Ho:YAG laser and dusting-high power vs low power: there is no difference.

The introduction of the Ho:YAG laser 3 decades ago revolutionized the endoscopic treatment of urolithiasis. Since then, a variety of innovations have continued to evolve these devices, including the development of high-power lasers capable of high-frequency lithotripsy. The clinical utility of high-frequency lithotripsy, however, has not necessarily lived up to the potential suggested by in vitro studies. A review of the relevant literature, confirming strong similarities between the outcomes associated with high and lower power laser lithotripsy, follows.

Pulse-modulated Holmium:YAG Laser vs the Thulium Fiber Laser for Renal and Ureteral Stones: A Single-center Prospective Randomized Clinical Trial.

PURPOSE: We sought to compare the clinical effectiveness of the pulse-modulated Ho:YAG (holmium:yttrium-aluminum-garnet) laser and the thulium laser fiber for ureteroscopic stone management in a randomized clinical trial. The primary outcome was the ureteroscope time required to adequately fragment stones to 1 mm or less. Secondary outcomes were stone-free rate, complications, subjective surgeon measurement of laser performance, patient related stone quality of life outcomes, and measurements of laser efficiency. MATERIALS AND METHODS: An Institutional Review Board-approved randomized clinical trial was conducted to randomize patients to outpatient treatment with either the Moses 2.0 or thulium laser fiber in a 1:1 manner after stratification into groups based on the maximal diameter of treated stone (3-9.9 mm or 10-20 mm). Patient, stone, and operative parameters were compared using the appropriate categorical/continuous and parametric/nonparametric statistical tests (SPSS 25). RESULTS: From July 16, 2021 to March 11, 2022, 108 patients were randomized and had primary endpoint data available for analysis; 52 patients were randomized to Ho:YAG and 56 patients to thulium laser fiber. Groups were well balanced with no significant differences observed for patient or stone characteristics. Ureteroscope time was not significantly different between modalities (Ho:YAG mean 21.4 minutes vs thulium laser fiber mean 19.9 minutes, P = .60), or within subgroup analysis by stone size, median Hounsfield units, or stone location. There were no significant differences observed in the stone-free rate and complications rate between the 2 lasers. CONCLUSIONS: This randomized clinical trial suggests no significant clinical advantage of one laser technology over the other. Surgeon and institutional preference are the best approach when selecting one or the other.

Imaging in stone diagnosis and surgical planning.

PURPOSE OF REVIEW: Radiological imaging techniques and applications are constantly advancing. This review will examine modern imaging techniques in the diagnosis of urolithiasis and applications for surgical planning. RECENT FINDINGS: The diagnosis of urolithiasis may be done via plain film X-ray, ultrasound (US), or contrast tomography (CT) scan. US should be applied in the workup of flank pain in emergency rooms and may reduce unnecessary radiation exposure. Low dose and ultra-low-dose CT remain the diagnostic standard for most populations but remain underutilized. Single and dual-energy CT provide three-dimensional imaging that can predict stone-specific parameters that help clinicians predict stone passage likelihood, identify ideal management techniques, and possibly reduce complications. Machine learning has been increasingly applied to 3-D imaging to support clinicians in these prognostications and treatment selection. SUMMARY: The diagnosis and management of urolithiasis are increasingly personalized. Patient and stone characteristics will support clinicians in treatment decision, surgical planning, and counseling.

Lincoln Trail District Health Department's Innovative Shift to Public Health 3.0.

The Lincoln Trail District Health Department's (LTDHD) transformation into the Public Health 3.0 model was applied from frameworks established through public health accreditation standards and innovative strategies. The awareness of strengths and weaknesses discovered through strategic planning and a culture of quality improvement built over time has created numerous performance improvement opportunities. Those opportunities established greater collaboration and transparency between departments. The shift to the Public Health 3.0 and focus on Foundational Public Health Services model made for an easier transition into Kentucky's larger plan for public health transformation. LTDHD continues to provide public health protection by preventing the spread of disease, ensuring the safety of food, air, and water quality, supporting maternal and child health, improving access to clinical care services, and preventing chronic disease and injury.

