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Heidenberg DJ, Nethery E, Wymer KM, Judge N, Cheney SM, Stern KL, Humphreys MR. Are adverse events during surgery for benign prostatic hyperplasia device related? A review of the MAUDE database. Urologia 2024:3915603241240646. [PMID: 38520298 DOI: 10.1177/03915603241240646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
PURPOSE The Manufacturer and User Facility Device Experience database contains anonymous, voluntary medical device reports. A review of device-related adverse events associated with Benign Prostatic Hyperplasia surgeries was completed. The objective was to evaluate the occurrence and contributing factors to clinically significant complications in a cohort of patients electing to undergo surgical intervention for Benign Prostatic Hyperplasia. METHODS The Manufacturer and User Facility Device Experience database was queried for "Aquablation, Greenlight Laser, Holmium Laser, Morcellator, Water Vapor Thermal Therapy, Loop Resection, and Prostatic Urethral Lift" from 2018 through 2021. A complication classification system (Level I-IV) based on the Clavien-Dindo system was used to categorize events. These events were then correlated with procedural technology malfunctions and classified as "device related" and "non-device related." Chi squared analysis was performed to identify associations between procedural technology and complication classification distribution. RESULTS A total of 873 adverse events were identified. The adverse events were classified into level I (minimal harm) versus levels II-IV (clinically significant). Aquablation (p < 0.017) and Water Vapor Thermal Therapy (p < 0.012) were associated with a higher proportion of reports with Level II-IV complications compared with other procedure types. Level II-IV complications were not associated with a reported device related malfunction. CONCLUSIONS Aquablation and water vapor thermal therapy demonstrated noteworthy clinically significant complications which were not driven by device-related malfunctions.
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Affiliation(s)
| | - Ethan Nethery
- Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, VA, USA
| | - Kevin M Wymer
- Department of Urology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Karen L Stern
- Department of Urology, Mayo Clinic, Phoenix, AZ, USA
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Heidenberg DJ, Choudry MM, Wymer K, Stagg J, Parker N, Campagna J, Narang G, Humphreys MR, Cheney SM. The Impact of Standard vs Early Apical Release Holmium Laser Enucleation of the Prostate Technique on Postoperative Incontinence and Quality of Life. Urology 2024:S0090-4295(24)00156-0. [PMID: 38492757 DOI: 10.1016/j.urology.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/11/2024] [Accepted: 03/05/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE To investigate the difference in postoperative incontinence and quality of life comparing standard vs early apical release (EAR) Holmium Laser Enucleation of the Prostate (HoLEP). METHODS A retrospective review was performed to identify patients who underwent HoLEP from December 2021 to December 2022 at a single tertiary referral center with two participating consultant urologists. Patients were assessed with questionnaires and evaluated clinically. We performed propensity score matching with a logistic regression and a 1:1 matching method. A propensity score-adjusted logistic regression (PSRM) was performed to compare the pads per day between surgical techniques controlling for age, prostate size, preoperative survey data, uroflow, and postvoid residual. RESULTS One hundred fourteen patients underwent HoLEP, of which 60 patients were treated with EAR and 54 patients with standard technique. EAR technique demonstrated shorter operative times (P = .046). The EAR cohort demonstrated improved AUASS (P = .034, P = .001), QOL (P = .001, P <.001), and continence rates (P <.001, P <.001) at 6 and 12weeks postoperatively. PSRM showed that the standard HoLEP increased the risk of requiring ≥2 pads per day 4.2x (P = .031, HR 95%, CI=1.16, 15.35) and 8.3x (P <.001, HR 95% CI 3.17, 21.6) at 6 and 12weeks postoperatively. CONCLUSION EAR technique promoted earlier return of continence and improved quality of life within 6weeks of surgery.
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Affiliation(s)
| | | | - Kevin Wymer
- Department of Urology, Mayo Clinic, Rochester, MN
| | | | | | | | - Gopal Narang
- Department of Urology, University of North Carolina, Chapel Hill, NC
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Nakai H, Nagayama H, Takahashi H, Froemming AT, Kawashima A, Bolan CW, Adamo DA, Carter RE, Fazzio RT, Tsuji S, Lomas DJ, Mynderse LA, Humphreys MR, Dora C, Takahashi N. Cancer Detection Rate and Abnormal Interpretation Rate of Prostate MRI in Patients With Low-Grade Cancer. J Am Coll Radiol 2024; 21:387-397. [PMID: 37838189 DOI: 10.1016/j.jacr.2023.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 10/16/2023]
Abstract
PURPOSE The aim of this study was to evaluate the utility of cancer detection rate (CDR) and abnormal interpretation rate (AIR) in prostate MRI for patients with low-grade prostate cancer (PCa). METHODS This three-center retrospective study included patients who underwent prostate MRI from 2017 to 2021 with known low-grade PCa (Gleason score 6) without prior treatment. Patient-level highest Prostate Imaging Reporting & Data System (PI-RADS®) score and pathologic diagnosis within 1 year after MRI were used to evaluate the diagnostic performance of prostate MRI in detecting clinically significant PCa (csPCa; Gleason score ≥ 7). The metrics AIR, CDR, and CDR adjusted for pathologic confirmation rate were calculated. Radiologist-level AIR-CDR plots were shown. Simulation AIR-CDR lines were created to assess the effects of different diagnostic performances of prostate MRI and the prevalence of csPCa. RESULTS A total of 3,207 examinations were interpreted by 33 radiologists. Overall AIR, CDR, and CDR adjusted for pathologic confirmation rate at PI-RADS 3 to 5 (PI-RADS 4 and 5) were 51.7% (36.5%), 22.1% (18.8%), and 30.7% (24.6%), respectively. Radiologist-level AIR and CDR at PI-RADS 3 to 5 (PI-RADS 4 and 5) were in the 36.8% to 75.6% (21.9%-57.5%) range and the 16.3%-28.7% (10.9%-26.5%) range, respectively. In the simulation, changing parameters of diagnostic performance or csPCa prevalence shifted the AIR-CDR line. CONCLUSIONS The authors propose CDR and AIR as performance metrics in prostate MRI and report reference performance values in patients with known low-grade PCa. There was variability in radiologist-level AIR and CDR. Combined use of AIR and CDR could provide meaningful feedback for radiologists to improve their performance by showing relative performance to other radiologists.
