Risk Factors for Common Kidney Stones Are Correlated with Kidney Function Independent of Stone Composition.

INTRODUCTION: Kidney stone type varies with age, sex, season, and medical conditions. Lower estimate glomerular filtration rate (eGFR) leads to changes in urine chemistry, and risk factors for kidney stones are thought to vary by stone type. We explore the association between eGFR, urine risk factors, and common stone compositions. METHODS: This was a retrospective cohort study of 811 kidney stone patients seen at Yale Medicine between 1994 and 2021 with serum chemistries and 24-h urine chemistries matched within 1 year of baseline stone analysis. Patients' eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 equation. Demographics and medical history were compared by χ2 tests. 24-h urine chemistries and stone analyses were analyzed by one-way ANOVA. Linear regressions were performed to control for demographics, comorbidities, and stone composition. RESULTS: With lower eGFR, the proportion of calcium stones declined while uric acid (UA) stones increased. On univariable analysis, lower eGFR was associated with lower urine pH, calcium, citrate, UA, magnesium, phosphorus, and ammonium. On multivariable analysis, controlling for age, sex, ethnicity, body mass index, comorbidities, and stone type, these factors remained significant. Stone formers with lower eGFR had elevated supersaturation for UA, but reduced supersaturations for calcium-containing stones. Though urine oxalate was significant on univariable analysis, it was not on multivariable analysis. CONCLUSION: Changes in urine parameters are strongly correlated with eGFR regardless of stone type. Renal function may play a key role in modulating kidney stone risk factors. Strategies to mitigate stone risk may need to vary with kidney function, especially when patient urine or stone composition data are unavailable.

Urology in Undergraduate Medical Education.

PURPOSE OF REVIEW: Urology is an essential topic in undergraduate medical education (UME). The objective of this article is to review the current state of exposure to urology in medical school, to discuss why it is critical to maintain a urology curriculum, and to review methods in establishing an effective curriculum for all students with limited resources. RECENT FINDINGS: UME curriculum in urology should be geared toward the widest group of students, namely those entering primary care or internal medicine, where patients with urologic complaints are most likely to first present. Hands-on teaching should focus on skills such as the genitourinary exam and Foley catheter placement, while ancillary modules should be utilized for complex concepts. Medical schools do not sufficiently incorporate didactics in urology as part of their core curriculum. As such, educators in urology must develop curricula that provide fundamental knowledge to all students, especially those pursuing non-urologic specialties who will undoubtedly treat patients with urologic complaints.

Incorporation of the fluoroless C-Arm Trainer at the American Urological Association hands on training percutaneous renal access.

OBJECTIVES: To assess for usefulness and validity evidence for incorporating the C-Arm Trainer (CAT) simulator into the annual AUA hands on course for training percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: The course started with a didactic session followed by four stations for training the "bull's eye" technique using the CAT simulator. Each station included a pre-test, 30-min practice on the simulator, and post-test. All participants were assessed using a 4-item checklist. All participants were asked to fill in a qualitative self-assessment questionnaire after the pre- and the post-test, and respond to a course evaluation questionnaire and post-course survey. RESULTS: A total of 38 physicians, who attended the hands on course, voluntarily participated in the study. Only 21.1% had previous practice on PCNL simulators. Compared with the results of the checklist total score and the qualitative self-assessment questionnaire scores after the pre-test, there was significant improvement in the checklist total score (p < 0.001), temporal demands (p = 0.003), situational stress (p = 0.003, and performance (0.003) after the post-test. A total of 14 (36%) participants responded to the course evaluation questionnaire, 50% evaluated the course as excellent, 28.6% as very good, and 21.4% as good. Unfortunately, only five (13%) participants responded to the post-course survey, 4/5 implemented the new competencies and knowledge into their practice, and 3/5 have attempted to obtain fluoroscopic guided PCA without assistance. CONCLUSION: The CAT simulator was considered useful for training the percutaneous renal access procedure. There was significant improvement in the qualitative and quantitative assessment parameters after the post-test compared with the pre-test.

Variation in National Opioid Prescribing Patterns Following Surgery for Kidney Stones.