Effect of stone composition on surgical stone recurrence: single center longitudinal analysis.

INTRODUCTION The objective of this study is to explore the association between urinary stone composition and surgical recurrence. MATERIALS AND METHODS: Patients who underwent kidney stone surgeries (between 2009-2017), were followed for > 1 year, and had ≥ 1 stone composition analyses were included in our analysis. Surgical stone recurrence (repeat surgery) was defined as the second surgery on the same kidney unit. Recurrence-free survival analysis was used. RESULTS: A total number of 1051 patients were included (52.7% men, average age 59.1 +/- 15.1 years). Over 4.7 +/- 2.5 years follow up, 26.7% of patients required repeat surgery. Patients' stone compositions were calcium oxalate (66.0%), uric acid (12.2%), struvite (10.0%), brushite (5.7%), apatite (5.1%) and cystine (1.0%). Results suggested that patients with cystine stones had the highest surgical recurrence risk; brushite had the second-highest surgical recurrence risk. Struvite, uric acid, and apatite stones were at higher risk compared with calcium oxalate stones (lowest risk in our cohort). When pre and postoperative stone size was controlled, patients with a history of uric acid, brushite, and cystine stones were at higher surgical risk. After controlling clinical and demographic factors, only brushite and cystine stones were associated with higher surgical recurrence. CONCLUSIONS: Patients with cystine stones had the highest surgical recurrence risk; brushite stones had the second highest surgical recurrence risk. Struvite, uric acid, and apatite stones were at higher risk compared with calcium oxalate stones. When pre and postoperative stone size, clinical and demographic factors were controlled, only those with brushite or cystine stones were at significantly higher risk of surgical recurrence.

Role of Residual Fragments on the Risk of Repeat Surgery after Flexible Ureteroscopy and Laser Lithotripsy: Single Center Study.

PURPOSE: We analyzed the impact of residual stone fragments seen on abdominal x-ray after ureteroscopy and laser lithotripsy on the risk of repeat surgical intervention. MATERIALS AND METHODS: Our study included 781 patients (802 renal units) who underwent ureteroscopy and laser lithotripsy with abdominal x-ray within 3 months postoperatively and who had at least 1 year of followup. Ureteroscopy and laser lithotripsy were performed using the dusting technique. We analyzed the association between surgical recurrence-free survival and the size of the largest residual fragment. RESULTS: During a median followup of 4.2 years repeat surgery was performed on 161 renal units (20%). Of the repeat interventions 75% were done for symptomatic nephrolithiasis. Postoperative imaging showed residual stone fragments in 42% of cases. In the entire group the risk of repeat surgery was increased in renal units with residual fragments greater than 2 mm. The effect of the size of residual fragments on the risk of surgical recurrence varied by patient body mass index. It was much larger in nonobese subjects, who were at increased risk for repeat surgery with residual fragments of any size. In the obese subgroup only fragments greater than 2 mm increased the risk of surgical recurrence. CONCLUSIONS: The association between the size of residual stone fragments detected by abdominal x-ray after ureteroscopy and laser lithotripsy, and the risk of repeat surgical intervention depends on patient body mass index. Nonobese patients with residual stone fragments of any size are at increased risk for repeat intervention compared to those with a negative abdominal x-ray. The predictive value of abdominal x-ray after ureteroscopy and laser lithotripsy is limited in obese patients.

Risk Factors for Complications and Nondiagnostic Results following 1,155 Consecutive Percutaneous Core Renal Mass Biopsies.