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Affiliation(s)
| | - Hiroki Nagayama
- Department of Radiology, Mayo Clinic, Rochester, Minnesota; Department of Radiology, Nagasaki University School of Medicine, Nagasaki, Japan
| | | | - Adam T Froemming
- Division Chair of Abdominal Imaging, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Candice W Bolan
- Chief, Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Daniel A Adamo
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Rickey E Carter
- Vice Chair, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida
| | - Robert T Fazzio
- Division Chair of Breast Imaging, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Derek J Lomas
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Chandler Dora
- Department of Urology, Mayo Clinic, Jacksonville, Florida
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Nagayama H, Nakai H, Takahashi H, Froemming AT, Kawashima A, Bolan CW, Adamo DA, Carter RE, Fazzio RT, Tsuji S, Lomas DJ, Mynderse LA, Humphreys MR, Dora C, Takahashi N. Cancer Detection Rate and Abnormal Interpretation Rate of Prostate MRI Performed for Clinical Suspicion of Prostate Cancer. J Am Coll Radiol 2024; 21:398-408. [PMID: 37820833 DOI: 10.1016/j.jacr.2023.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE To report cancer detection rate (CDR) and abnormal interpretation rate (AIR) in prostate MRI performed for clinical suspicion of prostate cancer (PCa). MATERIALS AND METHODS This retrospective single-institution, three-center study included patients who underwent MRI for clinical suspicion of PCa between 2017 and 2021. Patients with known PCa were excluded. Patient-level Prostate Imaging-Reporting and Data System (PI-RADS) score was extracted from the radiology report. AIR was defined as number of abnormal MRI (PI-RADS score 3-5) / total number of MRIs. CDR was defined as number of clinically significant PCa (csPCa: Gleason score ≥7) detected at abnormal MRI / total number of MRI. AIR, CDR, and CDR adjusted for pathology confirmation rate were calculated for each of three centers and pre-MRI biopsy status (biopsy-naive and previous negative biopsy). RESULTS A total of 9,686 examinations (8,643 unique patients) were included. AIR, CDR, and CDR adjusted for pathology confirmation rate were 45.4%, 23.8%, and 27.6% for center I; 47.2%, 20.0%, and 22.8% for center II; and 42.3%, 27.2%, and 30.1% for center III, respectively. Pathology confirmation rate ranged from 81.6% to 88.0% across three centers. AIR and CDR for biopsy-naive patients were 45.5% to 52.6% and 24.2% to 33.5% across three centers, respectively, and those for previous negative biopsy were 27.2% to 39.8% and 11.7% to 14.2% across three centers, respectively. CONCLUSION We reported CDR and AIR in prostate MRI for clinical suspicion of PCa. CDR needs to be adjusted for pathology confirmation rate and pre-MRI biopsy status for interfacility comparison.
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Affiliation(s)
- Hiroki Nagayama
- Department of Radiology, Mayo Clinic, Rochester, Minnesota; Department of Radiology, Nagasaki University School of Medicine, Nagasaki, Japan
| | | | | | - Adam T Froemming
- Division Chair of the Abdominal Imaging in Minnesota, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Candice W Bolan
- Chief, Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Daniel A Adamo
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Rickey E Carter
- Vice Chair, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida
| | - Robert T Fazzio
- Division Chair of the Breast Imaging, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Derek J Lomas
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Chandler Dora
- Department of Urology, Mayo Clinic, Jacksonville, Florida
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Wymer KM, Boddu SP, Choudry M, Narang G, Heidenberg DJ, Payne NG, Girardo M, Humphreys MR, Stern KL. Access to Care and Health Care Utilization Among Patients With Nephrolithiasis. Urology 2024:S0090-4295(24)00097-9. [PMID: 38432429 DOI: 10.1016/j.urology.2023.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/12/2023] [Accepted: 11/28/2023] [Indexed: 03/05/2024]
Abstract
OBJECTIVE To characterize the impact of nephrolithiasis diagnosis and treatment on health care utilization and identify predictors of barriers to care in the patient population. METHODS We conducted a retrospective cohort study using the All of Us Database, a National Institutes of Health database targeting recruitment of underrepresented populations. Patients with a diagnosis of kidney stones were included and matched to a control group. Primary outcomes were patients' self-reported health care access and utilization. Univariable and multivariable regression analyses were performed. RESULTS 9173 patients with a diagnosis of nephrolithiasis were included and matched to 9173 controls without a diagnosis of nephrolithiasis. Patients with kidney stones were less likely to have had >1 year since last provider visit (1.7% vs 3.8%, P <.001), but did not report increased delays obtaining care (31%), inability to afford care (11.4%), or higher likelihood of skipping medications (12.9%). Among patients with stones, 1208 (13.2%) had been treated surgically. On multivariable analysis, younger age, female sex, lower income, lower education, non-insured status, and lower physical and mental health were all associated with delays obtaining care, difficulty affording care, skipping medications, and/or prolonged time since seeing a provider. CONCLUSION A diagnosis of nephrolithiasis and subsequent surgical intervention were not associated with an increase in patient-reported barriers to care. However, among patients with nephrolithiasis, younger, comorbid, female patients from lower socioeconomic status are at significant risk of being unable to access and utilize treatment.
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Affiliation(s)
| | - Sayi P Boddu
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ.
| | | | - Gopal Narang
- Department of Urology, University of North Carolina, Chapel Hill, NC.
| | | | | | - Marlene Girardo
- Mayo Clinic Department of Qualitative Health Sciences, Scottsdale, AZ.
