The latest medical research on Urology

The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about urology gathered by our medical AI research bot.

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Same day discharge after robotic radical prostatectomy.

J Urol

The typical mean length of stay (LOS) following robotic-assisted laparoscopic prostatectomy (RALP) is 24-48hrs. We began routinely offering same day discharge (SDD) after RALP and evaluate the success rate, safety and cost implications in the only large series of SDD to date.

Beginning September 2016, all patients were given the option for SDD without it being mandated. After allowing a period of 3 months to solidify the protocol, we evaluated our prospective database for the next 500 patients.

Of 500 consecutive RALPs by one surgeon (RA) in 18mos, 246 patients (49.2%) were discharged the day of surgery with all of the remaining 254 discharged the next day for a mean LOS of 0.51 days. Mean age was 62yrs (42-81yrs) and BMI 29.7kg/m2 (20-53kg/m2). Thirty-four (6.8%) overall had a Clavien-Dindo grade I-III complication within 90 days with no grade IV-V complications. Only 5 required an emergency department (ED) visit (1%) and only 8 required readmission (1.6%). Among SDD patients, only one was readmitted, and only one presented to the ED. The estimated charge for overnight stay at our institution is $2,109, such that the approximate reduction in charges was $518,814 over 18 months ($345,876/yr) with no increase in costs from ED visits or readmissions compared with overnight patients. Among the most recent 100 patients, the rate of SDD improved to 65%.

Same-day discharge following RALP can be safely routinely offered with no increase in readmissions or emergency visits and may lead to significant savings in healthcare costs.

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

J Urol

Prescription opioid use is increasing, leading to increased addiction and mortality. Post-operative care is often patients' first exposure to opioids, however little data exists on national prescription patterns in urology. We aimed to examine post-discharge opioid fills after urological procedures and their association with long term use.

We identified patients in a private national insurance database undergoing 15 urological procedures between October 1, 2010 and September 30, 2014. Patients with an opioid fill in the preceding 6 months were excluded. Claims for opioids from 30 days before until 7 days after an operation characterized an initial prescription. Factors associated with persistent opioid use (an opioid claim 91-180 days after the operation) and chronic opioid use (≥10 refills for ≥120 days supply in the year following the operation) were analyzed using multivariable logistic regression.

Overall, 96,580 patients were included, and 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 undergoing transurethral resection of the prostate, vasectomy, female sling, cystoscopy, and stent insertion were associated with an increased risk of both persistent and chronic use.

National variation in opioid prescribing practice exists after urological operations. Patients filling larger amounts of opioids after certain major and minor urological procedures are at an increased risk of long term opioid use. This provides evidence for procedure specific prescribing guidelines to minimize risk and promote standardization.

Effect of stepwise voltage escalation on treatment outcomes following extracorporeal shockwave lithotripsy of renal calculi: a prospective randomized study.

J Urol

This study aimed to assess the effects of a ramping protocol in patients receiving extracorporeal shockwave lithotripsy (SWL) for renal stones.

In this prospective study, patients with renal stones were randomized to receive SWL delivered using a ramping (First 1000 shocks at energy level-5, followed by 1000shocks at energy level-6 and 1000 final shocks at energy level-7; Group-1) or fixed-voltage (All 3000 shocks at energy level-7; Group-2) protocols by Modulith SLX-F2. The primary outcome was treatment success at 12weeks after a single SWL session, defined as the lack of a stone or a stone fragment <4 mm on computed tomography. Other outcomes included stone-free rate and the incidence of perinephric hematoma.

300 patients (150 per group) were recruited between February 2016 and June 2018. The two groups did not differ in terms of baseline parameters. Group-1 received significantly lower energy delivered than Group-2 (14.8% less, p<0.001). The treatment success rates for Group-1 and Group-2 were 67.8% and 73.6%, respectively, and were not statistically different (crude odds ratio for Group-1: 0.753; 95% confidence interval 0.456 to 1.244; p=0.268). The stone-free rates for Group-1 and Group-2 were 36.6% and 41.9%, respectively, and did not differ between the groups. However, in Group-1 and Group-2, 23.8% and 43.8% of patients developed perinephric hematoma, respectively, and was statistically significant difference (p<0.001).

