Real-time estimation of nephron activity with a linear measurement system (RENAL-MS) predicts postoperative estimated glomerular filtration rate.

OBJECTIVE: To determine whether a simple point-of-care measurement system estimating renal parenchymal volume using tools ubiquitously available could be used to replace nuclear medicine renal scintigraphy (NMRS) in current clinical practice to predict estimated glomerular filtration rate (eGFR) after nephrectomy by estimating preoperative split renal function. PATIENTS AND METHODS: We performed a retrospective review of patients who underwent abdominal cross-sectional imaging (computed tomography/magnetic resonance imaging) and mercaptoacetyltriglycine (MAG3) NMRS prior to total nephrectomy at a single institution. We developed the real-time estimation of nephron activity with a linear measurement system (RENAL-MS) method of estimating postoperative renal function via the following technique: renal parenchymal volume of the removed kidney relative to the remaining kidney was estimated as the product of renal length and the average of six renal parenchymal thickness measurements. The utility of this value was compared to the utility of the split renal function measured by MAG3 for prediction of eGFR and new onset Stage 3 chronic kidney disease (CKD) at ≥90 days after nephrectomy using uni- and multivariate linear and logistic regression. RESULTS: A total of 57 patients met the study criteria. The median (interquartile range [IQR]) age was 69 (61-80) years. The median (IQR) pre- and postoperative eGFR was 74 (IQR 58-90) and 46 (35-62) mL/min/1.73 m2 , respectively. [Correction added on 29 December 2023, after first online publication: The data numbers in the preceding sentence have been corrected.] Correlations between actual and predicted postoperative eGFR were similar whether the RENAL-MS or NMRS methods were used, with correlation using RENAL-MS being slightly numerically but not statistically superior (R = 0.82 and 0.76; P = 0.138). Receiver operating characteristic curve analysis using logistic regression estimates incorporating age, sex, and preoperative creatinine to predict postoperative Stage 3 CKD were similar between RENAL-MS and NMRS (area under the curve 0.93 vs. 0.97). [Correction added on 29 December 2023, after first online publication: The data numbers in the preceding sentence have been corrected.] CONCLUSION: A point-of-care tool to estimate renal parenchymal volume (RENAL-MS) performed equally as well as NMRS to predict postoperative eGFR and de novo Stage 3 CKD after nephrectomy in our population, suggesting NMRS may not be necessary in this setting.

Safety of neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer and malignant ureteric obstruction.

OBJECTIVES: To determine whether patients with carcinoma invading bladder muscle (MIBC) and ureteric obstruction can safely receive cisplatin-based neoadjuvant chemotherapy (C-NAC), and to determine whether such patients require relief of obstruction with a ureteric stent or percutaneous nephrostomy prior to beginning C-NAC. PATIENTS AND METHODS: We performed a single-institution retrospective analysis of MIBC patients receiving C-NAC and falling into three groups: no ureteric obstruction (NO); relieved ureteric obstruction (RO); and unrelieved ureteric obstruction (URO). To address whether patients with obstruction can safely receive C-NAC, we compared patients with NO to those with RO, with the primary outcome of premature chemotherapy discontinuation. To investigate whether patients with obstruction should have the obstruction relieved prior to NAC, we compared RO to URO patients using a primary composite outcome of grade ≥ 3 adverse events, premature chemotherapy discontinuation, dose reduction, or dose interruption. The primary outcomes were compared using multivariable logistic regression. Sensitivity analyses were performed for the RO vs URO comparison, in which patients with only mild degrees of obstruction were excluded from the URO group. RESULTS: A total of 193 patients with NO, 49 with RO, and 35 with URO were analysed. There were no statistically significant differences between those with NO and those with RO in chemotherapy discontinuation (15% vs 22%; P = 0.3) or any secondary outcome. There was no statistically significant difference between those with RO and URO in the primary composite outcome (51% vs 53%; P = 1) or any secondary outcome. CONCLUSION: Patients with ureteric obstruction can safely receive C-NAC. Relief of obstruction was not associated with increased safety of C-NAC delivery.

Adverse Events Reported by Patients With Cancer After Administration of a 2-Dose mRNA COVID-19 Vaccine.

