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Purpose Two randomized trials published in 2001 provided level 1 evidence for the use of cytoreductive nephrectomy (CyNx) for the treatment of metastatic renal cell carcinoma (mRCC). However, the regulatory approval of vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) in 2005 has left an “evidence void” regarding the use of CyNx. We evaluated the patterns in the use of CyNx in the cytokine and VEGFR-TKI eras, and the patient characteristics associated with the use of CyNx. Methods The Surveillance, Epidemiology, and End Results registry was used to identify patients with histologically or cytologically confirmed stage IV RCC between 2001 and 2008. Patients were classified as treated during the cytokine (2001–2005) or VEGFR-TKI (2006–2008) eras. A multivariate logistic regression analysis was performed to calculate the odds of undergoing CyNx according to treatment era and socioeconomic characteristics. Results Overall, 1,112 of 2,448 patients (45 %) underwent CyNx. CyNx use remained stable between 2001 and 2005 (50 %), but decreased to 38 % in 2008. Logistic regression analysis revealed that older age (OR 0.82, 95 % CI: 0.68, 0.99), black race (OR 0.64, 95 % CI: 0.46, 0.91), Hispanic ethnicity (OR 0.71, 95 % CI: 0.54, 0.93), and treatment in the VEGFR-TKI era (OR 0.82, 95 % CI: 0.68, 0.99) were independently associated with decreased use of CyNx. Conclusions Use of CyNx in the United States has declined in the VEGFR-TKI era. Older patients and minorities are less likely to receive CyNx. Results of ongoing phase III trials are needed to refine the role of this treatment modality.

PurposeRezum is a minimally invasive surgery for benign prostatic hyperplasia. Current guidelines recommend Rezum for prostates < 80 cc, but little data exist describing outcomes in patients with prostates ≥ 80 cc. We compare outcomes after Rezum between men with small < 80 cc (SP) and large ≥ 80 cc prostates (LP).MethodsPatients undergoing Rezum between Jan 2017–Feb 2020 were subdivided by prostate volume (< 80, ≥ 80 cc). Outcomes were documented pre- and postoperatively. Descriptive analyses of urodynamics data (Qmax, PVR), symptom scores (AUA-SS, SHIM), disease management (medications, catheterization, retreatments), and clinical outcomes were conducted.Results36 (17.6%) men had prostates ≥ 80 cc (LP mean prostate size 106.8 cc). LP men had improved Qmax and PVR postoperatively; those with longitudinal follow-up exhibited improved Qmax, PVR, and AUA-SS. After one year, alpha-blocker usage decreased significantly (LP 94.44–61.11%, p = 0.001, SP 73.96–46.15%, p = 0.001); other medication usage and self-catheterization rates remained unchanged. Compared to SP patients, differences in passing trial void (LP 94.44%, SP 93.45%), postoperative UTI (LP 19.44%, SP 10.12%), ED visits (LP 22.22%, SP 17.86%), readmissions (LP 8.33%, SP 4.76%), and retreatment (LP 8.33%, SP 4.76%) were insignificant. However, mean days to foley removal (LP 9, SP 5.71, p = 0.003) and urosepsis rates (LP 5.56%, SP 0.00%, p = 0.002) differed.ConclusionIn select LP patients, Rezum provided short-term symptomatic relief and improved voiding function comparable to SP patients. Postoperatively, though alpha-blocker usage decreased significantly, use of other medications did not change, and nearly two-thirds of patients still needed alpha-blockade. Further efforts should explore the possibility of expanding Rezum’s inclusion criteria.

Frailty has been shown to be a predictor of adverse postoperative outcomes. This study aims to evaluate a 5-item frailty index (5-iFI) as a predictor of complications as well as healthcare resource utilization (HCRU) following adrenalectomy. All adrenalectomy cases recorded in the ACS-NSQIP database from 2015 to 2018 were analyzed. Primary outcomes of interest were Clavien-Dindo [CD] I/II or CD IV complications and HCRU. HCRU outcomes were prolonged length of stay (PLOS), discharge to continued care (DCC), and unplanned 30-day readmission (UR). 4358 patients were included. Higher 5-iFI scores were associated with higher rates of CDI/II, CDIV, and increased HCRU (p < 0.05). On multivariate analysis, 5-iFI scores were found to be independent predictors of adverse clinical and HCRU outcomes. Frailty tools like the 5i-FI can be useful in preoperative risk-benefit analysis, patient counseling, and planning prehabilitation interventions. •A condensed 5-item frailty index predicts adrenalectomy outcomes.•Frailty is associated with higher rates of clinical complications.•Frailty is also associated with increased healthcare resource utilization.•Frailty scores are predictors of adverse adrenalectomy outcomes.

