Effect of iodinated contrast material on post-operative eGFR when administered during renal mass ablation.

OBJECTIVE: To evaluate the effect of intravenous iodinated contrast on estimated glomerular filtration rate (eGFR) when administered immediately after thermal ablation of clinically localized T1a (cT1a) renal cell carcinoma (RCC). METHODS: This HIPAA-compliant, dual-center retrospective study was performed under a waiver of informed consent. Three hundred forty-two consecutive patients with cT1a biopsy-proven RCC were treated with percutaneous ablation between January 2010 and December 2017. Immediate post-ablation contrast-enhanced CT was the routine standard of care at one institution (contrast group), but not the other (control group). One-month pre- and 6-month post-ablation eGFR were compared using the Wilcoxon signed-rank test or the Kruskal-Wallis test. Multivariate linear regression was used to determine the effect of contrast on eGFR. A 1:1 propensity score matching was performed for all patients with a logistic model using patient, tumor, and procedural covariates. RESULTS: In total, 246 patients (158 M; median age 69 years, IQR 62-74) were included. Median tumor diameter (2.4 vs 2.5, p = 0.23) and RENAL nephrometry scores (6 vs 6, p = 0.92), surrogates for ablation zone size, were similar. Baseline kidney function was similar for the control and contrast groups, respectively (median eGFR: 70 vs 74 mL/min/1.73 m2, p = 0.29). There was an expected mild decline in eGFR after ablation (control: 70 vs 60 mL/min/1.73 m2, p < 0.001; contrast: 75 vs 71 mL/min/1.73 m2, p = 0.001). Intravenous iodinated contrast was not associated with a decline in eGFR on multivariate linear regression (1.91, 95% CI - 3.43-7.24, p = 0.46) or 1:1 propensity score-matched model (- 0.33, 95% CI - 6.81-6.15, p = 0.92). CONCLUSION: Intravenous iodinated contrast administered during ablation of cT1a RCC has no effect on eGFR. KEY POINTS: • Intravenous iodinated contrast administered during thermal ablation of clinically localized T1a renal cell carcinoma has no effect on kidney function. • Thermal ablation of clinically localized T1a renal cell carcinoma results in a mild decline in kidney function. • A decline in kidney function is similar for radiofrequency and microwave ablation of clinically localized T1a renal cell carcinoma.

Transrectal ultrasound guided prostate biopsy performed by supervised junior and senior residents is safe and does not result in inferior outcomes.

PURPOSE: To compare transrectal ultrasound guided prostate biopsy (TRUSBx) cancer detection and complication rates between residents at different levels of training and attending physicians at a single academic center. METHODS: We performed a retrospective review of consecutive series of 623 men undergoing TRUSBx from June 2014 to February 2017. The procedure was performed either by resident physicians under direct supervision by an attending physician or by an attending physician. In total, junior residents, senior residents and attending physicians performed 244, 212, and 167 biopsies, respectively. Prostate cancer detection, 30-day complications, and 30-day hospitalizations rates were the outcomes of interest. We performed multivariable logistic regression analysis to identify predictors of these outcomes and examined the hypothesis that TRUSBx performed by trainees would not be associated with inferior outcomes. RESULTS: There was no statistically significant difference in patient populations between the three groups when stratified by age, BMI, Charleston co-morbidity index, aspirin use, PSA level and palpable nodule on DRE. Prostate cancer was detected in 43.8% of the biopsies and there was no difference in detection rates (P = 0.53), Gleason score (P = 0.11), number of positive cores (P = 0.95), 30-day hospitalization (P = 0.86), and 30-day complication rates (P = 0.67) between TRUSBx performed by trainees and attending physicians. CONCLUSIONS: TRUSBx performed by residents and attending physicians yielded equivalent rates of cancer detection with no significant difference in 30-day complications or 30-day hospitalizations rates. There was no difference in outcomes between junior and senior residents suggesting that with adequate faculty supervision, it is safe for trainees at all levels to perform prostate biopsies.

Successful Diabetic Control as Measured by Hemoglobin A1c Is Associated with Lower Urine Risk Factors for Uric Acid Calculi.

INTRODUCTION AND OBJECTIVES: To examine the association of glycemic control, including strict glycemic control, with 24-hour urine risk factors for uric acid and calcium calculi. MATERIALS AND METHODS: With institutional review board (IRB) approval, we identified 183 stone formers (SFs) with 459 twenty-four-hour urine collections. Hemoglobin A1c (HgbA1c) measures were obtained within 3 months of the urine collection. Collections were categorized into normoglycemic (NG, HgbA1c < 6.5) and hyperglycemic (HG, HgbA1c ≥ 6.5) cohorts; 24-hour urine parameters were compared. The NG cohort was further divided into patients with and without a history of diabetes mellitus (DM) type 2. Variables were analyzed using chi-square, Welch's t-test and multivariate linear regression to adjust for clustering, body mass index (BMI), age, gender, thiazide use, and potassium citrate use. RESULTS: Patients in the HG group were older with higher BMI. Multivariate analysis of the total study population revealed that hyperglycemia correlated with lower pH, higher uric acid relative saturation (RS), lower brushite RS, and higher citrate. NG SFs with and without a history of DM had similar risk factors for uric acid stone formation. Among NG SFs, those with DM had higher urine calcium and calcium oxalate RS than those without DM. However, this difference may be related to other factors since neither parameter correlated with DM on multivariate regression (p > 0.05). CONCLUSIONS: Successful glycemic control may be associated with reduced urinary risk factors for uric acid stone formation. Patients with well-controlled DM had equivalent risk factors to those without DM. Glycemic control should be considered a target of the multidisciplinary medical management of stone disease.

Effectiveness of a transrectal prostate needle biopsy protocol with risk-tailored antimicrobials in a veterans cohort.