BACKGROUND: Most safety and efficacy trials of the SARS-CoV-2 vaccines excluded patients with cancer, yet these patients are more likely than healthy individuals to contract SARS-CoV-2 and more likely to become seriously ill after infection. Our objective was to record short-term adverse reactions to the COVID-19 vaccine in patients with cancer, to compare the magnitude and duration of these reactions with those of patients without cancer, and to determine whether adverse reactions are related to active cancer therapy. PATIENTS AND METHODS: A prospective, single-institution observational study was performed at an NCI-designated Comprehensive Cancer Center. All study participants received 2 doses of the Pfizer BNT162b2 vaccine separated by approximately 3 weeks. A report of adverse reactions to dose 1 of the vaccine was completed upon return to the clinic for dose 2. Participants completed an identical survey either online or by telephone 2 weeks after the second vaccine dose. RESULTS: The cohort of 1,753 patients included 67.5% who had a history of cancer and 12.0% who were receiving active cancer treatment. Local pain at the injection site was the most frequently reported symptom for all respondents and did not distinguish patients with cancer from those without cancer after either dose 1 (39.3% vs 43.9%; P=.07) or dose 2 (42.5% vs 40.3%; P=.45). Among patients with cancer, those receiving active treatment were less likely to report pain at the injection site after dose 1 compared with those not receiving active treatment (30.0% vs 41.4%; P=.002). The onset and duration of adverse events was otherwise unrelated to active cancer treatment. CONCLUSIONS: When patients with cancer were compared with those without cancer, few differences in reported adverse events were noted. Active cancer treatment had little impact on adverse event profiles.

Prolonged Length of Stay After Robotic Prostatectomy: Causes and Risk Factors.

BACKGROUND: Robot-assisted radical prostatectomy (RARP) can generally be performed with 1-2 nights of postoperative monitoring before discharge from the hospital. Little is known about what causes individual patients to remain in hospital beyond the second postoperative day. METHODS: Data for RARPs performed between 2013 and 2015 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The fraction of cases with prolonged length of stay (PLOS) that can be reasonably attributed to complications was examined. Logistic regression was performed to identify risk factors for PLOS in the overall population and separately in the population of patients with PLOS without any perioperative complications. RESULTS: Of 11,440 patients, 10,342 (90.4%) were discharged on postoperative days 0-2; 80.6% (887/1101) of patients with PLOS did not experience any perioperative complications. The most common complication was bleeding requiring transfusion, but this was present in only 5.6% (62/1101) of patients with PLOS. Logistic regression identified predictors of PLOS as age, race, wound class, American Society of Anesthesiologists class, smoking, diabetes, dyspnea, dependent functional health status, congestive heart failure, operative time, and pelvic lymph node dissection. Results of this regression were insensitive to the exclusion of patients who experienced no perioperative complications. CONCLUSIONS: This study utilizes logistic regression on NSQIP data to identify risk factors for PLOS after RARP and, in particular, to evaluate the role of postoperative complications in PLOS. The analysis shows that postoperative complications account for a small minority of cases of PLOS after RARP.

National Variation in Opioid Prescription Fills and Long-Term Use in Opioid Naïve Patients after Urological Surgery.

PURPOSE: Prescription opioid use is increasing, leading to increased addiction and mortality. Postoperative care is often the first exposure to opioids of a patient but little data exist on national prescription patterns in urology. We examined post-discharge opioid fills after urological procedures and the association with long-term use. MATERIALS AND METHODS: We identified patients in a private national insurance database who underwent 1 of 15 urological procedures between October 1, 2010 and September 30, 2014. Patients with an opioid fill in the preceding 6 months were excluded from study. Claims for opioids from 30 days before the operation until 7 days after discharge characterized an initial prescription. Factors associated with persistent opioid use (an opioid claim 91 to 180 days after the operation) and chronic opioid use (10 or more refills of a 120-day or greater supply in the year after the operation) were analyzed using multivariable logistic regression. RESULTS: Overall 96,580 patients were included in study, of whom 49,391 (51%) filled an initial opioid prescription. Variation in the initial prescribed amount existed within procedures. Persistent use occurred in 6.2% of patients while chronic use occurred in 0.8%. Increased prescription in patients treated with transurethral prostate resection, vasectomy, female sling surgery, cystoscopy and stent insertion were associated with an increased risk of persistent as well as chronic use. CONCLUSIONS: National variation in opioid prescribing practice exists after urological operations. Patients who fill larger amounts of opioids after certain major and minor urological procedures are at increased risk for long-term opioid use. This provides evidence for procedure specific prescribing guidelines to minimize risk and promote standardization.