The fixed-voltage SWL and ramping protocols provided similar treatment success rates for renal stones. However, ramping protocol could reduce the incidence of post-SWL perinephric hematoma.

Cost-Effectiveness of Active Surveillance, Radical Prostatectomy, and External Beam Radiotherapy for Localized Prostate Cancer: An Analysis of the ProtecT Trial.

J Urol

Despite increasing emphasis on value-based care, the cost-effectiveness of prostate cancer (PCa) management options has not been compared using prospective clinical trial data. The prostate testing for cancer and treatment (ProtecT) trial demonstrated no difference in survival for patients randomized to active surveillance (AS), external beam radiotherapy (RT), or radical prostatectomy (RP). Herein, we compare the cost-effectiveness among the arms of ProtecT.

A Markov model compared the cost-effectiveness of AS, RP, and RT based on ProtecT outcomes; specifically, 6-year quality of life data and 10 year oncologic data. Costs were based on 2017 Medicare reimbursement while utility values were assigned from the literature. Univariable and multivariable sensitivity analyses were performed.

At 6 years after randomization, mean costs per patient were $12,143 (AS), $17,781 (RP), and $29,238 (RT). The incremental cost-effectiveness ratio relative to AS was $133,314/QALY for RP and $389,915/QALY for RT. At 10 years after randomization, both RP ($5,627/QALY) and RT ($78,291/QALY) were found to be more cost-effective than AS. The model was sensitive to the metastasis rate on AS, with a threshold of 2.4% at 10 years, below which AS was more cost-effective than RP. On multivariable sensitivity analysis at 10 years, using a willingness-to-pay threshold of $100,000/QALY, the most cost-effective strategy was RP in 45%, RT in 30%, and AS in 25% of model micro-simulations.

Although AS represents a cost-effective management strategy for localized PCa during the initial several years after diagnosis, the relative cost-effectiveness of treatment emerges with extended follow up.

Personalized risks of overdiagnosis for screen-detected prostate cancer incorporating patient comorbidities: Estimation and communication.

J Urol

Shared patient-physician decision-making regarding treatment for prostate cancer detected by prostate-specific antigen screening involves a complex calculus weighing the risk of the cancer and patient life expectancy. We investigated quantifying these competing risks using the probability that the cancer was "overdiagnosed"-i.e., would not have been clinically diagnosed (diagnosed without screening) during the patient's remaining lifetime.

Using an established model of prostate cancer screening and clinical diagnosis, we simulated screen-detected cases and determined whether modeled clinical diagnosis would occur before non-cancer death, which was based on comorbidity-adjusted population lifetables. Logistic regression models were fitted to the simulated data and used to estimate overdiagnosis probabilities given patient age, PSA level, Gleason sum, and comorbidity category. An online calculator was developed to communicate overdiagnosis estimates; face validity and ease of use was assessed by surveying 32 clinical experts.

Estimated probabilities of overdiagnosis ranged 4%-78% across clinicopathologic variables and comorbidity status. Ignoring comorbidity, the estimated probability for a 70-year-old man with PSA 9.4 ng/mL and Gleason 6 is 34%; if he has severe comorbidities, the estimate increases to 51%, a personalization that may help inform the choice between active surveillance and definitive treatment. Based on responses from 20/32 experts, we modified the online calculator's explanation of overdiagnosis and input method for comorbid conditions.

The probability of overdiagnosis is strongly influenced by comorbidity status in addition to age. Personalized estimates incorporating comorbidity may contribute to shared decision-making between patients and providers regarding personalized treatment selection.

Clinical parameters outperform molecular subtypes for predicting outcome in bladder cancer: Results from multiple cohorts including TCGA.

J Urol

Studies report molecular subtypes within muscle invasive bladder cancer (MIBC) predict clinical outcome. We evaluated whether subtyping by a simplified method and established classifications could predict clinical outcome.