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Wymer KM, Thao V, Narang G, Sharma V, Borah BJ, Cheney S, Humphreys MR. Evaluation of Private Payer and Patient Out-of-Pocket Costs Associated With the Surgical Management of Benign Prostatic Hyperplasia. Urology 2024; 184:87-93. [PMID: 38065310 DOI: 10.1016/j.urology.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/28/2023] [Accepted: 10/14/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE To evaluate and compare the financial burden of various surgical interventions for the management of benign prostatic hyperplasia (BPH). METHODS We identified commercially insured men with a diagnosis of BPH who underwent a procedure of interest (simple prostatectomy (SP), transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), photovaporization of the prostate (PVP), prostatic urethral lift (PUL), or water vapor thermal therapy (WVTT)) between 2015 and 2021 with the OptumLabs Data Warehouse. Primary outcome was total health care costs (THC) which included both patient out-of-pocket (OOP) and health plan paid costs for the index procedure and combined follow-up years 1-5. A generalized linear model was used to estimate adjusted costs controlling for demographic and clinical characteristics. Patients undergoing WVTT were excluded from extended follow-up analyses due to limited data. RESULTS Among 25,407 patients with BPH, 10,117 (40%) underwent TURP, 6353 (25%) underwent PUL, 5411 (21%) underwent PVP, 1319 (5%) underwent SP, 1243 (5%) underwent WVTT, and 964 (4%) underwent HoLEP. Index procedure costs varied significantly with WVTT being the least costly [THC: $2637 (95% confidence interval (CI): $2513-$2761)], and SP being the costliest [THC: $14,423 (95% CI: $12,772-$16,075)]. For aggregate index and 5-year follow-up costs, HoLEP ($31,926 [95% CI: $29,704-$34,148]) was the least costly and PUL ($36,596 [95% CI: $35,369-37,823]) was the costliest. CONCLUSION BPH surgical treatment is associated with significant system-level health care costs. The level of impact varies between procedures. Minimally invasive options, such as WVTT, may offer initial cost reductions; however, HoLEP and SP are associated with lower follow-up costs.
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Affiliation(s)
- Kevin M Wymer
- Department of Urology, Mayo Clinic, Rochester, MN; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN.
| | - Viengneesee Thao
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
| | - Gopal Narang
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Bijan J Borah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
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7
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Narang GL, Rojanasarot S, Cutone B, Humphreys MR. Is Race Associated with the Surgical Treatment for Benign Prostatic Hyperplasia? An Analysis of 30,000 Medicare Lives. J Racial Ethn Health Disparities 2024; 11:528-534. [PMID: 37095287 PMCID: PMC10781854 DOI: 10.1007/s40615-023-01538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUNDS With an increased prevalence and burden of benign prostatic hyperplasia (BPH), effective and equitable treatment is a priority. Limited data exist evaluating treatment disparities for patients with BPH by race. This study examined the association between race and BPH surgical treatment rates among Medicare beneficiaries. METHODS Medicare claims data were used to identify men newly diagnosed with BPH from January 1, 2010 through December 31, 2018. Patients were followed until their first BPH surgery, a diagnosis of prostate/bladder cancer, termination of Medicare enrollment, death, or end of study. Cox proportional hazards regression compared the likelihood of BPH surgery between men of different races (White vs. Black, Indigenous, and People of Color (BIPOC)), controlling for patients' geographical region, Charlson comorbidity score, and baseline comorbidities. RESULTS The study included 31,699 patients (13.7% BIPOC). BIPOC men had significantly lower BPH surgery rates (9.5% BIPOC vs. 13.4% White; p=0.02). BIPOC race was associated with a 19% lower likelihood of receiving BPH surgery than White race (HR, 0.81; 95% CI 0.70, 0.94). Transurethral resection of the prostate was the most common surgery for both groups (49.4% Whites vs. 56.8% BIPOC; p=0.052). A higher proportion of BIPOC men underwent procedures in inpatient settings compared to White men (18.2% vs. 9.8%; p<0.001). CONCLUSIONS Among a cohort of Medicare beneficiaries with BPH, there were notable treatment disparities by race. BIPOC men had lower rates of surgery than White men and were more likely to undergo procedures in the inpatient setting. Improving patient access to outpatient BPH surgical procedures may help address treatment disparities.
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Durant AM, Whitney MA, Chang YHH, Larson MA, Shah PH, Lyon TD, Humphreys MR, Etzioni DA, Tyson MD. Surgical Site Infections in Open and Laparoscopic Operations in Rooms With Open-floor Drainage Systems. Urol Pract 2023; 10:622-629. [PMID: 37498642 DOI: 10.1097/upj.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/30/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Surgical site infections are common postoperative complications. Some operating rooms have open-floor drainage systems for fluid disposal during endourologic cases, although nonendoscopy cases are not always allowed in these rooms. We hypothesized that operating rooms with open-floor drainage systems would not materially affect risk of surgical site infections for patients undergoing open and laparoscopic procedures. METHODS Patients who had surgical site infections from 2016 through 2020 were identified from data of the National Surgical Quality Improvement Program. Patients without surgical incisions, with open wounds, and with surgical site infections at surgery were excluded. The primary outcome was surgical site infection occurrence within 30 days of surgery. Multilevel multivariable logistic regression was used to estimate the observed-to-expected surgical site infection ratio for each operating room (2 with and 23 without open-floor drainage systems). RESULTS We identified 8,419 surgical cases, of which 802 (9.5%) were performed in operating rooms with open-floor drainage systems; 166 patients (2.0%) had surgical site infections. Of the surgical site infections, 7 (4.2%) occurred in operating rooms with open-floor drainage systems. Surgical specialty, American Society of Anesthesiologists physical status, higher case acuity, dyspnea, immunosuppression, longer surgical duration, and wound classification were associated with surgical site infections (P < .05 for all). The observed-to-expected ratios of surgical site infections occurring in the 2 operating rooms with open-floor drainage systems were 0.85 and 1.15. The odds ratio of surgical site infections for urologic cases performed in room with vs without open-floor drainage systems was 1.30 (P = .65). CONCLUSIONS Urology operating room designs often include open-floor drainage systems for water-based cases. These drainage systems were not associated with an increased risk of surgical site infections.