Early discharge and post-discharge outcomes in patients undergoing radical cystectomy for bladder cancer.

OBJECTIVE: To assess whether discharging patients early after radical cystectomy (RC) is associated with an increased risk of readmission and post-discharge complications. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database was queried to identify patients who underwent an elective RC from 2012 to 2015. Patients were stratified into two groups: those with a length of hospital stay (LOS) of 4-5 days (early-discharge group) and those with an LOS of 6-9 days (routine-discharge group). We used multivariable logistic regression analyses to assess the impact of early discharge on 30-day readmission and post-discharge complication rates. Sensitivity analyses and subgroup analyses were performed to validate the robustness of our primary analyses. RESULTS: A total of 3 311 patients were included. Unadjusted outcomes comparison showed no difference in readmission rate (21.6% vs 23.0%) or post-discharge complication rate (17.7% vs 19.6%) between the early-discharge and the routine-discharge group. Multivariable logistic regression also showed that early discharge was not associated with increased odds of readmission (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.82-1.22; P = 1.000) or post-discharge complications (OR 0.95, 95% CI 0.77-1.17; P = 0.616). Two-step sensitivity analyses (excluding patients with LOS of 8-9 days, followed by patients with any pre-discharge adverse event) validated the robustness of our primary analyses. Subgroup analyses also yielded similar results in all subgroups except for the subgroup of patients aged ≥85 years. CONCLUSIONS: Early discharge after RC was not associated with increased readmissions or post-discharge complications. Future prospective studies, with defined peri-operative care pathways, are needed to identify potential components that may enable hospitals to discharge patients early without compromising post-discharge outcomes.

Hospital volume and outcomes of robot-assisted partial nephrectomy.

OBJECTIVE: To evaluate the impact of hospital volume on outcomes of robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: Patients with renal cell carcinoma who underwent RAPN between 2010 and 2013 were identified in the National Cancer Database. Hospital yearly RAPN volume was categorized into groups by sorting patients as closely as possible into five groups of equal size (quintiles): very low; low; medium; high; and very high volume. Outcomes included 30-day mortality, 90-day mortality, open conversion, prolonged length of hospital stay (PLOS; defined as >3 days), 30-day readmission rate, and positive surgical margin (PSM) rate. Unadjusted analyses and multivariable logistic regressions were used to compare outcomes. Sensitivity analyses with hospital volume considered as a continuous variable were also performed. RESULTS: A total of 18 724 RAPN cases were included. Hospital volume quintiles were: very low volume, 1-7 cases (n = 3 693); low volume, 8-14 cases (n = 3 719); medium volume, 15-23 cases (n = 3 833); high volume, 24-43 cases (n = 3 649); and very high volume, ≥44 cases (n = 3 830). There was no significant difference in 30-day or 90-day mortality among the five groups. Multivariable logistic regression analysis (reference: very low volume) showed that higher hospital volume was associated with lower odds of conversion (low [odds ratio {OR}: 0.88; P = 0.377]; medium [OR: 0.60; P = 0.001]; high [OR: 0.57; P < 0.001]; very high [OR: 0.47; P < 0.001]), lower odds of PLOS (low [OR: 0.93; P = 0.197], medium [OR: 0.75; P < 0.001]; high [OR: 0.62; P < 0.001]; very high [OR: 0.45; P < 0.001]), and lower odds of PSMs (low [OR: 0.76; P < 0.001]; medium [OR: 0.76, P < 0.001]; high [OR: 0.59; P < 0.001]; very high [OR: 0.34; P < 0.001]). Sensitivity analyses confirmed increasing hospital volume (per 1-case increase) was associated with lower odds of conversion (OR: 0.986; P < 0.001), PLOS (OR: 0.989; P < 0.001) and PSMs (OR: 0.984; P < 0.001). A difference in 30-day readmission rate was found in unadjusted analysis but not in adjusted analyses. CONCLUSION: Undergoing RAPN at higher-volume hospitals may have better peri-operative outcomes (conversion to open and LOS) and lower PSM rates. Future studies are needed to explore the detailed components that lead to the superior outcomes in higher-volume hospitals.

Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting.

AIM: To describe a technique for surgical correction of adult buried penis, including a technique for skin graft harvesting from the escutcheonectomy specimen itself, with an emphasis on remaining open questions in the literature. METHODS: We present our method for surgical correction of adult buried penis with a review of the literature. MAIN OUTCOME MEASURE: Components of successful buried penis repair include return of directed voiding, elimination of local skin inflammation and infection, improvement in hygiene, return of sexual functioning, cosmesis, and patient satisfaction. To date, there are no broadly accepted tools for comprehensive measurement of outcomes after buried penis repair. RESULTS: Adult buried penis repair is generally associated with excellent rates of satisfaction and improvement in functioning. Currently available data are extremely limited; however, they do suggest that, when in doubt, more aggressive debridement of diseased tissue combined with split-thickness skin grafting may provide superior outcomes. Split-thickness skin grafts are associated with excellent rates of successful graft take, even in cases of severe preoperative pathology and patient comorbidity. Although these grafts come at the cost of some increased surgical morbidity, they are associated with low rates of major complications. Morbidity can be further significantly decreased by harvesting the graft from the excised escutcheon itself, a technique that we present here. CONCLUSION: Surgical correction of adult buried penis is safe and effective; however, future work is required to further optimize outcomes and reduce surgical morbidity. Strother MC, Skokan AJ, Sterling ME, et al. Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting. J Sex Med 2018;15:1198-1204.

Hospital volume and short-term outcomes after cytoreductive nephrectomy.

PURPOSE: To investigate the impact of hospital volume on short-term outcomes after cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC). METHODS: We identified mRCC patients who underwent CN from 2006 to 2013 in the National Cancer Database. Annual hospital CN volume was categorized as high (top 20th percentile) and low. Multivariable logistic regressions were used to compare 30-day mortality, 90-day mortality, prolonged length of stay (PLOS, ≥7 days), and 30-day readmission rates. Sensitivity analyses were performed with hospital volume considered as a continuous variable. RESULTS: A total of 9789 patients were included with high-volume (n = 1916) defined as ≥8 cases and low-volume (n = 7873) as 1-7 cases annually. Multivariable logistic regression showed that high-volume was associated with lower odds of 30-day mortality (OR = 0.69, P = 0.013), 90-day mortality (OR = 0.65, P < 0.001), PLOS (OR = 0.82, P = 0.002), and 30-day readmission (OR = 0.78, P = 0.028). Sensitivity analyses showed that increasing hospital volume (per case) was associated with lower odds of 30-day mortality (OR = 0.965, P = 0.008), 90-day mortality (OR = 0.966, P < 0.001), PLOS (OR = 0.982, P = 0.001), and 30-day readmission (OR = 0.975, P = 0.012). CONCLUSION: Higher hospital volume was associated with better short-term outcomes after CN. Future studies are needed to validate our findings and explore the potential components leading to better outcomes in the higher volume hospitals.

Minimally Invasive Techniques for the Management of Adult UPJ Obstruction.

Ureteropelvic junction obstruction (UPJO) is a common congenital abnormality that often presents in adulthood. Open dismembered pyeloplasty was considered the gold standard for the management of this condition; however, recent advancements in laparoscopic and robotic surgery have dramatically shifted the landscape to more minimally invasive techniques. A literature search of ureteropelvic junction obstruction, pyeloplasty, endopyelotomy, laparoscopic pyeloplasty, robotic pyeloplasty, and microlaparoscopic pyeloplasty was performed. A focus was placed on literature published since 2013. Minimally invasive laparoscopic and robotic techniques have become the gold standard for the management of UPJO. With the rise of robotic pyeloplasty, open repairs are becoming less frequent, while endoscopic treatments have remained stable. Minimally invasive (robotic) techniques have become the gold standard for the management of UPJO. Newer, even less-invasive techniques are also showing promise, but technical challenges still exist.