Background: Opioid misuse is a significant public health problem. As initial exposures to opioids are frequently encountered through the management of postoperative pain, we examined patterns of opioid prescribing following surgical treatment for nephrolithiasis. Methods: We identified patients with nephrolithiasis in the national Women Veterans Cohort Study (WVCS) who were treated surgically by diagnosis and procedure codes. Using standard conversion factors, we calculated the morphine milligram equivalent (MME) dose prescribed. We used descriptive statistics to characterize opioid prescription across management strategy and multivariable regression to examine clinical and demographic characteristics associated with dispensed dose. Results: We identified 22,609 patients diagnosed with kidney stones during 1999-2014, 1,976 of whom were treated surgically and 1,582 (80.1%) of whom received an opioid prescription. The median age was 39 years, and 1,366 (90%) were male; 1,314 (86.3%) were treated with ureteroscopy, 172 (11.3%) with extracorporeal shockwave lithotripsy, and 36 (2.4%) with percutaneous nephrolithotomy. The median number of days supplied per opioid prescription (interquartile range) was 10 (5-14), and patients were dispensed a median of 180 (140-300) MME. A total of 6.4% of patients received ≥50 MME/d. On multivariable analysis, comorbid diagnosis of post-traumatic stress disorder (PTSD) was associated with higher total dispensed dose, whereas surgery type was not. Conclusions: We observed substantial variation in opioid prescribing following surgical treatment of nephrolithiasis. Although type of surgical intervention did not impact opioid dosing, patients with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing.

Can Activities of Daily Living Predict Complications following Percutaneous Nephrolithotomy?

PURPOSE: Activities of daily living provide information about the functional status of an individual and can predict postoperative complications after general and oncological surgery. However, they have rarely been applied to urology. We evaluated whether deficits in activities of daily living could predict complications after percutaneous nephrolithotomy and how this compares with the Charlson comorbidity index and the ASA(®) (American Society of Anesthesiologists(®)) classification. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent percutaneous nephrolithotomy between March 2013 and March 2014. Those with complete assessment of activities of daily living were included in analysis. Perioperative outcomes, complications and hospital length of stay were examined according to the degree of deficits in daily living activities. RESULTS: Overall 176 patients underwent a total of 192 percutaneous nephrolithotomies. Deficits in activities of daily living were seen in 16% of patients, including minor in 9% and major in 7%. Complications developed more frequently in those with vs without deficits in daily living activities (53% vs 31%, p = 0.029) and length of stay was longer (2.0 vs 4.5 days, p = 0.005). On multivariate logistic regression activities of daily living were an independent predictor of complications (OR 1.11, p = 0.01) but ASA classification and Charlson comorbidity index were not. CONCLUSIONS: Activities of daily living are easily evaluated prior to surgery. They independently predict complications following percutaneous nephrolithotomy better than the Charlson comorbidity index or the ASA classification. Preoperative assessment of daily living activities can help risk stratify patients and may inform treatment decisions.

Percutaneous nephrolithotomy in super obese patients (body mass index ≥ 50 kg/m²): overcoming the challenges.

OBJECTIVE: To analyse our experience with and the outcomes and lessons learned from percutaneous nephrolithotomy (PCNL) in the super obese (body mass index [BMI] ≥50 kg/m(2) ). PATIENTS AND METHODS: In this institutional review board approved study we retrospectively reviewed our PCNL database between July 2011 and September 2014 and identified all patients with a BMI ≥ 50 kg/m(2) . Patient demographics, peri-operative outcomes and complications were determined. Additionally, we identified a number of special PCNL considerations in the super obese that can maximize safe outcomes. RESULTS: A total of 21 PCNL procedures performed on 17 super obese patients were identified. The mean patient age was 54.8 years, the mean BMI was 57.2 kg/m(2) and the mean stone area was 1 037 mm(2) . Full staghorn stones were observed in six patients and partial staghorns in four patients. The mean operating time was 106 min and the mean haemoglobin decrease was 1.2 g/dL. The overall stone-free rate was 87%. There were four total complications: two Clavien grade II, one Clavien IIIb and one Clavien IVb. We identified several special considerations for safely preforming PCNL in the suber obese, including using extra-long nephroscopes and graspers, using custom-cut extra long access sheaths with suture 'tails' secured to easily retrieve the sheath, choosing the shortest possible access tract, readily employing flexible nephroscopes, placing nephroureteral tubes rather than nephrostomy tubes postoperatively, and meticulous patient positioning and padding. CONCLUSION: With appropriate peri-operative considerations and planning, PCNL is feasible and safe in the super obese. Stone clearance was similar to that reported in previous PCNL series in the morbidly obese, and is achievable with few complications.

Indications for adult circumcision: a contemporary analysis.

