Nishant Patel

Survival outcomes after radical and partial nephrectomy for clinical T2 renal tumours categorised by R.E.N.A.L. nephrometry score

We evaluated survival outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) for clinical T2 renal masses (cT2RM) controlling for R.E.N.A.L. nephrometry score.

Epidemiology and etiology of benign prostatic hyperplasia and bladder outlet obstruction

Benign prostatic hyperplasia (BPH) is a histological diagnosis associated with unregulated proliferation of connective tissue, smooth muscle and glandular epithelium. BPH may compress the urethra and result in anatomic bladder outlet obstruction (BOO); BOO may present as lower urinary tract symptoms (LUTS), infections, retention and other adverse events. BPH and BOO have a significant impact on the health of older men and health-care costs. As the world population ages, the incidence and prevalence of BPH and LUTS have increased rapidly. Although non-modifiable risk factors – including age, genetics and geography – play significant roles in the etiology of BPH and BOO, recent data have revealed modifiable risk factors that present new opportunities for treatment and prevention, including sex steroid hormones, the metabolic syndrome and cardiovascular disease, obesity, diabetes, diet, physical activity and inflammation. We review the natural history, definitions and key risk factors of BPH and BOO in epidemiological studies.

Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European-American Multi-institutional Analysis

BACKGROUNDnLaparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique.nnnOBJECTIVEnTo report a large multi-institutional series of minimally invasive SP (MISP).nnnDESIGN, SETTING, AND PARTICIPANTSnConsecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis.nnnINTERVENTIONnLaparoscopic or robotic SP.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnDemographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score <8, maximum flow rate >15ml/s, and no perioperative complications.nnnRESULTS AND LIMITATIONSnOverall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100ml (range: 89-128). Median estimated blood loss was 200ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p=0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p=0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss (p=0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis.nnnCONCLUSIONSnThis study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications.nnnPATIENT SUMMARYnAnalysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.

Fluoroquinolone Resistant Rectal Colonization Predicts Risk of Infectious Complications after Transrectal Prostate Biopsy

PURPOSEnInfection after transrectal prostate biopsy has become an increasing concern due to fluoroquinolone resistant bacteria. We determined whether colonization identified by rectal culture can identify men at high risk for post-transrectal prostate biopsy infection.nnnMATERIALS AND METHODSnSix institutions provided retrospective data through a standardized, web based data entry form on patients undergoing transrectal prostate biopsy who had rectal culture performed. The primary outcome was anyxa0post-transrectal prostate biopsy infection and the secondary outcome was hospital admission 30 days after transrectal prostate biopsy. We used chi-square and logistic regression statistical analysis.nnnRESULTSnA total of 2,673 men underwent rectal culture before transrectal prostate biopsy from January 1, 2007 to September 12, 2013. The prevalence of fluoroquinolone resistance was 20.5% (549 of 2,673). Fluoroquinolone resistant positive rectal cultures were associated with post-biopsy infection (6.6% vs 1.6%, p <0.001) and hospitalization (4.4% vs 0.9%, p <0.001). Fluoroquinolone resistant positive rectal culture increased the risk of infection (OR 3.98, 95% CI 2.37-6.71, p <0.001) and subsequent hospital admission (OR 4.77, 95% CI 2.50-9.10, p <0.001). If men only received fluoroquinolone prophylaxis, the infection and hospitalization proportion increased to 8.2% (28 of 343) and 6.1% (21 of 343), with OR 4.77 (95% CI 2.50-9.10, p <0.001) and 5.67 (95% CI 3.00-10.90, p <0.001), respectively. The most common fluoroquinolone resistant bacteria isolates were Escherichia coli (83.7%). Limitations include the retrospective study design, nonstandardized culture and interpretation of resistance methods.nnnCONCLUSIONSnColonization of fluoroquinolone resistant organisms in the rectum identifies men at high risk for infection and subsequent hospitalization from prostate biopsy, especially in those with fluoroquinolone prophylaxis only.

Evaluation of national trends in the utilization of partial nephrectomy in relation to the publication of the American Urologic Association guidelines for the management of clinical T1 renal masses.