PURPOSE: The purpose of this study was to evaluate patient, tumor and technical factors associated with procedural complications and nondiagnostic findings following percutaneous core renal mass biopsy. MATERIALS AND METHODS: We reviewed core renal mass biopsies from 2000 to 2017. Complications at 30 days or less were graded using the Clavien-Dindo system. Univariate and multivariable analyses were done to evaluate associations between clinical characteristics and the risk of complications or nondiagnostic findings. RESULTS: Of the 1,155 biopsies performed in a total of 965 patients procedural complications were identified in 24 patients (2.2%), including 5 (0.4%) with major complications (Clavien 3a or greater). No patients were identified with tumor seeding of the biopsy tract. Patient age, body mass index, gender, Charlson comorbidity index, smoking, mass diameter, nephrometry score, number of cores and prior biopsy were not associated with complication risk (p = 0.06 to 0.53). Complications were not increased for patients on aspirin or those with low platelets (25,000 to 160,000/µl blood) or a mildly elevated INR (international normalized ratio) (1.2 to 2.0, p = 0.16, 0.07 and 0.50, respectively). The complication risk was not increased during the initial 50 cases of a radiologist or when a trainee was present (p = 0.35 and 0.12, respectively). Nondiagnostic findings were present in 14.6% of biopsies. Independent predictors included cystic features, contrast enhancement, mass diameter and skin-to-mass distance (p <0.001, 0.002, 0.02 and 0.049, respectively). Radiologist experience was not associated with the nondiagnostic rate (p = 0.23). Prior nondiagnostic biopsy was not associated with an increased nondiagnostic rate on subsequent attempts (19.2% vs 14.2%, p = 0.23). CONCLUSIONS: Procedural complications following biopsy are rare even with low serum platelets, a mildly elevated INR or when the patient remains on aspirin. Cystic features, hypo-enhancement on imaging, a smaller mass diameter and a longer skin-to-tumor distance increase the risk of nondiagnostic findings.

Collagen organization of renal cell carcinoma differs between low and high grade tumors.

BACKGROUND: The traditional pathologic grading for human renal cell carcinoma (RCC) has low concordance between biopsy and surgical specimen. There is a need to investigate adjunctive pathology technique that does not rely on the nuclear morphology that defines the traditional grading. Changes in collagen organization in the extracellular matrix have been linked to prognosis or grade in breast, ovarian, and pancreatic cancers, but collagen organization has never been correlated with RCC grade. In this study, we used Second Harmonic Generation (SHG) based imaging to quantify possible differences in collagen organization between high and low grades of human RCC. METHODS: A tissue microarray (TMA) was constructed from RCC tumor specimens. Each TMA core represents an individual patient. A 5 µm section from the TMA tissue was stained with standard hematoxylin and eosin (H&E). Bright field images of the H&E stained TMA were used to annotate representative RCC regions. In this study, 70 grade 1 cores and 51 grade 4 cores were imaged on a custom-built forward SHG microscope, and images were analyzed using established software tools to automatically extract and quantify collagen fibers for alignment and density assessment. A linear mixed-effects model with random intercepts to account for the within-patient correlation was created to compare grade 1 vs. grade 4 measurements and the statistical tests were two-sided. RESULTS: Both collagen density and alignment differed significantly between RCC grade 1 and RCC grade 4. Specifically, collagen fiber density was greater in grade 4 than in grade 1 RCC (p < 0.001). Collagen fibers were also more aligned in grade 4 compared to grade 1 (p < 0.001). CONCLUSIONS: Collagen density and alignment were shown to be significantly higher in RCC grade 4 vs. grade 1. This technique of biopsy sampling by SHG could complement classical tumor grading approaches. Furthermore it might allow biopsies to be more clinically relevant by informing diagnostics. Future studies are required to investigate the functional role of collagen organization in RCC.

Clinical and demographic predictors of repeat stone surgery.