Institutional cohort-1 (n=52; MIBC: 39), Oncomine-dataset (MIBC: 151) and The Cancer Genome Atlas (TCGA)-dataset (MIBC: 402) were subtyped by simplified panels (MCG-1; MCG-Ext) that included only transcripts common among published studies, and analyzed for predicting metastasis, cancer-specific survival (CSS), overall-survival (OS), and recurrence-free survival (RFS). TCGA-dataset was further analyzed using Lund-Taxonomy, BC-Molecular Taxonomy Group Consensus (Consensus), and mRNA-subtype (TCGA-2017) classifications.

MIBC specimens from cohort-1 and Oncomine-dataset showed intra-tumor heterogeneity for transcript/protein expression. MCG-1 subtypes did not predict outcome in univariate or Kaplan-Meier analyses. In multivariate analyses, N-stage (P≤0.007), T-stage (P≤0.04), M-stage (P=0.007) and/or age (P=0.01) predicted metastasis, CSS/OS and/or cisplatin-based adjuvant-chemotherapy response. In the TCGA-dataset, publications report that subtypes risk-stratify patients for OS. Consistently, MCG-1 and MCG-Ext subtypes associated with OS, but not RFS, in univariate and Kaplan-Meier analyses. TCGA-dataset includes low-grade specimens (21/402) and subtypes associated with tumor-grade (P=0.005). However, MIBC is rarely low-grade (<1%). Among only high-grade specimens, MCG-1 and MCG-Ext subtypes could not predict OS. Subtypes by Consensus, TCGA-2017 and Lund-Taxonomy associated with tumor-grade (P<0.0001) and OS (P=0.01-<0.0001) univariately. Regardless of classification, subtypes had ∼50%-60% sensitivity and specificity to predict OS/RFS. In multivariate analyses, N-stage and lymphovascular-invasion consistently predicted RFS (P=0.039) and OS (P=0.003).

Molecular subtypes reflect bladder tumor heterogeneity and associate with tumor-grade. In multiple cohorts/subtyping-classifications, clinical parameters outperform subtypes for predicting outcome.

Transition Planning for the Senior Surgeon: Guidance and Recommendations From the Society of Surgical Chairs.

JAMA Surgery

Aging is well documented to be associated with declines in cognitive function and psychomotor performance, but only limited guidance is currently available from medical professional societies or regulatory agencies on how to translate these observations into the appropriate monitoring of physician performance.

The Society of Surgical Chairs conducted a panel discussion at its 2017 annual meeting and a subsequent survey of its membership in 2018 to develop recommendations for the transitioning of the senior surgeon.

Recommendations include mandatory cognitive and psychomotor testing of surgeons by at least age 65 years, potentially as a component of ongoing professional practice evaluation; career transition discussions with surgeons beginning early in their careers; respectful consideration of the potential financial needs, long-standing work commitments, and work-life concerns of retiring surgeons; and creation of teaching, mentoring or coaching, and/or administrative opportunities for senior surgeons in modified clinical or nonclinical roles. Ideally, these initiatives will catalyze a thoughtful and comprehensive new vista in supporting an aging workforce while ensuring the safety of patients, the efficient management of health care organizations, and the avoidance of unnecessary depletions to a sufficiently sized cadre of physicians with case-specific competencies.

Fracture Risk After Roux-en-Y Gastric Bypass vs Adjustable Gastric Banding Among Medicare Beneficiaries.

JAMA Surgery

Roux-en-Y gastric bypass (RYGB) is associated with significant bone loss and may increase fracture risk, whereas substantial bone loss and increased fracture risk have not been reported after adjustable gastric banding (AGB). Previous studies have had little representation of patients aged 65 years or older, and it is currently unknown how age modifies fracture risk.

To compare fracture risk after RYGB and AGB procedures in a large, nationally representative cohort enriched for older adults.

This population-based retrospective cohort analysis used Medicare claims data from January 1, 2006, to December 31, 2014, from 42 345 severely obese adults, of whom 29 624 received RYGB and 12 721 received AGB. Data analysis was performed from April 2017 to November 2018.

The primary outcome was incident nonvertebral (ie, wrist, humerus, pelvis, and hip) fractures after RYGB and AGB surgery defined using a combination of International Classification of Diseases, Ninth Edition and Current Procedural Terminology 4 codes.