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Affiliation(s)
- Adri M Durant
- Department of Urology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona
| | - Madeline A Whitney
- Student, Mayo Clinic Alix School of Medicine-Arizona campus, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona
| | - Yu-Hui H Chang
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | | | - Paras H Shah
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Timothy D Lyon
- Department of Urology, Mayo Clinic, Jacksonville, Florida
| | | | | | - Mark D Tyson
- Department of Urology, Mayo Clinic, Phoenix, Arizona
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Nakai H, Takahashi H, Adamo DA, LeGout JD, Kawashima A, Thomas JV, Froemming AT, Kuanar S, Lomas DJ, Humphreys MR, Dora C, Takahashi N. Decreased prostate MRI cancer detection rate due to moderate to severe susceptibility artifacts from hip prosthesis. Eur Radiol 2023:10.1007/s00330-023-10345-4. [PMID: 37889268 DOI: 10.1007/s00330-023-10345-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/15/2023] [Accepted: 08/24/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVES To evaluate the impact of susceptibility artifacts from hip prosthesis on cancer detection rate (CDR) in prostate MRI. MATERIALS AND METHODS This three-center retrospective study included prostate MRI studies for patients without known prostate cancer between 2017 and 2021. Exams with hip prosthesis were searched on MRI reports. The degree of susceptibility artifact on diffusion-weighted images was retrospectively categorized into mild, moderate, and severe (> 66%, 33-66%, and < 33% of the prostate volume are evaluable) by blind reviewers. CDR was defined as the number of exams with Gleason score ≥7 detected by MRI (PI-RADS ≥3) divided by the total number of exams. For each artifact grade, control exams without hip prosthesis were matched (1:6 match), and CDR was compared. The degree of CDR reduction was evaluated with ratio, and influential factors were evaluated by expanding the equation. RESULTS Hip arthroplasty was present in 548 (4.8%) of the 11,319 MRI exams. CDR of the cases and matched control exams for each artifact grade were as follows: mild (n = 238), 0.27 vs 0.25, CDR ratio = 1.09 [95% CI: 0.87-1.37]; moderate (n = 143), 0.18 vs 0.27, CDR ratio = 0.67 [95% CI: 0.46-0.96]; severe (n = 167), 0.22 vs 0.28, CDR ratio = 0.80 [95% CI: 0.59-1.08]. When moderate and severe artifact grades were combined, CDR ratio was 0.74 [95% CI: 0.58-0.93]. CDR reduction was mostly attributed to the increased frequency of PI-RADS 1-2. CONCLUSION With moderate to severe susceptibility artifacts from hip prosthesis, CDR was decreased to 74% compared to the matched control. CLINICAL RELEVANCE STATEMENT Moderate to severe susceptibility artifacts from hip prosthesis may cause a non-negligible CDR reduction in prostate MRI. Expanding indications for systematic prostate biopsy may be considered when PI-RADS 1-2 was assigned. KEY POINTS • We proposed cancer detection rate as a diagnostic performance metric in prostate MRI. • With moderate to severe susceptibility artifacts secondary to hip arthroplasty, cancer detection rate decreased to 74% compared to the matched control. • Expanding indications for systematic prostate biopsy may be considered when PI-RADS 1-2 is assigned.
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Affiliation(s)
| | | | - Daniel A Adamo
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | | | - John V Thomas
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Shiba Kuanar
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Derek J Lomas
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | | | - Chandler Dora
- Department of Urology, Mayo Clinic, Jacksonville, FL, USA
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Nguyen MV, Berger JH, Flores AR, Chen TT, Yared J, Pais V, Chew B, Humphreys MR, Stern KL, Sur RL. Case series - Liver injury during percutaneous nephrolithotomy. Can Urol Assoc J 2023; 17:E297-E301. [PMID: 37458736 PMCID: PMC10544404 DOI: 10.5489/cuaj.8291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Affiliation(s)
- Mimi V. Nguyen
- University of California San Diego School of Medicine, San Diego, CA, United States
| | - Jonathan H. Berger
- Department of Urology, University of California San Diego, La Jolla, CA, United States
| | - Alec R. Flores
- University of California San Diego School of Medicine, San Diego, CA, United States
| | - Tony T. Chen
- Department of Urology, University of California San Diego, La Jolla, CA, United States
| | - Joseph Yared
- Department of Urology, Dartmouth-Hitchcock, Lebanon, NH, United States
| | - Vernon Pais
- Department of Urology, Dartmouth-Hitchcock, Lebanon, NH, United States
| | - Benjamin Chew
- Department of Urology, University of British Columbia, Vancouver, BC, Canada
| | | | - Karen L. Stern
- Department of Urology, Mayo Clinic, Scottsdale, AZ, United States
| | - Roger L. Sur
- Department of Urology, University of California San Diego, La Jolla, CA, United States
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Rose KM, Murray KS, Labbate C, Woldu S, Linehan J, Jacob J, Kaimakliotis H, Dickstein R, Feldman A, Matin SF, Lotan Y, Humphreys MR, Sexton WJ. Mitomycin Gel (UGN-101) as a Kidney-sparing Treatment for Upper Tract Urothelial Carcinoma in Patients with Imperative Indications and High-grade Disease. Eur Urol Focus 2023; 9:807-812. [PMID: 37059620 DOI: 10.1016/j.euf.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/24/2023] [Accepted: 03/23/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Intracavitary UGN-101 is approved for the treatment of low-grade noninvasive upper tract urothelial carcinoma (UTUC). Post-commercialization studies underscore the benefit of UGN-101 administration for patients with imperative indications for whom radical nephroureterectomy (RNU) is not a viable option. OBJECTIVE To describe the use, efficacy, and safety of UGN-101 in patients with UTUC with imperative indications for renal preservation, including high-grade disease. DESIGN, SETTING, AND PARTICIPANTS Patients receiving UGN-101 with imperative indications were retrospectively analyzed using a multicenter centralized registry from 15 high-volume academic and community centers. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We defined imperative indications as patients with a solitary kidney, the presence of chronic kidney disease (CKD) with a glomerular filtration rate <30 ml/min, bilateral UTUC, and patients unfit for or unwilling to undergo surgical extirpation. Tumor characteristics, disease progression/recurrence, and adverse events were recorded on a per-renal-unit basis. RESULTS AND LIMITATIONS UGN-101 was instilled into 52 renal units (38%) in 48 patients for imperative indications, including 29 patients (56%) with a solitary kidney, 11 kidneys (21%) in the setting of bilateral UTUC, six patients (12%) with CKD, and six patients (12%) who were unfit for or unwilling to undergo RNU. Twelve renal units had biopsy-proven high-grade papillary disease. Tumors were completely ablated before induction therapy in 34% of cases, while 66% had tumor present. Following induction therapy, 17 patients (40%) had no evidence of disease (NED) on ureteroscopy, 88% of whom maintained this status at median follow-up of 10.8 mo. In the cohort with high-grade disease, five patients (45%) had NED at initial post-induction primary disease evaluation. Adverse events included pyelonephritis (8%), ureteral stenosis (8%), anemia (6%), and acute renal failure (4%). Limitations include the retrospective study design, the lack of long-term follow up, and patient selection bias. CONCLUSIONS Intracavitary therapy with UGN-101 in patients with UTUC and imperative indications shows promise as a kidney-sparing treatment modality. While long-term follow-up is needed, this intracavitary treatment may help in prolonging time to RNU and delaying the morbidity of hemodialysis in this comorbid population. PATIENT SUMMARY We reviewed results for patients with cancer in the upper urinary tract and an additional condition that would not allow kidney removal who received treatment with a gel called UGN-101. Our results suggest that UGN-101 shows promise as a kidney-sparing treatment. It may delay the time until kidney removal is needed in these patients and avoid the negative effects associated with dialysis.