OBJECTIVE: To identify the clinical and demographic predictors of repeat stone surgery. MATERIALS AND METHODS: We retrospectively analysed 1496 consecutive patients, aged > 18 years, who underwent stone surgery at our institution in the period from January 2009 to May 2017 and who had at least 12 months of postoperative follow-up. We defined surgical recurrence as repeat surgery on the same renal unit or on the opposite renal unit if the original imaging did not demonstrate significant stones on that side. Characteristics associated with the risk of surgical recurrence in univariate Cox regression analysis were entered into a multivariate model. RESULTS: Most patients underwent ureteroscopy and laser lithotripsy (83.0%). Approximately 60% of the patients had a personal history of stone disease and 50% were obese. Over a mean (median; interquartile range) follow-up of 4.1  (3.9; 2.4-5.9) years, 24.5% of patients had surgical recurrence, with 82% of repeat surgeries performed for symptomatic nephrolithiasis. The factors associated with increased risk of surgical recurrence in the multivariate model were: age <60 years, female gender, malabsorptive gastrointestinal disease, diabetes, recurrent urinary tract infections, personal history of nephrolithiasis, renal stones and bilateral nephrolithiasis. The hazard ratios for these variables ranged within an interval of <0.5 (from 1.30 to 1.71). CONCLUSION: We identified eight demographic and clinical factors associated with increased risk of repeat renal stone surgery. These factors could be combined as a numerical count that allows stratification of patients into low-, intermediate- and high-risk subgroups.

Reflex urine culture testing in an ambulatory urology clinic: Implications for antibiotic stewardship in urology.

OBJECTIVES: To evaluate the performance characteristics of urinalysis and urine microscopy parameters for predicting urine culture results and to implement a reflex urine culture program. METHODS: We reviewed the charts of all patients presenting to our clinic January-March 2013 and June-August 2014, excluding those who were catheter-dependent or with urinary diversions. We assessed the association of urinalysis and urine microscopy parameters on urine culture outcomes defining a positive urinalysis as nitrite-positive and/or the presence of ≥5 white blood cells per high-powered field with bacteria and a positive urine culture as ≥10 000 colony-forming units/mL excluding diphtheroids. We carried out logistic regression to assess for predictors of positive urine culture to inform implementation of a reflex urine culture program. RESULTS: A total of 2764 patients were evaluated. Logistic regression using urinalysis variables identified positive nitrites (odds ratio 18.6, P < 0.001) and large leukocyte esterase (odds ratio 41.8, P < 0.001) as the strongest predictors of positive urine culture. Logistic regression using urine microscopy variables identified >50 white blood cells per high-powered field (odds ratio 13.6, P < 0.001) and moderate/many bacteria (odds ratio 16.8, P < 0.001) as the strongest predictors of positive urine culture. We used our positive urinalysis definition to implement the reflex urine culture program and noted a 60% reduction in urine culture rates over the first 3 months of implementation. CONCLUSIONS: A urine positive for nitrites and/or ≥50 white blood cells per high powered field with bacteria seems to have a strong association with a positive urine culture and the best negative predictive value. A reflex urine culture program is an effective strategy to decrease the rates of unnecessary urine culture and their associated costs.

Do Urinary Cystine Parameters Predict Clinical Stone Activity?

PURPOSE: An accurate urinary predictor of stone recurrence would be clinically advantageous for patients with cystinuria. A proprietary assay (Litholink, Chicago, Illinois) measures cystine capacity as a potentially more reliable estimate of stone forming propensity. The recommended capacity level to prevent stone formation, which is greater than 150 mg/l, has not been directly correlated with clinical stone activity. We investigated the relationship between urinary cystine parameters and clinical stone activity. MATERIALS AND METHODS: We prospectively followed 48 patients with cystinuria using 24-hour urine collections and serial imaging, and recorded stone activity. We compared cystine urinary parameters at times of stone activity with those obtained during periods of stone quiescence. We then performed correlation and ROC analysis to evaluate the performance of cystine parameters to predict stone activity. RESULTS: During a median followup of 70.6 months (range 2.2 to 274.6) 85 stone events occurred which could be linked to a recent urine collection. Cystine capacity was significantly greater for quiescent urine than for stone event urine (mean ± SD 48 ± 107 vs -38 ± 163 mg/l, p <0.001). Cystine capacity significantly correlated inversely with stone activity (r = -0.29, p <0.001). Capacity also correlated highly negatively with supersaturation (r = -0.88, p <0.001) and concentration (r = -0.87, p <0.001). Using the suggested cutoff of greater than 150 mg/l had only 8.0% sensitivity to predict stone quiescence. Decreasing the cutoff to 90 mg/l or greater improved sensitivity to 25.2% while maintaining specificity at 90.9%. CONCLUSIONS: Our results suggest that the target for capacity should be lower than previously advised.