BackgroundPartial nephrectomy has been underutilized in the United States. We investigated national trends in partial nephrectomy (PN) utilization before and after publication of the American Urological Association (AUA) Practice Guideline for management of the clinical T1 renal mass.MethodsWe identified adult patients who underwent radical (RN) or PN from November 2007 to October 2011 in the Nationwide Inpatient Sample (NIS). PN prevalence was calculated prior to (11/2007-10/2009) and after Guidelines publication (11/2009-10/2011) and compared the rate of change by linear regression. We also examined the nephrectomy trends in patients with chronic kidney disease (CKD). Statistical analysis included linear regression to determine point-prevalence of PN rates in CKD patients and logistic regression to identify variables associated with PN.ResultsDuring the study period, 30,944 patients underwent PN and 64,767 RN. The prevalence PN increased from 28.9% in the years prior to guideline release to 35.3% in the years following guideline release with an adjusted odds ratio (OR) of 1.24 (CI 1.01–1.54; pu2009=u20090.049). The rate of PN significantly increased throughout the study period (R2 0.15, pu2009=u20090.006): however, the rate of change was not increased after the guidelines. (pu2009=u20090.46). Overall rate of PN in patients with CKD did not increase over time (R2 0.0007, pu2009=u20090.99).ConclusionWe noted a 6.4% absolute increase in PN after release of the AUA guidelines on clinical T1 renal mass was published; however, the rate of increase was not likely associated with guideline release. The rate of PN performed is increasing; however, further investigation regarding medical decision-making surrounding PN is needed.

Does Timing of Cytoreductive Nephrectomy Impact Patient Survival With Metastatic Renal Cell Carcinoma in the Tyrosine Kinase Inhibitor Era? A Multi-institutional Study

OBJECTIVEnTo compare outcomes of metastatic renal cell carcinoma (mRCC) patients who underwent primary cytoreductive nephrectomy (CRN), followed by adjuvant sunitinib therapy, vs those who underwent primary sunitinib therapy before planned CRN.nnnMETHODSnThis was a multi-institutional retrospective analysis of 35 mRCC patients from June 2005 to August 2009 (median follow-up, 28.5 months): 17 underwent primary CRN, followed by adjuvant sunitinib (group 1); 18 underwent primary sunitinib therapy, followed by planned CRN (group 2). Response to therapy was determined using Response Evaluation Criteria in Solid Tumors. Group 2 patients who had partial response (PR)/stable disease (SD) proceeded to CRN (group 2xa0+CRN). Group 2 patients who progressed were treated with salvage systemic therapy (group 2 no-CRN). Primary and secondary outcomes were disease-specific survival (DSS) and overall survival (OS).nnnRESULTSnPatient demographic and tumor characteristics were similar. The groups had similar rates of DSS and OS on univariate analysis (Pxa0= .318 and Pxa0= .181). In group 2, 11 (61%) had PR/DS; 7xa0(39%) progressed. Mean times to disease-specific death in group 1, group 2 (+CRN), and group 2 (no-CRN) were 29.2, 4.6, and 28.7 months, respectively (Pxa0= .025). Kaplan-Meier analysis of DSS and OS demonstrated significant improvement in group 2 (+CRN) vs group 1 vs group 2xa0(no-CRN; Pxa0<.001), which remained significant on multivariate regression.nnnCONCLUSIONnNonresponders to primary sunitinib therapy had a poor prognosis. Offering CRN, if safely feasible, combined with sunitinib, was associated with improved disease-specific outcome in mRCC. Responders to primary sunitinib who underwent CRN had better DSS and OS than patients who underwent primary CRN, followed by sunitinib. Further investigation is required toxa0assess the role, timing, and sequencing of targeted therapy and CRN in treatment of mRCC.

Analysis of Renal Functional Outcomes After Radical or Partial Nephrectomy for Renal Masses ≥7 cm Using the RENAL Score.

OBJECTIVEnTo determine if partial nephrectomy (PN) confers a renal functional benefit compared to radical nephrectomy (RN) for clinical T2 renal masses (T2RM) when adjusting for tumor complexity characterized by the RENAL nephrometry score.nnnMETHODSnA 2-center study of 202 patients with T2RM undergoing RN (122) or PN (80) (median follow-up, 41.5xa0months). RN and PN cohorts were subanalyzed according to RENAL sum as a categorical variable ofxa0<10 orxa0≥10. Primary outcome was median change in estimated glomerular filtration rate (ΔeGFR) between preoperative to 6 months postoperative. Logistic regression-identified prognostic factors and survival models analyzed association between the RENAL sum and the freedom from de novo chronic kidney disease (CKD; eGFR<60xa0mL/min/1.73m(2)).nnnRESULTSnNo significant differences existed between PN and RN for RENAL score. ΔeGFR was greater in RN (-19.7) vs PN (-11.9; Pxa0= .006). De novo CKD was 40.2% after RN vs 16.3% after PN (Pxa0<.001). RENAL scorexa0≥10 (odds ratio, 6.67; Pxa0= .025) and RN among patients with RENAL scorexa0<10 (odds ratio, 24.8; Pxa0<.001) were independently associated with de novo CKD at 6xa0months by logistic regression. Among patients with RENAL scorexa0<10, median CKD-free survival was PN 38 vs RN 16xa0months (Pxa0= .001). Cox proportional hazard demonstrated decreasing risk of CKD for PN vs RN from RENAL 10 (hazard ratio, 0.836) to RENAL 6 (hazard ratio, 0.003; Pxa0= .001).nnnCONCLUSIONnRN is independently associated with decreased renal function compared to PN for T2RM with RENAL sumxa0≤10, but not >10, with larger relative decrease in eGFR for each decrease in RENAL sum. Further investigation is required to determine optimal candidates for PN in T2RM.