PURPOSE: To prospectively implement a prostate biopsy protocol to identify high-risk patients for bleeding or infectious complications and use risk-tailored antimicrobials, patient education, and postbiopsy monitoring with the objective of reducing complications. MATERIALS AND METHODS: Overall, 637 consecutive patients from June 2014 to August 2016 underwent prostate biopsy at our Veterans Affairs hospital. In the protocol cohort, patients were screened before biopsy and prophylaxis was tailored (high risk = ceftriaxone; low risk = ciprofloxacin). Patients were also provided additional education about bleeding and monitored for up to 1-hour. We defined complications as any deviation from normal postbiopsy activities. Comparisons were made between preprotocol/postprotocol cohorts. Logistic regression was used to identify risk factors for admissions or complications. RESULTS: Median age was 67 years (IQR: 64-69, P = 0.29) in both groups (pre n = 334, post n = 303). Preprotocol, 99% patients received ciprofloxacin; postprotocol, 86% received ciprofloxacin and 14% received ceftriaxone (P<0.001). There were no deaths in either group. There were decreased 30-day complication and hospitalization rates in the postprotocol group (pre 15% vs. post 8.9%, P = 0.025; 3.3% vs. 1.0%, P = 0.048). Sepsis occurred in 2 patients preprotocol and no patients postprotocol. Postprotocol group was associated with decreased 30-day complications on multivariable logistic regression (OR = 0.58, 95% CI: 0.35-0.95, P = 0.031). CONCLUSIONS: A screening protocol before prostate biopsy is a targeted approach for selecting prophylactic antimicrobials and closer monitoring postbiopsy for bleeding. Our results suggest that the protocol has a favorable effect on complication and hospitalization rates.

Percutaneous microwave ablation for local control of metastatic renal cell carcinoma.

PURPOSE: The purpose of the article is to evaluate the safety and oncologic efficacy of microwave ablation for metastatic renal cell carcinoma (mRCC). MATERIALS AND METHODS: From September 2011 to December 2016, 33 mRCC were ablated in 18 patients using percutaneous microwave ablation. Sites of mRCC include retroperitoneum (n = 12), contralateral kidney (n = 6), liver (n = 6), lung (n = 5), adrenal gland (n = 5). Technical success, local, and distant tumor progression, and complications were assessed at immediate and follow-up imaging. The Kaplan-Meier method was used for survival analysis. RESULTS: Technical success was achieved for 33/33 (100%) mRCC tumors. Ablation provided durable local control for 28/30 (93%) mRCC tumors in 17 patients at a median duration of clinical and imaging follow-up of 1.6 years (IQR 0.7-3.6) and 0.8 years (IQR 0.5-2.7), respectively. In-hospital and perioperative mortality was 0%. There were 5 (15%) procedure-related complications including one high-grade event (Clavien-Dindo III). Four patients have died from mRCC at a median of 1.3 years (range 0.7-5.1) following ablation. Estimated OS (95% CI number still at risk) at 1, 2, and 5 years were 86% (53-96%, 11), 75% (39-92%, 8), and 75% (39-92%, 3), respectively. CONCLUSIONS: Microwave ablation of oligometastatic renal cell carcinoma is safe and provides durable local control in appropriately selected patients.

Systematic Assessment Reveals Lack of Understandability for Prostate Biopsy Online Patient Education Materials.

OBJECTIVE: To evaluate the accuracy, readability, understandability, and actionability of Internet patient education materials (PEM) about transrectal ultrasound-guided prostate biopsy. METHODS: A comprehensive Internet search was performed to find PEM with pre- or postbiopsy instructions. PEM that were duplicates, government affiliated, international, or video based were excluded. Biopsy instructions were evaluated for accuracy and presence of essential topics. Readability was assessed via word count and Flesch-Kincaid Grade Level. Understandability and actionability were measured using the Patient Education Materials Assessment Tool (PEMAT). Effects of authorship and geographical variation were determined using Fischer exact and Kruskal-Wallis tests. RESULTS: We identified 148 unique PEM. Only 31 (21%) sites adhered to the recommended <8th grade reading level. Most PEM did not contain recommended graphics (14%), checklists (2%), or summaries (6%). The PEMAT understandability score for academic PEM was higher than private (P = .02) and unaffiliated PEM (P = .01). No websites had inaccurate content. Only 2 PEM sites (1%) included all essential content (stop anticoagulants, antibiotics, need for urinalysis, biopsy pain, when to resume activity, and bleeding complications). Few significant differences based on geographic region were observed for word count, readability, PEMAT scores, or content. CONCLUSION: Transrectal ultrasound-guided prostate biopsy PEM adhere poorly to guidelines for easy-to-understand materials. Most PEM lack vital information and are written at a reading level that is too complex for patient comprehension. The urology community can construct better websites by consulting PEM advisory materials and providing nontechnical language, figures, and specific instructions.

Combined totally endoscopic robotic coronary bypass and mitral valve repair via right-sided ports.

We present a case of combined coronary artery bypass grafting and mitral valve (MV) repair using a robotic totally endoscopic right-sided approach. A 61-year-old man presented with fatigue due to significant mitral regurgitation and was found to have a tight stenosis in the mid left anterior descending artery. Using the da Vinci robotic system, the patient underwent a left internal mammary artery graft to the left anterior descending artery using the C-Port Flex A distal anastomotic device followed by a MV repair. Both procedures were performed endoscopically via right chest ports and right femorofemoral bypass successfully. The patient was discharged from the hospital 3 days postoperatively and returned to normal activity within 3 weeks after surgery. This case study shows the feasibility of using an endoscopic robotic approach in selected patients undergoing combined MV coronary artery bypass grafting surgery.