Modified Gleason grade of prostatic adenocarcinomas detected in the PLCO cancer screening trial.

PURPOSE: We determined the modified Gleason grade of prostatic adenocarcinomas detected in PLCO to assess grade distribution and compare modified Gleason grades of cancer detected in the intervention arm (organized annual screening) vs the control arm (opportunistic screening). MATERIALS AND METHODS: Modified Gleason grading was performed in 859 radical prostatectomy cases by a single urological pathologist. We compared the proportion of cases with high grade disease in the screened arm vs the control arm by logistic regression analysis. RESULTS: In the intervention arm a modified Gleason score of 5, 6, 7 (3+4), 7 (4+3), 8, 9 and 10 was assigned in 3.6%, 43.3%, 39%, 7.4%, 3.5%, 3.2% and 0.1% of cases, respectively. In the control arm a modified Gleason score of 5, 6, 7 (3+4), 7 (4+3), 8, 9 and 10 was assigned in 3.0%, 35.7%, 46.4%, 7.1%, 5.4%, 1.9% and 0.5% of cases, respectively, after correcting for high grade disease over sampling. A high grade modified Gleason score of 7 or greater was detected in 53% of cases in the intervention arm vs 61.3% in the control arm after correction (p=0.019). The median modified Gleason score was 7 (3+4) in each arm. CONCLUSIONS: A significant percent of cancers in each arm had a component of high grade disease. The modified Gleason grade of prostate cancers detected by organized annual screening was slightly lower than the modified grade of those detected by opportunistic screening. This is an expected consequence of more intensive screening.

Symptomatic and functional recovery after transurethral resection of bladder tumor: Data from ecological momentary symptom assessment.

OBJECTIVES: To quantitatively describe the nature, severity, and duration of symptoms and functional impairment during recovery from transurethral resection of bladder tumors. MATERIALS AND METHODS: All patients scheduled for transurethral resection were approached for enrollment in a text-message based ecological momentary symptom assessment platform. Nine patients reported outcomes were measured 7 days before surgery and on postoperative days 1, 2, 3, 5, 7, 10, and 14 using a 5-point Likert scale. Self-reported degree of hematuria was collected using a visual scale. Clinical data was collected via retrospective chart review. RESULTS: A total of 159 patients were analyzed. Postoperative symptoms were overall mild, with the largest differences from baseline to postoperative day 1 seen in dysuria (median 0/5 vs. 3/5) and ability to work (median 5/5 vs. 4/5). Recovery was generally rapid, with 76% of patients reporting ≥4/5 agreement with the statement "I feel recovered from surgery" by postoperative day 2, although 15% of patients reported persistently lower levels of agreement on postoperative day 10 or 14. Patients undergoing larger resections (≥2cm) did take longer to return to baseline in multiple symptom domains, but the difference of medians vs. those undergoing smaller resections was less than 1 day across all domains. Multivariable analysis suggested that receiving perioperative intravesical chemotherapy was associated with longer time to recovery. 84% of patients reported clear yellow urine by postoperative day 3. CONCLUSION: In this population, hematuria and negative effects on quality of life resulting from transurethral resection of bladder tumors were generally mild and short-lived, although a small number of patients experienced longer recoveries.

Distinguishing lipid-poor angiomyolipoma from renal carcinoma using tumor shape.