Effect of Tumor Complexity and Technique on Efficacy and Complications after Percutaneous Microwave Ablation of Stage T1a Renal Cell Carcinoma: A Single-Center, Retrospective Study.

Purpose To evaluate the effects of tumor complexity and technique on early and midterm oncologic efficacy and rate of complications for 100 consecutive biopsy-proved stage T1a renal cell carcinomas (RCCs) treated with percutaneous microwave ablation. Materials and Methods This HIPAA-compliant, single-center retrospective study was approved by the institutional review board. The requirement to obtain informed consent was waived. Ninety-six consecutive patients (68 men, 28 women; mean age, 66 years ± 9.4) with 100 stage T1a N0M0 biopsy-proved RCCs (median diameter, 2.6 cm ± 0.8) underwent percutaneous microwave ablation between March 2011 and June 2015. Patient and procedural data were collected, including body mass index, comorbidities, tumor histologic characteristics and grade, RENAL nephrometry score, number of antennas, generator power, and duration of ablation. Technical success, local tumor progression, and presence of complications were assessed at immediate and follow-up imaging. The Kaplan-Meier method was used for survival analyses. Results Technical success was achieved for all 100 tumors (100%), including 47 moderately and five highly complex RCCs. Median clinical and imaging follow-up was 17 months (range, 0-48 months) and 15 months (range, 0-44 months), respectively. No change in estimated glomerular filtration rate was noted after the procedure (P = .49). There were three (3%) procedure-related complications and six (6%) delayed complications, all urinomas. One case of local tumor progression (1%) was identified 25 months after the procedure. Three-year local progression-free survival, cancer-specific survival, and overall survival were 88% (95% confidence interval: 0.52%, 0.97%), 100% (95% confidence interval: 1.0%, 1.0%), and 91% (95% confidence interval: 0.51%, 0.99%), respectively. Conclusion Percutaneous microwave ablation is an effective and safe treatment option for stage T1a RCC, regardless of tumor complexity. Long-term follow-up is needed to establish durable oncologic efficacy and survival relative to competing ablation modalities and surgery. © RSNA, 2017.

Prospective evaluation of flexible ureteroscopes with a novel evaluation tool.

INTRODUCTION: Assess the function and handling in the clinical setting of three different types of reusable or disposable ureteroscopes using a novel, comprehensive flexible ureteroscope evaluation tool. MATERIALS AND METHODS: Urologists used a fiberoptic (Olympus URF-P5/P6), digital reusable (Storz Flex Xc), or a new digital disposable ureteroscope (Boston Scientific LithoVue) during ureteroscopic laser lithotripsy. An investigator-designed evaluation tool was used to prospectively assess the performance and handling of the ureteroscopes related to user comfort, maneuverability, efficiency, and various mechanical qualities. After each procedure, surgeons involved in each case who used the ureteroscope completed the written evaluation of the ureteroscope he/she used independently of one another. RESULTS: We reviewed 79 evaluations that were completed after 34 surgical cases; residents and post-graduate MDs were involved in each case. On the characteristics evaluated, significant differences between ureteroscopes were noted. The Storz reusable digital ureteroscope received the highest ratings overall while the new LithoVue disposable ureteroscope generally scored lowest. Our evaluation tool demonstrated good internal consistency, suggesting reliable results. Ureteroscope maneuverability correlated most to overall satisfaction. CONCLUSION: The clinical evaluation of flexible ureteroscopes for stone removal is critical in equipment purchase decision-making and in planning surgical approaches. We created a comprehensive evaluation tool to standardize and quantify the assessment of ureteroscopes used at our institution. Results revealed significant differences between ureteroscopes for several user and performance characteristics and good reliability of the evaluation tool itself.