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Affiliation(s)
- Kyle M Rose
- H. Lee Moffitt Cancer Center, Tampa, FL, USA.
| | | | - Craig Labbate
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Solomon Woldu
- The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Joseph Jacob
- SUNY Upstate Medical University, Syracuse, NY, USA
| | | | | | | | - Surena F Matin
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yair Lotan
- The University of Texas Southwestern Medical Center, Dallas, TX, USA
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12
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Gerrity JJ, Berger J, Hsi R, Friedlander DF, Stern KL, Chew BH, Nimmagadda N, Kavoussi N, Chen TT, Krambeck AE, Large T, Bechis S, Monga M, Miller N, Lange D, Knudsen BE, Sourial MW, Humphreys MR, Shah O, Abbott JE, Abedi G, Sur RL. Quick Sequential Organ Failure Assessment (qSOFA) Score is a Better Predictor of Septic Shock after Percutaneous Nephrolithotomy: A secondary analysis of Two Multi-Center Prospective Trials. J Endourol 2023. [PMID: 37294208 DOI: 10.1089/end.2022.0677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
INTRODUCTION Recent retrospective literature suggests that the quick sequential organ failure assessment scoring (qSOFA) tool is a potentially superior tool over use of the systemic inflammatory response syndrome criteria (SIRS) to predict septic shock after percutaneous nephrolithotomy (PCNL) surgery. Here we examine use of qSOFA and SIRS to predict septic shock within data series collected prospectively on PCNL patients as part of a greater study of infectious complications. MATERIALS AND METHODS We performed a secondary analysis of two prospective multicenter studies including PCNL patients across nine institutions. Clinical signs informing SIRS and qSOFA scores were collected no later than post-operative day one. The primary outcome was sensitivity and specificity of SIRS and qSOFA (high risk score of greater-or-equal to 2 points) in predicting admission to the intensive care unit (ICU) for vasopressor support. RESULTS A total of 218 cases at nine institutions were analyzed. One patient required vasopressor support in the ICU. The sensitivity/specificity was 100%/72.4% (McNemar's test p < 0.001) for SIRS and was 100%/90.8% (McNemar's test p < 0.001) for qSOFA. CONCLUSION Although PPV for both qSOFA and SIRS in prediction of post-PCNL septic shock is low, prospectively collected data demonstrates use of qSOFA may offer greater specificity than SIRS criteria when predicting post-PCNL septic shock.
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Affiliation(s)
- Jillian J Gerrity
- University of California San Diego School of Medicine, 12220, La Jolla, California, United States;
| | - Jonathan Berger
- UC San Diego, 8784, Urology, San Diego, California, United States;
| | - Ryan Hsi
- Vanderbilt University Medical Center, 12328, Urology, 1161 21st Ave South, Nashville, Tennessee, United States, 37232;
| | - David F Friedlander
- The University of North Carolina at Chapel Hill, 2331, Chapel Hill, North Carolina, United States;
| | - Karen Lynne Stern
- Mayo Clinic Hospital, 23386, Urology, Phoenix, Arizona, United States;
| | - Ben H Chew
- University of British Columbia, Urologic Sciences, Level 6, 2775 Laurel st., Level 6 - 2775 Laurel St, Vancouver, British Columbia, Canada, V5Z 1M9
- University of British Columbia, 8166, Urologic Sciences, 2775 Laurel St, Level 6, Vancouver, British Columbia, Canada, V5Z 1M9;
| | - Naren Nimmagadda
- Vanderbilt University Medical Center, 12328, Urology, 1161 21st Ave. South, A-1302 Medical Center North, Nashville, Tennessee, United States, 37232;
| | - Nicholas Kavoussi
- Vanderbilt University Medical Center, 12328, Urology, 1211 Medical Center Drive, Nashville, Tennessee, United States, 37323;
| | - Tony T Chen
- UC San Diego, 8784, Urology, San Diego, California, United States;
| | - Amy E Krambeck
- Northwestern University School of Medicine, Department of Urology, Chicago, Illinois, United States;
| | - Tim Large
- Indiana University School of Medicine, 12250, Urology, 1801 N Senate Blvd, Suite 220, Indianapolis, Indiana, United States, 46202;
| | - Seth Bechis
- UC San Diego, 8784, Urology, San Diego, California, United States;
| | - Manoj Monga
- University of California San Diego, 8784, Urology, 200 w arbor dr, San Diego, California, United States, 92103;
| | - Nicole Miller
- Vanderbilt University Medical Center, 12328, Urology, A-1302 MCN, Nashville, Tennessee, United States, 37232;
| | - Dirk Lange
- University of British Columbia, 8166, Urologic Sciences, Jack Bell Research Centre, Rm 550-3, Vancouver, British Columbia, Canada, V6H 3Z6;
| | - Bodo E Knudsen
- Ohio State University Medical Center, Department of Surgery, Division of Urology, 4833 University Hospitals Clinic, 456 West 10th Avenue, 915 Olentangy River Road, Columbus, Ohio, United States, 43212;
| | - Michael W Sourial
- Ohio State University Wexner Medical Center, 12306, Department of Urology, 915 Olentangy River Road, Suite 3100, Columbus, Ohio, United States, 43212;
| | - Mitchell R Humphreys
- Mayo Clinic, Department of Urology, 5777 E Mayo Blvd, Phoenix, Arizona, United States, 85054
- Indiana, United States;
| | - Ojas Shah
- Columbia University College of Physicians and Surgeons, 12294, Urology, 161 Fort Washington Avenue, 11th Floor, New York, New York, United States, 10032;
| | - Joel E Abbott
- Pacific West Urology, Las Vegas, Nevada, United States;
| | - Garen Abedi
- UC San Diego, 8784, Urology, San Diego, California, United States;
| | - Roger L Sur
- UC San Diego, 8784, Urology, Department of Urology, 200 Arbor Drive #8897, San Diego, California, United States, 92130
- UC San Diego, 8784, Roger Sur, Department of Urology, 200 Arbor Drive #8897, San Diego, California, United States, 92130;
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13
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Wong VKF, Que J, Kong EK, Abedi G, Nimmagadda N, Emmott AS, Paterson RF, Lange D, Lundeen CJ, Nevo A, Shee K, Moore J, Pais V, Sur RL, Bechis SK, Miller NL, Hsi R, Knudsen BE, Sourial M, Humphreys MR, Stern KL, Eisner BH, Chew BH. The Fate of Residual Fragments After Percutaneous Nephrolithotomy: Results from the Endourologic Disease Group for Excellence Research Consortium. J Endourol 2023; 37:617-622. [PMID: 36960704 DOI: 10.1089/end.2022.0561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