INTRODUCTION: Circumcision is the most common surgical procedure performed worldwide. However, there is a dearth of literature regarding medical indications for adult circumcisions. Here, we describe our experience with adult circumcision and contemporary demographics, indications and complications. MATERIALS AND METHODS: We reviewed all circumcisions performed in our institution between July 2008 and January 2015. Patient demographics, procedure indications and postoperative complications were recorded, and patients were grouped by age as either less than 50 years old or 50 years and older. RESULTS: A total of 202 charts were reviewed. The most common indications for circumcision were phimosis (46.5%), dyspareunia (17.8%), balanitis (14.4%), and concurrent phimosis and balanitis (8.9%). Older patients were more likely to undergo circumcision for concurrent phimosis and balanitis or cancer, whereas younger patients sought circumcision for dyspareunia. The complication rate was 3.5% and there was no significant difference in complication rates between the two age groups. CONCLUSION: Circumcision is performed in the adult population for a variety of reasons. Circumcision remains a safe surgical option for patient management with a low complication rate.

Does Peak Inspiratory Pressure Increase in the Prone Position? An Analysis Related to Body Mass Index.

PURPOSE: Percutaneous nephrolithotomy is commonly performed with the patient prone. There is concern that the prone position, especially in obese patients, negatively affects ventilation due to the restriction of chest compliance and respiratory mechanics. We analyzed the change in airway resistance between supine and prone positioning of patients undergoing percutaneous nephrolithotomy. MATERIALS AND METHODS: We retrospectively reviewed the intraoperative respiratory parameters of 101 patients who underwent prone percutaneous nephrolithotomy. Peak inspiratory pressure was assessed with the patient supine, at several time points after being turned prone and at the end of the case. The change in peak inspiratory pressure with time was calculated. Results were stratified based on body mass index and data were compared using the paired t-test and Spearman ρ. RESULTS: Of 101 patients 50 (50%) were obese (body mass index 30 kg/m(2) or greater). Median body mass index was 25.6 kg/m(2) in the nonobese cohort and 38.3 kg/m(2) in the obese cohort. Average peak inspiratory pressure while supine and prone was 18.0 and 18.5 cm H2O in the nonobese cohort, and 25.5 and 26.6 cm H2O, respectively, in the obese cohort. Obese patients had significantly higher peak inspiratory pressure in the supine and the prone positions relative to nonobese patients (p <0.0001). However, there was no change in peak inspiratory pressure from the supine to the prone position in either cohort. CONCLUSIONS: Obese patients have higher baseline peak inspiratory pressure regardless of position. However, prone positioning does not impact peak inspiratory pressure in either cohort. It remains a safe and viable option.

Contemporary assessment of renal stone complexity using cross-sectional imaging.

Recently, several scoring systems have been proposed to predict outcomes of percutaneous nephrolithotomy, objectively and quantitatively assessing kidney calculi complexity using cross-sectional imaging. These scoring systems are promising new tools that can guide surgical decision making, predict surgical outcomes, counsel patients undergoing stone surgery, and improve standardized academic reporting in percutaneous kidney stone surgery. In this article, we review features of each of these systems, their similarities and differences, and their applicability in clinical practice and relevance in academic reporting.

Routine transition zone biopsy during active surveillance for prostate cancer rarely provides unique evidence of disease progression.

PURPOSE: Routine sampling of the transition zone during prostate biopsy has become increasingly common. Although approximately 10% of prostate cancers originate in the transition zone, the benefit of transition zone biopsies may be limited. We evaluated the usefulness of transition zone biopsy in patients with prostate cancer enrolled in active surveillance. MATERIALS AND METHODS: Patients on active surveillance followed at our institution between 1993 and 2011 were identified in the urological oncology database. All surveillance biopsies were stratified by transition and peripheral zone pathology results. The usefulness of transition zone biopsy was assessed by whether transition zone specific cancer characteristics, eg volume and grade, changed disease management recommendations. RESULTS: A single surgeon performed a total of 244 prostate biopsies in 92 men. Each patient underwent initial positive prostate biopsy and at least 1 active surveillance prostate biopsy. Mean age was 69 years. A mean of 2.7 biopsies were done per patient. Nine patients (10%) had positive transition zone cores on initial positive prostate biopsy, of whom 3 had transition zone unique cancers. One of these patients showed transition zone disease progression on active surveillance prostate biopsy, which led to up staging and exclusion from active surveillance. A total of 16 patients (17%) had positive transition zone cores on active surveillance prostate biopsy, of whom 13 had a negative transition zone on initial positive prostate biopsy. Transition and peripheral zone Gleason scores were identical in 9 of these patients and the transition zone score was lower in 4. Thus, transition zone pathology did not result in up staging or disease management alterations in any patient with new transition zone pathology. CONCLUSIONS: Up staging due to transition zone specific pathology is exceedingly rare. Transition zone biopsy in patients on active surveillance should be limited to those with transition zone involvement on initial positive prostate biopsy only.