OBJECTIVES: To validate the "overflowing beer sign" (OBS) for distinguishing between lipid-poor angiomyolipoma (AML) and renal cell carcinoma, and to determine whether it improves the detection of lipid-poor AML when added to the angular interface sign, a previously-validated morphologic feature associated with AML. METHODS: Retrospective nested case-control study of all 134 AMLs in an institutional renal mass database matched 1:2 with 268 malignant renal masses from the same database. Cross-sectional imaging from each mass was reviewed and the presence of each sign was identified. A random selection of 60 masses (30 AML and 30 benign) was used to measure interobserver agreement. RESULTS: Both signs were strongly associated with AML in the total population (OBS: OR 17.4 95% CI 8.0-42.5, p < 0.001; angular interface: OR 12.6, 95% CI 5.9-29.7, p < 0.001) and the population of patients excluding those with visible macroscopic fat (OBS: OR 11.2, 95% CI 4.8-28.7, p < 0.001; angular interface: 8.5, 95% CI 3.7-21.1, p < 0.001). In the lipid-poor population, the specificity of both signs was excellent (OBS: 95.6%, 95% CI 91.9%-98%; angular interface: 95.1%, 95% CI 91.3%-97.6%). Sensitivity was low for both signs (OBS: 31.4%, 95% CI 24.0-45.4%; angular interface: 30.5%, 95% CI 20.8%-41.6%). Both signs showed high levels of inter-rater agreement (OBS 90.0% 95% CI 80.5 - 95.9; angular interface 88.6, 95% CI 78.7-94.9) Testing for AML using the presence of either sign in this population improved sensitivity (39.0%, 95% CI 28.4%-50.4%, p = 0.023) without significantly reducing specificity (94.2%, 95% CI 90%-97%, p = 0.2) relative to the angular interface sign alone. CONCLUSIONS: Recognition of the OBS increases the sensitivity of detection of lipid-poor AML without significantly reducing specificity.

No difference in renal function outcomes for patients with oncocytoma managed with active surveillance vs. partial nephrectomy.

OBJECTIVES: To investigate the difference in renal function outcomes for patients with oncocytomas undergoing active surveillance (AS) vs. partial nephrectomy (PN). METHODS: We reviewed our institutional database for patients with biopsy/surgically confirmed oncocytoma from 2000-2020. The primary outcome was to assess for differences in renal function outcomes in patients undergoing AS vs. PN. We fit two generalized estimating equation (GEE) with an interaction term between follow up time and management strategy to predict 1) mean eGFR for patients managed with AS and PN and 2) the probability of progression to CKD stage III or greater. RESULTS: We identified 114 eligible patients, of which 32 were managed with AS. Median follow-up was 21 months vs. 44 months for PN vs. AS patients. AS patients tended to be older (median: 72 years vs. 65 years, P<0.001) and have lower baseline renal function (median: eGFR: 71 mL/min/1.73m2 vs. 82 mL/min/1.73m2, P<0.001) compared with PN patients. Renal mass size from baseline imaging was similar between patients undergoing PN vs. AS (2.8 cm vs. 2.9 cm, P=0.634). For patients undergoing PN vs. AS, there was not a significant difference in predicted longitudinal eGFR (-0.079, 95% CI -0.18-0.023, P=0.129) or predicted probability of progression to CKD stage III or greater (OR: 0.61, 95% CI: 0.16-2.33, P=0.47). CONCLUSIONS: In our institutional dataset, patients undergoing AS or PN with an oncocytoma had similar long-term renal function outcomes. Given similar renal function outcomes in patients undergoing AS and PN, surgery should remain reserved for select patients with oncocytomas.

Point of care parenchymal volume analyses to estimate split renal function and predict functional outcomes after radical nephrectomy.

Accurate prediction of new baseline GFR (NBGFR) after radical nephrectomy (RN) can inform clinical management and patient counseling whenever RN is a strong consideration. Preoperative global GFR, split renal function (SRF), and renal functional compensation (RFC) are fundamentally important for the accurate prediction of NBGFR post-RN. While SRF has traditionally been obtained from nuclear renal scans (NRS), differential parenchymal volume analysis (PVA) via software analysis may be more accurate. A simplified approach to estimate parenchymal volumes and SRF based on length/width/height measurements (LWH) has also been proposed. We compare the accuracies of these three methods for determining SRF, and, by extension, predicting NBGFR after RN. All 235 renal cancer patients managed with RN (2006-2021) with available preoperative CT/MRI and NRS, and relevant functional data were analyzed. PVA was performed on CT/MRI using semi-automated software, and LWH measurements were obtained from CT/MRI images. RFC was presumed to be 25%, and thus: Predicted NBGFR = 1.25 × Global GFRPre-RN × SRFContralateral. Predictive accuracies were assessed by mean squared error (MSE) and correlation coefficients (r). The r values for the LWH/NRS/software-derived PVA approaches were 0.72/0.71/0.86, respectively (p < 0.05). The PVA-based approach also had the most favorable MSE, which were 120/126/65, respectively (p < 0.05). Our data show that software-derived PVA provides more accurate and precise SRF estimations and predictions of NBGFR post-RN than NRS/LWH methods. Furthermore, the LWH approach is equivalent to NRS, precluding the need for NRS in most patients.