Background: Residual fragments (RFs) after percutaneous nephrolithotomy (PCNL) have a significant impact on patients' quality of life and clinical course. There is a paucity of studies that evaluate the natural history of RFs after PCNL. The objective of this study is to compare rates of reintervention, complications, stone growth, and passage in patients with RFs >4, ≤4, and ≤2 mm after PCNL. Methods: Sites from the Endourologic Disease Group for Excellence (EDGE) research consortium examined data of PCNL patients from 2015 to 2019 with at least 1-year follow-up. RF passage, regrowth, reintervention, and complications were recorded and RFs were stratified into >4 and ≤4 mm groups, as well as >2 and ≤2 mm groups. Potential predictors for stone-related events after PCNL were determined using multivariable logistic regression analysis. It was hypothesized that larger RF thresholds would result in lower passage rates, faster regrowth, and greater clinically significant events (complications and reinterventions) than smaller RF thresholds. Results: A total of 439 patients with RFs >1 mm on CT postoperative day 1 were included in this study. For RFs >4 mm, rates of reintervention were found to be significantly higher and Kaplan-Meier curve analysis showed significantly higher rates of stone-related events. Passage and RF regrowth were not found to be significantly different compared with RFs ≤4 mm. However, RFs ≤2 mm had significantly higher rates of passage, and significantly lower rates of fragment regrowth (>1 mm), complications, and reintervention compared with RFs >2 mm. On multivariable analysis, older age, body mass index, and RF size were found to be predictive of stone-related events. Conclusions: With the largest cohort to date, this study by the EDGE research consortium further confirms that clinically insignificant residual fragment is problematic for patients after PCNL, particularly in older more obese patients with larger RFs. Our study underscores the importance of complete stone clearance post-PCNL and challenges the use of Clinically insignificant residual fragment (CIFR).
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Affiliation(s)
- Victor K F Wong
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jessica Que
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emily K Kong
- Department of Urology, University of California San Diego, San Diego, California, USA
| | - Garen Abedi
- Department of Urology, University of California San Diego, San Diego, California, USA
| | | | - Anthony S Emmott
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ryan F Paterson
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dirk Lange
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Colin J Lundeen
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amihay Nevo
- Department of Urology, Ohio State University, Columbus, Ohio, USA
| | - Kevin Shee
- Department of Urology, Dartmouth College, Hanover, New Hampshire, USA
| | - Jonathan Moore
- Department of Urology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Vernon Pais
- Department of Urology, Dartmouth College, Hanover, New Hampshire, USA
| | - Roger L Sur
- Department of Urology, University of California San Diego, San Diego, California, USA
| | - Seth K Bechis
- Department of Urology, University of California San Diego, San Diego, California, USA
| | - Nicole L Miller
- Department of Urology, Vanderbilt, Nashville, Tennessee, USA
| | - Ryan Hsi
- Department of Urology, Vanderbilt, Nashville, Tennessee, USA
| | - Bodo E Knudsen
- Department of Urology, Ohio State University, Columbus, Ohio, USA
| | - Michael Sourial
- Department of Urology, Ohio State University, Columbus, Ohio, USA
| | | | - Karen L Stern
- Department of Urology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Brian H Eisner
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ben H Chew
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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14
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El Khoury LY, Pan X, Hlady RA, Wagner RT, Shaikh S, Wang L, Humphreys MR, Castle EP, Stanton ML, Ho TH, Robertson KD. Extensive intratumor regional epigenetic heterogeneity in clear cell renal cell carcinoma targets kidney enhancers and is associated with poor outcome. Clin Epigenetics 2023; 15:71. [PMID: 37120552 PMCID: PMC10149001 DOI: 10.1186/s13148-023-01471-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/21/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND Clear cell renal cell cancer (ccRCC), the 8th leading cause of cancer-related death in the US, is challenging to treat due to high level intratumoral heterogeneity (ITH) and the paucity of druggable driver mutations. CcRCC is unusual for its high frequency of epigenetic regulator mutations, such as the SETD2 histone H3 lysine 36 trimethylase (H3K36me3), and low frequency of traditional cancer driver mutations. In this work, we examined epigenetic level ITH and defined its relationships with pathologic features, aspects of tumor biology, and SETD2 mutations. RESULTS A multi-region sampling approach coupled with EPIC DNA methylation arrays was conducted on a cohort of normal kidney and ccRCC. ITH was assessed using DNA methylation (5mC) and CNV-based entropy and Euclidian distances. We found elevated 5mC heterogeneity and entropy in ccRCC relative to normal kidney. Variable CpGs are highly enriched in enhancer regions. Using intra-class correlation coefficient analysis, we identified CpGs that segregate tumor regions according to clinical phenotypes related to tumor aggressiveness. SETD2 wild-type tumors overall possess greater 5mC and copy number ITH than SETD2 mutant tumor regions, suggesting SETD2 loss contributes to a distinct epigenome. Finally, coupling our regional data with TCGA, we identified a 5mC signature that links regions within a primary tumor with metastatic potential. CONCLUSION Taken together, our results reveal marked levels of epigenetic ITH in ccRCC that are linked to clinically relevant tumor phenotypes and could translate into novel epigenetic biomarkers.