Diagnostic radiation exposure risk in a contemporary cohort of male patients with germ cell tumor.

PURPOSE: We determined the total amount of diagnostic radiation that a patient with testicular cancer receives during the course of treatment and the associated risk of secondary malignancy. MATERIALS AND METHODS: At a single institution 119 men with seminomatous and nonseminomatous germ cell tumors of the testis were retrospectively identified. Annual and lifetime exposure to radiation was determined for each histological subtype. Values were assessed for compliance with International Commission of Radiological Protection guidelines. RESULTS: The cohorts included 55 patients with seminomatous and 64 with nonseminomatous germ cell tumor. Between the groups no difference was found in the lifetime (215.5 and 214.1 mSV, p = 0.96) or the annual (104.6 and 104.6 mSV, respectively, p = 1.0) radiation dose. Of the 41 patients with more than 5-year followup 32 (78%) were in violation of guidelines by exceeding 20 mSV per year of radiation. Also, 74 patients (61.7%) received 50 mSV or greater of radiation during a 1-year period. Using the previously calculated excess relative risk for solid cancer and leukemia, excluding chronic lymphocytic leukemia, the RR was 1.06 and 1.33, [corrected] respectively, with a 2.1% lifetime risk of fatal cancer over the baseline risk. CONCLUSIONS: At a tertiary care center with experience with managing testicular cancer 78% of patients with more than 5 years of followup exceeded current national and standard safety limits for radiation exposure. Imaging should be done judiciously in this population at high risk for radiation overexposure.

Toradol to Reduce Ureteroscopy Symptoms Trial (TRUST).

OBJECTIVE: To assess the use of intraoperative IV ketorolac (Toradol) on the peri-operative total morphine milligram equivalent (MME) requirements of patients undergoing ureteroscopy for nephrolithiasis. METHODS: Patients undergoing ambulatory ureteroscopy for nephrolithiasis were randomized to receive ketorolac at time of anesthesia induction. Patients and surgeons were blinded to treatment. Intraoperative, postoperative and combined MME were calculated. Multivariable regression was used to identify independent predictors of MME requirement. Complications were recorded. RESULTS: A total of 94 patients were analyzed following randomization. There were 46 patients in the treatment arm and 48 patients in the control arm. There were no statistically significant differences in gender, age, BMI, operative length or baseline pain medication use between groups (P >.05). Patients in the treatment arm required lower intraoperative MME when compared to the control arm (17.1 vs 24, P< .01). There were no statistically significant differences in the postoperative MME requirements between groups. The combined peri-operative MME was lower in the treatment arm compared to the control arm (22.2 vs 30.4, P< .02). Ketorolac use was an independent predictor of lower MME use on multivariable analysis (beta coefficient -5.1, P< .01). There was no statistically significant difference with regards to complication numbers between the treatment arms. CONCLUSION: Ketorolac during ureteroscopy is associated with a 37% reduction in narcotic requirement and is an independent predictor of decreased peri-operative narcotic needs. These findings show that intra-operative use of ketorolac effectively reduces narcotic requirements and should be considered independently or as part of a multimodal pain control protocol, unless otherwise contraindicated.

Accuracy of the Kattan nomogram across prostate cancer risk-groups.