Of 42 345 participants, 33 254 (78.5%) were women. With a mean (SD) age of 51 (12) years, recipients of RYGB were younger than AGB recipients (55 [12] years). Both groups had similar comorbidities, medication use, and health care utilization in the 365 days before surgery. Over a mean (SD) follow-up of 3.5 (2.1) years, 658 nonvertebral fractures were documented. The fracture incidence rate was 6.6 (95% CI, 6.0-7.2) after RYGB and 4.6 (95% CI, 3.9-5.3) after AGB, which translated to a hazard ratio (HR) of 1.73 (95% CI, 1.45-2.08) after multivariable adjustment. Site-specific analyses demonstrated an increased fracture risk at the hip (HR, 2.81; 95% CI, 1.82-4.49), wrist (HR, 1.70; 95% CI, 1.33-2.14), and pelvis (HR, 1.48; 95% CI, 1.08-2.07) among RYGB recipients. No significant interactions of fracture risk with age, sex, diabetes status, or race were found. In particular, adults 65 years and older showed similar patterns of fracture risk to younger adults. Sensitivity analyses using propensity score matching showed similar results (nonvertebral fracture: HR 1.75; 95% CI, 1.22-2.52).

This study of a large, US population-based cohort including a substantial population of older adults found a 73% increased risk of nonvertebral fracture after RYGB compared with AGB, including increased risk of hip, wrist, and pelvis fractures. Fracture risk was consistently increased among RYGB patients vs AGB across different subgroups, and to a similar degree among older and younger adults. Increased fracture risk appears to be an important unintended consequence of RYGB.

A Four-Group Urine Risk Classifier for Predicting Outcome in Prostate Cancer Patients.

BJU International

To develop a risk classifier using urine-derived extracellular vesicle RNA (UEV-RNA) capable of providing diagnostic information of disease status prior to biopsy, and prognostic information for men on active surveillance (AS).

Post-digital rectal examination UEV-RNA expression profiles from urine (n = 535, multiple centres) were interrogated with a curated NanoString panel. A LASSO-based Continuation-Ratio model was built to generate four Prostate-Urine-Risk (PUR) signatures for predicting the probability of normal tissue (PUR-1), D'Amico Low-risk (PUR-2), Intermediate-risk (PUR-3), and High-risk (PUR-4) PCa. This model was applied to a test cohort (n = 177) for diagnostic evaluation, and to an AS sub-cohort (n = 87) for prognostic evaluation.

Each PUR signature was significantly associated with its corresponding clinical category (p<0.001). PUR-4 status predicted the presence of clinically significant Intermediate or High-risk disease, AUC = 0.77 (95% CI: 0.70-0.84). Application of PUR provided a net benefit over current clinical practice. In an AS sub-cohort (n=87), groups defined by PUR status and proportion of PUR-4 had a significant association with time to progression (p<0.001; IQR HR = 2.86, 95% CI:1.83-4.47). PUR-4, when utilised continuously, dichotomised patient groups with differential progression rates of 10% and 60% five years post-urine collection (p<0.001, HR = 8.23, 95% CI:3.26-20.81).

UEV-RNA can provide diagnostic information of aggressive PCa prior to biopsy, and prognostic information for men on AS. PUR represents a new & versatile biomarker that could result in substantial alterations to current treatment of PCa patients. This article is protected by copyright. All rights reserved.

African American Specific Gene Panel Predictive of Poor Prostate Cancer Outcome.

J Urol

Most prostate cancer in African American men lacks the ETS (E26 transforming specific) family fusion event (ETS-). We aimed to establish clinically relevant biomarkers in African American men by studying ETS dependent gene expression patterns to identified race specific genes predictive of outcomes.

Two multicenter cohorts of a total of 1,427 men were used for the discovery and validation (635 and 792 men, respectively) of race specific predictive biomarkers. We used false discovery rate adjusted q values to identify race and ETS dependent genes which were differentially expressed in African American men who experienced biochemical recurrence within 5 years. Principal component modeling along with survival analysis was done to assess the accuracy of the gene panel in predicting recurrence.