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Affiliation(s)
- Louis Y El Khoury
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Xiaoyu Pan
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Ryan A Hlady
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Ryan T Wagner
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Shafiq Shaikh
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Liguo Wang
- Division of Biomedical Statistics and Informatics, Department of Health Science Research, Mayo Clinic, Rochester, MN, USA
| | | | - Erik P Castle
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Melissa L Stanton
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, AZ, USA
| | - Thai H Ho
- Division of Hematology and Medical Oncology, Mayo Clinic Arizona, Scottsdale, AZ, USA.
| | - Keith D Robertson
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA.
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15
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Stern KL, Sur RL, Lim ES, Kong E, Wong KFV, Brar H, Moore J, Berger JH, Bechis SK, Monga M, Sivalingam S, Humphreys MR, Chew BH. Long-term follow-up on dusting versus basketing during ureteroscopy: a prospective multicenter trial from the EDGE Research Consortium. Urolithiasis 2023; 51:70. [PMID: 37061554 PMCID: PMC10105530 DOI: 10.1007/s00240-023-01439-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/25/2023] [Indexed: 04/17/2023]
Abstract
In 2018, the Endourology Disease Group for Excellence (EDGE) published a prospective trial comparing dusting versus basketing during ureteroscopy. One hundred fifty-nine patients were included in the original analysis, which found no difference in stone-free rate at 3 months. We report the intermediate and long-term outcomes of patients included in the original trial. Two analyses were performed. At 1-year, a retrospective chart review was performed, and data collected on stone episodes, Emergency Department (ED) visits, hospital admissions and surgical interventions. To obtain long-term outcomes, the four sites with the largest initial accrual were included in a second phase of data collection with updated analyses. The patients from those sites were contacted, re-consented, and data were collected on stone surgical interventions, stone episodes, stone recurrences on imaging, emergency department (ED) visits, and hospital admissions for stone-related care since their original procedure. One-year follow-up data were collected in 111 of the original 159 (69.8%) patients from the nine sites. There were no statistically significant differences in the number of painful episodes, ED visits, hospital admissions, or surgical interventions. 94 patients from four sites were included in the long-term analysis. There were no statistically significant differences in surgical interventions, painful stone episodes, stone recurrence on imaging, ED visits or hospitalizations for stone-related events between the two groups. Long-term outcomes of dusting versus basketing during ureteroscopy indicate that there are no significant differences in clinical outcomes between the two surgical modalities.
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Affiliation(s)
- Karen L Stern
- Department of Urology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Roger L Sur
- Department of Urology, University of California-San Diego, San Diego, CA, USA
| | - Elisabeth S Lim
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Emily Kong
- Department of Urology, University of California-San Diego, San Diego, CA, USA
| | - K F Victor Wong
- Department of Urology, University of British Columbia, Vancouver, BC, Canada
| | - Harmenjit Brar
- Department of Urology, Cleveland Clinic Foundation, Cleveland, OH, Canada
- , Fort Lauderdale, FL, USA
| | - Jonathan Moore
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Jonathan H Berger
- Department of Urology, University of California-San Diego, San Diego, CA, USA
| | - Seth K Bechis
- Department of Urology, University of California-San Diego, San Diego, CA, USA
| | - Manoj Monga
- Department of Urology, University of California-San Diego, San Diego, CA, USA
| | - Sri Sivalingam
- Department of Urology, Cleveland Clinic Foundation, Cleveland, OH, Canada
| | - Mitchell R Humphreys
- Department of Urology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Ben H Chew
- Department of Urology, University of British Columbia, Vancouver, BC, Canada
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16
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Rose KM, Narang G, Rosen G, Labatte C, Dumitrascu CI, Campagna J, Yu A, Manley BJ, Spiess PE, Li R, Adibi M, Murray KS, Sexton WJ, Humphreys MR. Antegrade administration of mitomycin gel for upper tract urothelial carcinoma via percutaneous nephrostomy tube: a multi-institutional retrospective cohort study. BJU Int 2023; 131:471-476. [PMID: 36285629 DOI: 10.1111/bju.15925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the safety profile of antegrade mitomycin gel instillation through a percutaneous nephrostomy tube (PCNT) for upper tract urothelial carcinoma (UTUC) with the aim of decreasing morbidity associated with therapy. PATIENTS AND METHODS Patients undergoing antegrade administration of mitomycin gel via PCNT were retrospectively included for analysis from four tertiary referral centres between 2020 and 2022. The primary outcome was safety profile, as graded by Common Terminology Criteria for Adverse Events (v5.0). Post-therapy disease burden was assessed by primary disease evaluation (PDE) via ureteroscopy. RESULTS Thirty-two patients received at least one dose of mitomycin gel via PCNT for UTUC, 29 of whom completed induction and underwent PDE. Thirteen patients (41%) had residual tumour present prior to induction therapy. At a median of 15.0 months following first dose of induction therapy, ureteric stenosis occurred in three patients (9%), all of whom were treated without later recurrence or chronic stenosis. Other adverse events included fatigue (27%), flank pain (19%), urinary tract infection (12%), sepsis (8%) and haematuria (8%). No patients had impaired renal function during follow-up and there were no treatment-related deaths. Seventeen patients (59%) had no evidence of disease at PDE and have not experienced recurrence at a median follow-up of 13.0 months post induction. CONCLUSIONS Administration of mitomycin gel via a PCNT offers a low rate of ureteric stenosis, demonstrates a favourable safety profile, and is administered without general anaesthesia.