OBJECTIVE: • To investigate the predictive ability of nomograms at the extremes of preoperative clinical parameters by examining the predictive ability across all prostate cancer risk groups. PATIENTS AND METHODS: • The Columbia University Urologic Oncology Database was reviewed: 3663 patients underwent radical prostatectomy from 1988 to 2008. Patients who had received neoadjuvant or adjuvant therapy, or had insufficient clinical parameters for estimation of 5-year progression-free probability using the preoperative Kattan nomogram were excluded. • A total of 1877 patients were included and stratified by D'Amico risk criteria. Mean estimated nomogram progression rates were compared with actuarial Kaplan-Meier survival statistics. • A regression model to predict progression-free survival was fitted with estimated nomogram score and concordance indices were calculated for the entire model and subsequently for each risk group. RESULTS: • Of 1877 patients, 857 (45.6%) were low risk, 704 (37.5%) were intermediate risk, and 316 (16.8%) were high risk by D'Amico criteria. • Mean estimated nomogram survival and actuarial Kaplan-Meier survival at 5 years were 90.5% and 92.2% (95% CI 89.2-94.3) for low-risk, 76.7% and 77.8% (73.3-81.7) for intermediate-risk, and 65.8% and 60.4% (52.0-67.7) for high-risk groups, respectively. Using nomogram score in the regression model, the c-index for the full model was 0.61. • For low-, intermediate- and high-risk patients independently the c-index was 0.60, 0.59 and 0.57, respectively. When low-, intermediate- and high-risk patients were independently removed from the model the c-index was 0.64, 0.65 and 0.55, respectively. • The c-index for the full model using the categorical nomogram risk scores was 0.67. Similar to the D'Amico model, the c-index improved to 0.69 when intermediate-risk patients were removed from the model. CONCLUSIONS: • The study confirms the ability of preoperative nomograms to accurately predict actuarial survival across all risk groups. • The predictive ability of the nomogram varies by risk group, yet even at the extremes of high-risk and low-risk prostate cancer the nomogram accurately predicts outcome.

Update on technological and selection factors influencing shockwave lithotripsy of renal stones in adults and children.

PURPOSE OF REVIEW: The aim of this review is to evaluate recently published peer reviewed literature on the subject of shockwave lithotripsy. RECENT FINDINGS: Based on in-vitro animal studies, escalating voltage results in better stone comminution and ultimately applies less total voltage to the surrounding tissue, theoretically causing less harm. Several studies have also shown that a slower shockwave rate improves stone fragmentation for intrarenal stones. Stones measuring greater than 1000 HU require a significantly greater number of shocks to destroy. The current literature continues to support shockwave lithotripsy as both a safe and effective means for managing stone disease in pediatric patients. Medical expulsive therapy with alpha-blockers appears to be efficacious, shortening the time to stone and fragment expulsion as well as minimizing pain. Skin-to-stone distance, Hounsfield units, stone size, and location are the best studied and most validated parameters that correlate with shockwave lithotripsy success. SUMMARY: Shockwave lithotripsy continues to evolve with the advent of better technology, improved imaging, and the development of several parameters that can be used to predict success, to counsel our patients, and improve stone-free rates.

Access to Urologic Care at Urgent Care Centers.

OBJECTIVE: To evaluate Medicaid insurance access disparities for urologic care at urgent care centers (UCCs) in the United States. MATERIALS AND METHODS: We conducted a cross-sectional study using a "secret shopper" methodology. We sampled 240 UCCs across 8 states. Using a standardized script, researchers posed as a patient with either Medicaid or commercial insurance in the clinical setting of obstructing nephrolithiasis. The primary study endpoint was whether a patient's insurance (Medicaid vs commercial) was accepted. We assessed factors associated with Medicaid acceptance using logistic regression models adjusted for state-level and facility-level characteristics. Additionally, we calculated triage rates, emergency department referral rates, and the ability of a UCC to refer the patient to a specialist. RESULTS: Of 240 UCCs contacted, 239 (99.6%) accepted commercial insurance and 159 (66.2%) accepted Medicaid. UCCs in Medicaid expansion states more frequently accepted patients with Medicaid insurance (74.2% vs 58.3%, respectively, P < .01). On multivariable logistic regression analysis, state Medicaid expansion (OR 1.84, 95% CI 1.04-3.26, P = .04) and affiliation with an institution (OR 2.97, 95% CI 1.59-5.57, P < .01) were independently associated with greater odds of accepting Medicaid. Medicaid-insured patients were significantly less likely to be triaged or referred to the emergency department compared to commercial patients. CONCLUSION: We identified significant disparities in access to UCCs for Medicaid patients presenting with a urologic condition. Given the expanding national role of UCCs, these findings highlight potential sources of insurance disparity in the context of a urologic emergency.

Urology Residency Training in Medically Underserved Areas Through the Integration of a Federally Qualified Health Center Rotation.