A survey of patient preferences regarding medical expulsive therapy following the SUSPEND trial.

INTRODUCTION: Several recent trials have reported limited benefit for medical expulsive therapy (MET) in terms of stone passage rates, analgesic requirements, or need for intervention. We evaluated patient attitudes regarding MET after explaining these new findings. MATERIALS AND METHODS: Over a 12 week period, an investigator-designed survey was offered to sequential patients during routine appointments in our urologic clinic. A brief summary of the conflicting data for MET was provided. Patients then answered questions about their attitudes toward using MET. RESULTS: Patients (n = 200; 103 M, 97 F) were 56 ± 14 years old (range 20-103 years) and were mostly being seen for management of kidney stones (88%). Forty-nine percent reported they would try tamsulosin despite the new data; 26% said they would not, and 25% were unsure. Of patients indicating they would take tamsulosin, 35% stated they would also be willing to take steroids. Thirty-five percent of patients said they were willing to pay the full price of tamsulosin if needed. Seventy-one percent said they would prefer to try medical therapy prior to pursuing surgical therapy, again, despite new evidence regarding the efficacy of MET. CONCLUSION: In this initial report of patient attitudes about MET after SUSPEND trial results, we found that nearly half of patients would still try MET and that the vast majority of patients prioritize medical over surgical therapy when possible. As new research emerges, ways to translate this information to patients and to assess their attitudes and perceptions should be developed.

Utility of routine urinalysis and urine culture testing in an ambulatory urology clinic: a quality improvement initiative in a Veterans healthcare facility.

INTRODUCTION: Urinalysis (UA) and urine culture (UCx) are commonly performed tests in the urology clinic. Many of these urine studies are performed prior to the patient visit may not always be indicated, thus contributing to unintended consequences such as antibiotic use and costs without enhancing patient care. Our objective was to perform a quality improvement initiative aimed to assess the utility of routine UA/UCx. MATERIALS AND METHODS: The practice pattern at our site's Veteran Affairs (VA) urology clinic prior to 2014 was to obtain routine UA/UCx on most clinic visits prior to patient evaluation. Starting in 2014, we designed an intervention whereby our nurse practitioner triaged all new patient referrals and selectively ordered UA/UCx. We performed multivariable logistic regression to assess for predictors of obtaining UA or UCx. RESULTS: A total of 1308 patients were seen in January-March 2013 and 1456 in June-August 2014 and were included in this analysis. Fewer patients in 2014 received UA (59.8% versus 70.0%, p < 0.001) and UCx (49.6% versus 64.2%, p < 0.001). There was a decreased odds of obtaining UA in 2014 (OR 0.52, p < 0.001) as well as a decreased odds of obtaining UCx in 2014 (OR0.38, p < 0.001) on multivariable logistic regression. The results of UA/UCx only rarely resulted in change of management in either cohort (3%). Selective ordering resulted in an estimated cost savings of $4915.08/month in UCx costs alone. CONCLUSIONS: Our quality improvement initiatives reduced rates of UA/UCx testing when providers assess patients prior to ordering these tests. The implication of this initiative is significant cost savings for the healthcare system.

Clinical use of patient decision-making aids for stone patients.