Our goal was to assess the use and perceptions of complementary and alternative medicine (CAM) for kidney stones among a diverse, urban population. This was a cross-sectional study of patients treated for kidney stones in the Bronx, NY. We assessed demographic information, personal history of kidney stones, as well as knowledge and use of CAM for kidney stones. Patient demographics and responses were analyzed using chi-squared, t tests, and binomial logistic regression. 113 patients were surveyed. 90% identified as non-white, of whom 58% indicated Hispanic, 46% Latinx, and 23% Black. 56% of patients were born outside the United States. 56% of patients had heard of CAM for kidney stones and 44% had used CAM for kidney stones. The most common CAM were fruits (N = 42, 84%). Recurrent stone formers were more likely than first-time stone formers to have heard of CAM (68 vs 44% p = 0.013) and to have used CAM (56 vs 30%, p = 0.008). Those identifying as Hispanic were more likely to have both heard of and tried CAM for kidney stones (p = 0.036 and 0.022, respectively) compared to non-Hispanic patients. CAM are commonly used among our diverse, urban patient population. While some remedies are high in citrate and alkali (i.e., lemon, cranberry), others are high in oxalate (i.e., beets) and could potentially contribute to stone formation. These findings underpin the importance that medical providers educate themselves on the CAM used in their specific patient populations and discussing use with patients. Providers should aim to identify and reconcile therapeutics that oppose goals of treatment.

PurposeThe aim of this review is to highlight the unique factors that predispose geriatric patients to nephrolithiasis and to compare the utility and efficacy of surgical techniques in this specific patient population.MethodsPubMed and EMBASE databases were reviewed, and studies were organized according to surgical treatments.ResultsFew prospective studies exist comparing kidney stone removal in the elderly to younger cohorts. In addition, various age cut-offs were used to determine who was considered elderly. Most studies which analyzed Percutaneous Nephrolithotomy (PCNL) found a slightly higher rate of minor complications but comparable stone free rate and operative time. For ureteroscopy (URS) and extracorporeal shockwave lithotripsy (ESWL), there were minimal complications observed and no difference in clinical success in the elderly. All surgical techniques were presumed to be safe in the elderly and most found no difference in stone-free rates.ConclusionsUnique attributes of the geriatric population contribute to stone formation and must be considered when determining appropriate management modalities. This review provides an overview of the utility and efficacy of PCNL, URS and ESWL in the elderly, as well as a porposed algorithm for management in this population.

The objective of this study is to evaluate the conventional dietary recommendations for stone prevention among patients in the National Health and Nutritional Examination Survey (NHANES) and compare dietary components and special diets between stone formers and non-stone formers. We analyzed the NHANES 2011–2018 dietary and kidney condition questionnaires, among 16,939 respondents who were included in this analysis. Dietary variables were selected based on the American Urological Association (AUA) guideline for Medical Management of Kidney Stones and from other studies on kidney stone prevention. Weighted multivariate logistic regression models were used to assess the relationship of dietary food components (categorized into quartiles) and dietary recommendations with kidney stone formation (yes vs no), adjusted for total caloric intake, comorbidities, age, race/ethnicity, and sex. The prevalence of kidney stones was 9.9%. Our results showed association of kidney stones with lower levels of potassium (p for trend = 0.047), which was strongest for < 2000 mg (OR = 1.35; 95% CI 1.01–1.79). Higher vitamin C intake was inversely associated with stone formation (p for trend = 0.012), particularly at daily intake levels between 60 and 110 mg (OR = 0.76; 95% CI 0.60–0.95) and above 110mcg (OR = 0.80; 95% CI 0.66–0.97). There were no associations between other dietary components and kidney stone formation. Higher levels of dietary vitamin C and potassium intake may be indicated for stone prevention and warrants further investigation.