OBJECTIVE: To identify workforce related barriers to urologic care in Medically Underserved Areas (MUA) and Health Professional Shortage Areas (HPSA). Federally Qualified Health Centers (FQHC) are community-based organizations that aim to close gaps, but little is known about exposure to underserved areas during residency training. METHODS: The objective of this study was to characterize the experiences of urology residents who participated in a rotation within a FQHC. The study consisted of: (1) 12-item post-rotation self-assessment (2) review of career paths of former graduates who completed the rotation, and (3) retrospective review of patients treated at FQHC from 2016 to 2018. RESULTS: There were a total of 1735 patient visits, 97 were for cystoscopy, 76.36% of patients had Medicaid or no insurance. There were 1092 unique patients seen and 281 (25.73%) were referred for surgery. A majority of residents (100%) stated they had a better appreciation of treating patients in underserved areas. A majority of residents (71.6%) of residents said they were more likely to practice in an underserved area after residency. Among former graduates who rotated through the clinic, 100% (n = 4) were practicing in a MUA or HPSA. CONCLUSION: The integration of an FQHC during urology residency training was associated with highly favorable satisfaction by trainees. Given persistent workforce related shortages in urology, these findings support exposure to medically underserved areas during training.

Novel Use of the Epic Electronic Medical Record Platform to Identify Lost Ureteral Stents.

Introduction and Objective: Ureteral stents are utilized in the management of many urologic conditions including nephrolithiasis, ureteral strictures, ureteral injuries, and malignant obstruction. Prolonged placement has a risk of stent failure with obstruction, infection, and encrustation. We describe the novel use of the Epic electronic medical record (EMR) platform to identify patients lost to follow-up after ureteral stent placement. We additionally identified risk factors for lost stents. Methods: A methodology was created in Epic to log ureteral stent insertion and removal, with automated reporting of stents implanted for >90 days. Starting in January 2015, a nurse reviewed the reports monthly and contacted lost patients to arrange follow-up. We retrospectively reviewed patient charts for clinical characteristics including age, gender, race, surgical urgency (elective vs emergent), and insurance status to identify risk of failure to follow-up. Results: We identified 1788 patients who underwent ureteral stent placement over the study period. Sixteen patients (0.9%) failed to follow-up for ureteral stent explantation. Using multivariate logistic regression, stents placed in an emergent setting (odds ratio [OR] 3.5, p = 0.018) and black race (OR 4.03, p = 0.018) were independent predictors of failure to follow-up. Age, gender, and insurance status were not predictors of follow-up. On average, explanted stents were in place for 15 days vs 165 days among those patients lost to follow-up. Conclusions: Lost ureteral stents are rare, however, potentially high impact events. Automated data collected through an EMR such as Epic facilitates easy identification of these events before potential complications. Stents placed in an emergent setting are at a higher risk of poor follow-up as they may not be readily connected in the health care system or misunderstand discharge instructions, creating barriers to follow-up. Black race is an independent predictor of a stent being retained and is of uncertain etiology, which will require further investigation to clarify.

Minimally Invasive Therapy for Upper Tract Urothelial Cell Cancer.

Minimally invasive therapy for upper tract urothelial cell cancer has assumed an important role in the management of this relatively uncommon genitourinary malignancy. In this review, current standards for patient selection, surgical approach, as well as overall outcomes will be discussed. Moreover, the use of intraluminal agents in upper tract disease is examined along with its efficacy and associated complications.

A Case for Nephron Sparing Surgery in the Management of Upper Tract Urothelial Carcinoma.

Upper tract urothelial carcinoma (UTUC) is rare and its management presents many challenges. Outside of distal ureterectomy for select cases, management has been primarily radical nephroureterectomy. Endoscopic nephron sparing management (NSM) is recognized to have some role in UTUC treatment; however, it is yet to gain firm footing in the treatment algorithm. In this review, we discuss the benefits of NSM with regards to oncologic outcomes, renal function preservation, and cost savings. Finally, we propose recognition of endoscopic NSM as a first-line treatment in selected patients with low risk disease.

Unsuspected Malignancy During Percutaneous Nephrolithotomy: The Snake in the Grass.

Squamous cell carcinoma of the upper tract (SCC-UT) is a rare neoplasm that disproportionately affects patients with longstanding nephrolithiasis. Diagnosis is challenging and typically comes at late stages; as such, the prognosis is poor. The absence of a reliable diagnostic predictor for SCC highlights the need to keep the diagnosis in mind for at-risk patient populations. In this study, we describe a small case series of rapidly progressive SCC-UT incidentally discovered during percutaneous nephrolithotomy.