INTRODUCTION: Patient decision-making aids (PDMAs) help patients make informed healthcare decisions and improve patient satisfaction. The utility of PDMAs for patients considering treatments for urolithiasis has not yet been published. We report our experience using PDMAs developed at our institution in the outpatient clinical setting in patients considering a variety of treatment options for stones. MATERIALS AND METHODS: Patients with radiographically confirmed urolithiasis were given PDMAs regarding treatment options for their stone(s) based on their clinical profile. We assessed patients' satisfaction, involvedness, and feeling of making a more informed decision with utilization of the PDMAs using a Likert Scale Questionnaire. Information was also collected regarding previous stone passage, history and type of surgical intervention for urolithiasis, and level of education. RESULTS: Patients (n = 43; 18 males, 23 females and two unknown) 53 +/- 14years old were included. Patients reported that they understood the advantages and disadvantages outlined in the PDMAs (97%), that the PDMAs helped them make a more informed decision (83%) and felt more involved in the decision making process (88%). Patients reported that the aids were presented in a balanced manner and used up-to-date scientific information (100%, 84% respectively). Finally, a majority of the patients prefer an expert's opinion when making a treatment decision (98%) with 73% of patients preferring to form their own opinion based on available information. Previous stone surgery was associated with patients feeling more involved with the decision making process (p = 0.0465). CONCLUSIONS: PDMAs have a promising role in shared decision-making in the setting of treatment options for nephrolithiasis.

Does Combination Therapy with Tamsulosin and Tolterodine Improve Ureteral Stent Discomfort Compared with Tamsulosin Alone? A Double-Blind, Randomized, Controlled Trial.

PURPOSE: Ureteral stent discomfort is a significant postoperative problem for many patients. Despite the use of narcotics and α-blockers patients often experience bothersome lower urinary tract symptoms and pain, which impair daily activities. We compared combination therapy with an α-blocker and an anticholinergic to monotherapy with an α-blocker. MATERIALS AND METHODS: A double-blind, randomized, controlled trial was performed from December 2012 to April 2014. A total of 80 patients were randomized, including 44 to the combination group (tamsulosin 0.4 mg and tolterodine early release 4 mg) and 36 to the monotherapy group (tamsulosin 0.4 mg and placebo). Patients with preexisting ureteral stent placement or current anticholinergic therapy were excluded from study. Patients completed USSQ (Urinary Stent Symptom Questionnaire) before stent placement on the day of surgery, the day after stent placement, the morning of stent removal and the day after stent removal. The questionnaire included questions regarding urinary symptoms, general health, body pain, and work and sexual history. RESULTS: A total of 80 patients (40 males and 40 females) were studied. Mean age was 51.5 vs 51.3 years (p = 0.95) and mean body mass index was 33.6 vs 31.9 kg/m(2) (p = 0.44) in monotherapy group 1 vs combination therapy group 2. Between the 2 groups there was no significant difference in urinary symptoms, body pain and activities of daily living from baseline to just before stent removal (p = 0.95, 0.40 and 0.95, respectively). Although there was no difference between the groups, both showed improvement in urinary symptoms from the time of initial stent insertion to just prior to stent removal (difference -0.50 for combination therapy and -0.40 for monotherapy). The mean stent indwelling time of 9.6 and 8.7 days in the combination and monotherapy groups, respectively, did not differ (p = 0.67). On ANOVA it had no significant impact on results (p = 0.64). CONCLUSIONS: Combination therapy with tamsulosin and tolterodine does not appear to improve urinary symptoms, bodily pain or quality of life in patients after ureteral stent placement for nephrolithiasis compared to tamsulosin alone. Both groups experienced worse urinary symptoms, pain and quality of life with a stent, suggesting that further research is necessary to improve stent discomfort.

Extreme obesity does not predict poor cancer outcomes after surgery for renal cell cancer.

