ureteroscopy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Serum sodium and osmolality, body temperature, subjective surgeon visualization, and objective turbidity clarity were analyzed. Chi-square or Fisher's exact tests for categorical variables and analysis of variance test for continuous variables were performed. RESULTS AND LIMITATIONS: A total of 121 individuals (mean age 57 ± 15 yr) underwent ureteroscopy (mean time 35 ± 18 min) with a mean irrigation volume of 839 ± 608 ml. For the 101 (83%) patients who had nephrolithiasis, the mean number of stones was 2 ± 1 and the mean stone burden was 13 ± 7 mm. There were no significant differences in demographic, clinical, and intraoperative variables between water and saline groups, except for a higher body mass index in the saline group (p = 0.01). There was no significant difference between groups in the incidence of hyponatremia, hypo-osmolality, or hypothermia. The median surgeon visualization score was significantly higher using water (p < 0.01). The mean turbidity was significantly lower with water (p = 0.02). Limitations were not objectively assessing hemolysis or fluid absorption. CONCLUSIONS: Water irrigant does not increase the incidence of hyponatremia in uncomplicated ureteroscopy and provides clearer visualization than saline. PATIENT SUMMARY: We compared safety and clarity of water and saline irrigation, which aid surgeon visualization, in ureteroscopy, which can treat kidney stones. We found that water irrigant does not reduce blood sodium levels significantly compared with saline in ureteroscopy and provides better visualization.

Transplant Radical Nephrectomy and Transplant Radical Nephroureterectomy for Renal Cancer: Postoperative and Survival Outcomes.

BACKGROUND The treatment of complex tumors in non-functioning renal transplants requiring surgical extirpation is challenging. Here, we report the largest series of patients who underwent transplant radical nephrectomy for renal cell carcinoma (RCC) and transplant radical nephroureterectomy for urothelial cell carcinoma (UCC) in their transplanted kidneys. MATERIAL AND METHODS From 2004 to 2018, 10 patients underwent transplant radical nephrectomy (7 patients) and nephroureterectomy (3 patients). Retrospective analyses, in terms of complications, oncological recurrence, and survival, of peri-operative and long-term outcomes, were performed. RESULTS Out of the 10 patients, 7 had RCC and 3 had UCC. No intraoperative mortality occurred. Three patients presented with Clavien-Dindo grade IIIa or greater within 30 days of surgery. Two patients died within 60 days of surgery, both due to vascular events: one due to myocardial infarction and one due to stroke. Two other patients died: one after 2.9 years, due to myocardial infarction, and the other after 6 years, due to unknown reasons. At the 7-year follow-up, there was a 60% overall survival rate. For all patients, average survival post-nephrectomy was approximately 4.5 years, including the 6 living patients and 4 deceased patients. Importantly, there was no observed cancer recurrence. CONCLUSIONS This study reports outcomes of the largest series of transplant radical nephrectomy and nephroureterectomy for malignancies of renal allografts. In the optimized setting, extirpative surgeries appear safe, with favorable long-term oncological and survival outcomes.

Variation in Practice Patterns and Reimbursements Between Female and Male Urologists for Medicare Beneficiaries.

Importance: Previous assessments of practice patterns and reimbursements for female urologists relied on surveys or board certification logs. A current evaluation of the geographic distribution and practice patterns by female urologists would reveal contemporary patterns of access for Medicare beneficiaries. Objective: To characterize the variation in practice patterns and reimbursements by urologist sex and the regional deficiencies in care provided by female urologists. Design, Setting, and Participants: This population-based cohort study used the publicly available Centers for Medicare & Medicaid Services Provider Payment database to evaluate payments for US urologists. The cohort (n = 8665) included urologists who provided and were paid for 11 or more services to Medicare beneficiaries in 2016. Data collection and analysis were performed from October 3, 2018, through June 19, 2019. Main Outcomes and Measures: Proportion of female-specific services, payments per beneficiary, and payments per work relative value unit (wRVU) by urologist sex were assessed. Density of female urologists across hospital markets was also identified. Results: Among the 8665 urologists who received payments in 2016, 7944 (91.7%) were men and 721 (8.3%) were women. Female urologists, compared with male urologists, saw a lower proportion of patients with cancer (mean [SD], 16.3% [9.2%] vs 22.7% [8.8%]; P < .001) and a greater proportion of female Medicare beneficiaries (mean [SD], 52.8% [23.2%] vs 24.4% [10.3%]; P < .001). Female urologists generated a greater proportion of wRVU from urodynamics (median [IQR], 2.88% [1.26%-4.84%] vs 1.07% [0.31%-2.26%]; P < .001) and gynecological operations (median [IQR], 0.68% [0.45%-1.07%] vs 0.41% [0.20%-0.81%]; P < .001) than male urologists. In addition, female urologists, compared with their male counterparts, received lower median payments per beneficiary seen ($70.12 [interquartile range (IQR), $60.00-$84.81] vs $72.37 [IQR, $59.63-$89.29]; P = .03) and lower payments per wRVU ($58.25 [IQR, $48.39-65.26] vs $60.04 [IQR, $51.93-$67.88]; P < .001). One-third (103 [33.7%]) of 306 hospital referral regions had 0 female urologists, and 80 (26.1%) had only 1 female urologist. Conclusions and Relevance: Female urologists were more likely to provide care for female Medicare beneficiaries, to receive lower payments per wRVU generated and beneficiaries seen, and to be difficult to access in certain geographic areas; these findings have policy-related implications and highlight the regional deficiencies in urological care and reimbursement discrepancies according to urologist sex.

Cognitive Impairment and Overall Survival in Frail Surgical Patients.

BACKGROUND: The definition of frailty, as modeled by the Fried criteria, has been limited primarily to the physical domain. The purpose of this study was to assess the additive value of cognitive function with existing frailty criteria to predict poor postoperative outcomes in a large multidisciplinary cohort of patients undergoing major operations. STUDY DESIGN: A 4-level composite frailty scoring system was created via the combination of the Fried frailty score and the Emory Clock Draw Test to assess preoperative frailty and cognitive impairment, respectively. Overall survival was defined as months from date of operation to date of death or last follow-up. RESULTS: This study included 330 patients undergoing major operations; mean age was 58 years and a total of 53 patient deaths occurred during 4-year follow-up. Among the robust cohort, 20 of 168 patients died (11.9%), and among those who were both physically frail and cognitively impaired, 11 of 26 patients died (42.3%). Multivariable analysis demonstrated the physically frail and cognitively impaired cohort to have a 3.92 higher risk of death (95% CI 1.66 to 9.26) compared with the cohort of robust patients (p = 0.002). Kaplan-Meier survival curves reveal an overall difference in long-term survival (log-rank p < 0.0001), driven mainly by the high risk of mortality among patients with both physical frailty and cognitive impairment. CONCLUSIONS: The use of a combined frailty and cognitive assessment score has a more powerful potential to predict adult patients at higher risk of overall survival than either measurement alone. The addition of cognitive assessment to physical frailty measure can lead to improved preoperative decision making and possibly early intervention, as well as more accurate patient counseling.