PurposeThis study aimed to investigate the relationship between self-reported food security and kidney stone formation.MethodsData were collected from the National Health and Nutrition Examination Survey (NHANES), a database representative of the United States population. Food security status was assessed using the US Household Food Security Survey Module: Six-Item Short Form. Characteristics of patients were compared using the Chi-square test and the student t-test. Multivariate logistic regression was performed using a multi-model approach.ResultsWe analyzed 6,800 NHANES survey respondents. 37.2% of respondents were categorized as having “low food security” (scores 2–4) and 24.0% having “very low food security” (scores 5–6). 8.4% of respondents had a history of kidney stones. We found that people with very low food security had a 42% increased likelihood of developing kidney stones compared to those with high or marginal food security, after controlling for race, age, and comorbidities (OR 1.42; 95% CI 1.01–1.99). Between the different food security groups, no significant differences were observed in age, race/ethnicity, body mass index, gout history, osteoporosis history, or coronary artery disease history. Lower food security was associated with slightly younger age (< 1 year difference, p = 0.001), higher poverty-income ratio (p = 0.001), and many comorbidities, including kidney stones (p = 0.007).ConclusionOur study provides evidence for an association between food access and the risk of kidney stone disease. Given these findings, food insecurity should be investigated as a modifiable risk factor for the development of kidney stone disease.

The factors driving early adoption of robotic-assisted simple prostatectomy (RASP) for large gland BPH have not yet been identified. This study aims to determine the patient, provider, and facility level differences and predictors in undergoing RASP versus OSP. This population-based cohort study used data from the all-payer New York State Statewide Planning and Research Cooperative System (SPARCS) database. Patient, provider, and facility characteristics for each cohort were analyzed, and a multivariate analysis was conducted to identify predictive factors associated with undergoing RASP versus OSP. From 2009 to 2017, 1881 OSP and 216 RASP cases were identified. RASP utilization increased from 2.6% of all cases in 2009 to 16.8% in 2017. Patient demographics were similar between both cohorts. Median length of stay was shorter for RASP patients (3 vs. 4 days, p  < 0.001), and OSP was associated with a long length of stay (> 7 days) ( p  < 0.001). There were no significant differences in 30- and 90-day readmission rates or 1-year mortality. More OSP patients were discharged to continued care facilities than RASP patients ( p  = 0.049), and more RASP patients were discharged to home compared to OSP patients ( p  = 0.035). Positive predictors for undergoing RASP included teaching hospital status, medium and high hospital bed volume, high hospital operative volume, high surgeon volume, and surgeons that graduated within 15 years of surgery. As RASP shows favorable perioperative outcomes, the diffusion of robotic technology and newer graduates entering the workforce may augment the upward trend of RASP utilization.

There have been more drugs approved by the US Food and Drug Administration for the treatment of castration-resistant prostate cancer in the past 3 years than in the prior 3 decades, with additional drugs on the verge of approval based on the results of recently reported randomized trials. While an improvement in the understanding of the pathogenesis of castration-resistant prostate cancer has undeniably accelerated the transition of novel approaches from \"bench to bedside,\" the recent successes in the treatment of prostate cancer are also a result of the efforts of clinical investigators to redefine the framework in which drugs for castration-resistant disease are evaluated. This review will explore the shifting paradigm in drug development for castration-resistant prostate cancer over the past several decades, and highlight how new definitions, trial designs, and endpoints have facilitated the emergence of new therapies for this challenging disease. [PUBLICATION ABSTRACT]

PurposeChildren who undergo lower urinary tract reconstruction (LUTR) often have asymptomatic bacteriuria or recurrent urinary tract infections (UTI). We aimed to determine the prevalence of positive preoperative urine cultures (PPUC) before LUTR and to analyze any impact on postoperative outcomes.MethodsThis retrospective review included all pediatric LUTR procedures utilizing bowel segments performed by one surgeon over 2 years. Preoperative cultures were obtained 1–2 days before surgery. Baseline characteristics and 90-day infection/readmission rates between patients with and without PPUC were compared using descriptive statistics, Fisher’s exact, and Mann–Whitney tests with significance p < 0.05.Results54 patients with mean age 10.1 ± 5.6 years underwent LUTR procedures using bowel including continent catheterizable channel (85%), enterocystoplasty (81%), and/or urinary diversion (9%). PPUC was present in 28 patients (52%). Postoperatively, 20% had inpatient infections, including eight UTI, four surgical site infections, and two bloodstream infections with no difference between those with or without PPUC. Within 90 days of discharge, 28% of patients were readmitted to the hospital, and there was no difference between groups. Postoperative urine cultures were positive in 83% of patients within 90 days.ConclusionsHalf of the patients undergoing LUTR have PPUC, but it does not increase the risk of postoperative infections or hospital readmissions. We believe complex LUTR can be safely performed in patients with PPUC.