OBJECTIVE: To assess whether extreme obesity (body mass index [BMI] ≥ 40 kg/m(2) ) is associated with peri-operative outcomes, overall survival (OS), cancer-specific survival (CSS), or recurrence-free survival (RFS) after surgical treatment for renal cell carcinoma (RCC). PATIENTS AND METHODS: After institutional review board approval, we used an institutional database to identify patients treated surgically between January 2000 and December 2014 with a pathological diagnosis of RCC. Comprehensive clinical and pathological data were reviewed. Kaplan-Meier analyses were used to estimate OS, RFS and CSS. Univariate and multivariate Cox proportional hazards analysis was used to evaluate associations with OS, CSS and RFS in patients with extreme obesity, among other known predictive variables. RESULTS: In all, 100 patients (11.9%) with a BMI ≥ 40 kg/m(2) and 743 patients (88.1%) with a BMI < 40 kg/m(2) who were treated surgically for RCC were identified. Morbid obesity was not associated with an increased risk of blood transfusion (odds ratio [OR] 1, 95% confidence interval [CI] 0.587-1.70; P = 1.0). The median (interquartile range) length of hospital stay (LOS) was 4 (3-6) days. Morbid obesity was not associated with longer LOS (P = 0.26) or 30-day hospital readmission rates (P = 1.0). Major complications (Clavien ≥ 3a) were recorded in 67 patients (7.95%). BMI ≥ 40 kg/m(2) was not a predictor of major complications (OR 0.58, 95% CI 0.227-1.47; P = 0.251) or 90-day mortality (P = 0.4067). BMI ≥ 40 kg/m(2) was not associated with worse OS (P = 0.7), CSS (P = 0.2) or RFS (P = 0.5). BMI ≥ 35 kg/m(2) was also not associated with worse OS, CSS or RFS (P = 0.3, 0.1, 0.5, respectively). The 5-year OS rate was 68.9% for the entire cohort, including 69 and 70% for patients with BMI < 40 kg/m(2) and BMI ≥ 40 kg/m(2) , respectively (P = 0.69). The 5-year CSS was 79.5% for the entire cohort, including 78.4 and 87.9% (P = 0.16) for patients with BMI < 40 kg/m(2) and BMI ≥ 40 kg/m(2) , respectively. The 5-year RFS rates for BMI < 40 kg/m(2) and BMI ≥ 40 kg/m(2) were 84.1 and 90.6%, respectively (P = 0.48). CONCLUSIONS: Extreme obesity is not associated with worse peri-operative or cancer outcomes after surgery for RCC. Surgery should remain a standard treatment option in well selected morbidly obese patients.

Patient and tumor characteristics can predict nondiagnostic renal mass biopsy findings.

PURPOSE: Identification of patient and tumor characteristics associated with nondiagnostic biopsies is necessary to improve prebiopsy counseling and patient selection. MATERIALS AND METHODS: We reviewed the clinical records and prebiopsy imaging of all patients treated with percutaneous biopsy for a renal mass 7 cm or less. Univariate and multivariate logistic regression models were constructed to examine the association between biopsy outcome and clinical/radiographic features. RESULTS: A total of 565 biopsies of renal tumors 7 cm or less in 525 patients were included in the study. There was no significant difference in age, body mass index, Charlson comorbidity score or gender between the patient cohorts with diagnostic and nondiagnostic biopsy. In 83 of 565 patients (14.7%) overall and in 72 of the 413 (17.4%) with a mass of 4 cm or less the biopsy findings were nondiagnostic. Overall 14.7% of masses were cystic and 85.3% were solid with a median tumor size of 2.75 cm (IQR 2.05-4.25). Independent predictors of nondiagnostic biopsy included cystic features, enhancement less than 20 HU, left tumor, tumor diameter and skin-to-tumor distance. The nondiagnostic rate of repeat biopsies was 20.8%, which did not statistically differ from the nondiagnostic rate at the initial renal mass biopsy attempt. Radiologist or pathologist experience was not associated with the biopsy nondiagnostic rate. In 7 of 565 patients (1.2%) hospital admission was required for adverse events after biopsy. CONCLUSIONS: Nondiagnostic renal mass biopsies are more common in cystic, nonenhancing, small masses when patients have a skin-to-tumor distance of 13 cm or greater. Excluding patients with these criteria decreased the nondiagnostic rate from 14.7% to 8.7%.