Balloon Dilation of the Ureter: A Contemporary Review of Outcomes and Complications

PURPOSEnDuring ureteroscopy ureteral balloon dilation may be necessary to allow for passage of endoscopic instruments or access sheaths. We assessed the efficacy and complications associated with ureteral balloon dilation.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records at 2 institutions from 2000 to 2012 to identify patients who underwent ureteral balloon dilation during ureteroscopic treatment of upper tract stones. An 18Fr balloon dilator was used in all cases. Patients with documented ureteral stricture, radiation therapy or urothelial cancer were excluded from analysis. Primary outcomes were the stone-free rate, operative complications, balloon dilation failure and the postoperative ureteral stricture rate. Complications were divided into intraoperative and postoperative groups according to the Satava and Clavien-Dindo classifications, respectively.nnnRESULTSnA total of 151 patients fulfilled study criteria. Median followup was 12 months. The stone-free rate was 72% and median time to first postoperative imaging was 2.8 months. Balloon dilation failed in only 8 patients (5%). Eight intraoperative ureteral perforations (5%) were identified, which were managed by a ureteral stent in 7 patients and a percutaneous tube in 1. Endoscopic re-treatment was required in 4 patients with Satava 2b postoperative complications. The postoperative complication rate was 8% (11 cases). A single ureteral stricture was attributable to balloon dilation.nnnCONCLUSIONSnIn this contemporary review balloon dilation of the ureter before endoscopic treatment of stone disease was associated with a high success rate and few complications. Ureteral balloon dilation may decrease the need for a secondary procedure in patients undergoing ureteroscopy to manage proximal ureteral and intrarenal stones.

Robotic-Assisted Simple Prostatectomy: Is there Evidence to go Beyond the Experimental Stage?

Open simple prostatectomy (OSP) is an effective and durable treatment for select patients with symptomatic benign prostatic hyperplasia (BPH) and large-volume prostate glands (>80xa0cc), yet is associated with clinically significant risk of bleeding, transfusion, prolonged hospital length of stay (LOS), and complications. Robotic-assisted simple prostatectomy (RASP) potentially reduces intraoperative blood loss and improves perioperative outcomes. Thirteen non-comparative series (Level 3 evidence) of RASP have established its safety and efficacy and have demonstrated substantially decreased risk of transfusion, complications, and mean LOS relative to published series of OSP, but with consistently longer operative times. Comparative outcomes data (Level 1 and Level 2 evidence), however, are relatively lacking. Thus, while RASP has advanced beyond the experimental stage, definitive outcomes studies are needed to establish its benefits and costs relative to OSP and transurethral surgery.

National Trends in the Management of Urethral Stricture Disease: A 14-Year Survey of the Nationwide Inpatient Sample

Introduction: Urethral strictures are common in general urology practice and can initially be treated with urethral dilation or incision. Unfortunately, many patients require retreatment. Urethroplasty provides a more durable effect but may be underused. We examined national trends in the management of urethral stricture disease. Methods: Using the NIS (Nationwide Inpatient Sample) database from 1998 to 2011 we identified patients with a primary or secondary admitting ICD‐9 diagnosis code of 598.X (urethral stricture) and excluded patients with urethral cancer, urethritis, urethral stone, abscess or epispadias. Inpatient procedure codes were used to classify 2 treatment groups, including 1) urethral dilation/incision and 2) urethral reconstruction. Linear regression was performed to determine the change in the utilization rate of incision/dilation and urethral reconstruction per 1,000 urethral strictures with time. Results: A total of 240,108 procedures were identified for 471,596 urethral stricture diagnoses upon hospital admission, including 217,869 (90.7%) for incision/dilation and 22,239 (9.3%) for urethral reconstruction/urethrostomy. Mean utilization of incision/dilation per 1,000 strictures decreased slightly by 10.74 per year (1%) (p ≤0.001). Mean utilization of urethral reconstruction increased slightly by 1.65 per year (0.17%) (p = 0.0062). For every 1 increase in urethral reconstruction there were 12 fewer urethral dilations per 1,000 urethral strictures per year. Conclusions: Urethral dilation/incision continues to be the foremost management of urethral stricture disease with known high recurrence and failure rates. Patients should be referred for urethral reconstruction to optimize treatment outcomes.