We identified 3,047 genes which were differentially expressed based on ETS status. Of these genes 362 were differentially expressed in a race specific manner (false discovery rate 0.025 or less). A total of 81 genes were race specific and over expressed in African American men who experienced biochemical recurrence. The final gene panel included APOD, BCL6, EMP1, MYADM, SRGN and TIMP3. These genes were associated with 5-year biochemical recurrence (HR 1.97, 95% CI 1.27-3.06, p = 0.002) and they improved the predictive accuracy of clinicopathological variables only in African American men (60-month time dependent AUC 0.72).

In an effort to elucidate biological features associated with prostate cancer aggressiveness in African American men we identified ETS dependent biomarkers predicting early onset biochemical recurrence only in African American men. Thus, these ETS dependent biomarkers representing ideal candidates for biomarkers of aggressive disease in this patient population.

Multiparametric magnetic resonance imaging prior to radical prostatectomy identifies intraductal and cribriform growth pattern of prostate cancer.

BJU International

To evaluate the diagnostic value of multiparametric prostate magnetic resonance imaging (MP-MRI) prior to radical prostatectomy with curative intent for detection of cribriform architecture (CA) and intraductal prostate cancer (IDC), which have recently been demonstrated to be adverse pathologic factors.

This study included 124 men who underwent MP-MRI prior to radical prostatectomy at our centre. Preoperative MP-MRI, prostatectomy histology, and clinical follow-up details were reviewed retrospectively. The diagnostic value of MP-MRI was evaluated on the basis of the detection rate. Secondly, the prognostic significance of CA/IDC among grade group 2 cancers with regard to biochemical recurrence-free survival was assessed using Kaplan-Meier analysis with the log rank test and Fisher's exact test.

Pathologic examination of radical prostatectomy specimens identified CA/IDC in 89 (71%) of 124 cases and MP-MRI identified 86/95 of tumours including any CA/IDC with a sensitivity of 90.5% (95% confidence interval 82.8%-95.6%). When localization of the lesions was compared, there was an association between the highest Prostate Imaging-Reporting and Data System (PI-RADS) classification and the highest pathologic grade in 106 (85.5%) of the 124 cases. In patients with grade group 2 lesions, biochemical recurrence occurred in 11 of 31 (35.5%) with CA/IDC and 2 of 21 (9.5%) without CA/IDC (p=0.034).

MP-MRI has good sensitivity for detection of pathologic primary prostate cancer, including most cases with CA/IDC. However, reliable prediction of grade group 2 tumours with CA/IDC for individual risk stratification remains challenging. This article is protected by copyright. All rights reserved.

Development and acceptability testing of a patient decision aid for urinary diversion with radical cystectomy.

J Urol

The choice of urinary diversion at the time of cystectomy is a life-altering decision. Patient decision aids (PtDA) are clinical tools that promote shared decision-making by providing information about management options and by helping patients communicate their values. We sought to develop and evaluate a PtDA for individuals undergoing cystectomy with urinary diversion.

The International Patient Decision Aids Standards (IPDAS) were used to guide a systematic development process. A literature review was performed to determine options for urinary diversion and incidence of outcomes. Using the Ottawa Decision Support Framework, a prototype was created. A 10-question survey assessed PtDA acceptability amongst patients, allied health professionals, and urologists. The primary outcome was acceptability of the PtDA.

Ileal conduit and orthotopic neobladder were included as primary urinary diversion options because they had the most evidence and are most commonly performed. Continent-cutaneous diversion was identified as an alternative option. Outcomes specific to ileal conduit were stomal stenosis and parastomal hernia. Outcomes specific to neobladder were daytime and nighttime urinary incontinence, and urinary retention. Acceptability testing was completed by 8 urologists, 9 patients, and 1 advanced practice nurse. Respondents reported the language was appropriate (94%), length was adequate (94%), and presentation of options were balanced (83%). The PtDA met IPDAS defining (6 of 6), certification (6 of 6), and 21 of 23 quality criteria.

A novel PtDA was created to improve the quality of decisions patients make when deciding between urinary diversion options. Effectiveness testing will be performed prospectively.