Prognostic significance of sarcomatoid features in metastatic renal cell carcinoma treated with cytoreductive nephrectomy and targeted therapy.

INTRODUCTION: The presence of sarcomatoid features in localized renal cell carcinoma (RCC) is associated with worse outcomes. We sought to use a national database to evaluate the outcomes and prognosis of metastatic RCC (mRCC) with sarcomatoid features treated with cytoreductive nephrectomy (CN) and targeted therapy (TT). METHODS: The National Cancer Database (2010-2013) was used to identify patients with mRCC at diagnosis. Only patients who underwent CN followed by TT were included. Kaplan-Meier curves, log-rank test, and multivariate Cox regression analysis were used to compare overall survival (OS) between mRCC with and without sarcomatoid features. Subgroup analysis in patients with clear cell RCC (ccRCC) was performed. RESULTS: A total of 1,427 patients with mRCC treated with CN followed by TT were included of which 364 (26%) had mRCC with sarcomatoid features. mRCC with sarcomatoid features were more likely to have Fuhrman grade 4 cancer. mRCC with sarcomatoid features had worse OS than mRCC without sarcomatoid features (24.6 vs 12.0 months, P < 0.001). For the clear cell cohort, mRCC with sarcomatoid features had worse OS than mRCC without sarcomatoid features (26.2 vs 14.0 months, P < 0.001). Multivariate Cox regression showed sarcomatoid features was significantly associated with worse OS in the overall cohort (hazard ratio [HR] =1.63, 95% confidence interval [CI] =1.38-1.91, P < 0.001) and the ccRCC subcohort (HR=1.53, 95% CI=1.23-1.90, P < 0.001). DISCUSSION/CONCLUSION: mRCC with sarcomatoid features treated with CN and TT has a very poor and drastically different prognosis compared with mRCC without sarcomatoid features. With the expansion of systemic RCC therapies, investigation is needed to optimize treatment in this high-risk cohort.

Harnessing choice architecture in urologic practice: Implementation of an opioid-sparing protocol grounded in cognitive behavioral theory.

PURPOSE: Opioids are prescribed excessively following surgery. As many urologic oncology procedures are performed minimally invasively, an opportunity exists to push forward initiatives to minimize postoperative opioid use. MATERIALS AND METHODS: A quality improvement initiative to reduce inpatient opioid prescribing was launched at a tertiary cancer center. In Phase I (December 2019-July 2020), providers were instructed to start standing acetaminophen. In Phase II (beginning August 2020), education was provided to the entire care team and ordersets were modified to an opioid sparing protocol (OSP). We analyzed the proportion of minimally invasive surgery (MIS) prostatectomy and nephrectomy patients that adhered to an OSP during each phase and compared them to controls from the preceding 2 years. RESULTS: A total of 303, 153, and 839 patients underwent MIS during the Phase I, Phase II, and control periods respectively. The proportion of patients adhering to an OSP increased from 16% at the beginning of Phase I to 76% at the end of Phase II (p-trend < 0.001). The median total oral morphine equivalents for oral opioids declined from 20 mg and 40 mg at baseline for prostatectomy and nephrectomy patients respectively to 0 mg for both groups (p-trends < 0.001). Multivariable analysis found that patients received 22% and 81% less oral morphine equivalents during Phase I and II respectively compared to the control period (P < 0.001). CONCLUSIONS: Adherence to an OSP is most effective when initiatives incorporate the entire team and are supported by nudge theory-based structural changes. Using these strategies, most patients following urologic MIS can dramatically reduce opioid use postoperatively.