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Affiliation(s)
- Kyle M Rose
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Gopal Narang
- Department of Urology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Geoffrey Rosen
- Division of Urology, Department of Surgery, University of Missouri, Columbia, MO, USA
| | - Craig Labatte
- Department of Urologic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Justin Campagna
- Department of Urology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Alice Yu
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Brandon J Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Phillippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Mehrad Adibi
- Department of Urologic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Katie S Murray
- Division of Urology, Department of Surgery, University of Missouri, Columbia, MO, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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17
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Narang G, Moore J, Wymer K, Chang YH, Lim E, Adeleye O, Humphreys MR, Stern KL. Effect of Cannabidiol Oil on Post-ureteroscopy Pain for Urinary Calculi: A Randomized, Double-blind, Placebo-controlled Trial. J Urol 2023; 209:726-733. [PMID: 36891837 DOI: 10.1097/ju.0000000000003139] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/20/2022] [Indexed: 03/10/2023]
Abstract
PURPOSE Post-ureteroscopy stent placement carries significant morbidity which can interfere with daily life. This discomfort unfortunately leads to high utilization of opioid pain medications, which have a known risk of addiction. Cannabidiol oil represents an alternative analgesic that has proven anti-inflammatory and antinociceptive effects. The purpose was to evaluate the effect of a Food and Drug Administration-approved cannabidiol oil (Epidiolex) on pain control and opioid usage in the post-ureteroscopy setting. MATERIALS AND METHODS This was a prospective, randomized, double-blind, placebo-controlled trial at a tertiary care center. Ninety patients undergoing ureteroscopy with stent placement for urinary stone disease were randomized 1:1 to placebo or 20 mg cannabidiol oil daily for 3 days postoperatively. Both groups were prescribed a rescue narcotic, tamsulosin, oxybutynin, and phenazopyridine. Daily pain scores, medication usage, and ureteral stent symptoms using the validated Ureteral Stent Symptom Questionnaire were recorded postoperatively. RESULTS Both the placebo and cannabidiol oil groups were not different in pre- and perioperative characteristics. There was no difference in pain scores or opioid usage between groups postoperatively. The level of discomfort with ureteral stents was also not different between groups when comparing physical activity, sleep, urination, and activities of daily life. CONCLUSIONS This randomized, blinded, placebo-controlled trial showed that cannabidiol oil is safe but ineffective when compared to placebo in reducing post-ureteroscopic stent discomfort or opioid usage. Despite the availability of numerous analgesic agents, stent symptoms continue to be a dissatisfier for most patients, suggesting additional work needs to focus on novel interventions and pain control.
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Affiliation(s)
- Gopal Narang
- Department of Urology, University of North Carolina, Chapel Hill, North Carolina
| | - Jonathan Moore
- Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kevin Wymer
- Department of Urology, Mayo Clinic Phoenix, Phoenix, Arizona
| | - Yu-Hui Chang
- Department of Quantitative Health Sciences, Mayo Clinic Scottsdale, Scottsdale, Arizona
| | - Elisabeth Lim
- Department of Quantitative Health Sciences, Mayo Clinic Scottsdale, Scottsdale, Arizona
| | | | | | - Karen L Stern
- Department of Urology, Mayo Clinic Phoenix, Phoenix, Arizona
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18
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Nevo A, Cheney SM, Callegari M, Moore JP, Stern KL, Zell MA, Abdul-Muhsin H, Humphreys MR. Median lobe vs. complete gland holmium laser enucleation of the prostate: A propensity score matching. Can Urol Assoc J 2023; 17:E39-E43. [PMID: 36121884 PMCID: PMC9872827 DOI: 10.5489/cuaj.7890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Benign prostatic hyperplasia (BPH) is a common condition affecting aging men. While holmium laser enucleation of the prostate (HoLEP) is one of the most effective treatments for BPH, variations of the procedure, such as median lobe HoLEP (MLHoLEP), are rarely reported. Here, we report our institution's experience with partial HoLEP. METHODS Our institutional prospective database was queried for patients having undergone median or individual lateral lobe enucleation between 2007 and 2018. A control cohort of patients who underwent standard HoLEP (sHoLEP) was identified using 1:2 propensity score matching based on age, prostate size, maximal flow rate (Qmax), postvoid residual volume (PVR), and American Urological Association symptom score (AUAss). Three and 12-month AUAss, PVR, and Qmax were compared. RESULTS Forty-seven patients were identified as having undergone MLHoLEP. At three-month followup, AUAss (p<0.01) and incontinence rates (p=0.045) were lower for MLHoLEP patients, in addition to them having shorter operative (36.5 mins vs. 64.5 mins, p<0.01) and enucleation (13.8 mins vs. 37 mins, p<0.01) times as compared to sHoLEP patients. No difference was noted between MLHoLEP and sHoLEP cohorts with respect to age, prostate volume, PVR, or Qmax. Significant improvement in AUAss, PVR, and Q max from baseline to three and 12 months was noted overall in both groups. CONCLUSIONS MLHoLEP could provide a surgical option with reduced operative time, quicker improvement in AUAss, and restored continence in appropriately selected patients. Ultimately, MLHoLEP represents a safe and effective treatment option to select patients who may not be eligible for or face potential morbidity concerns associated with sHoLEP.
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Affiliation(s)
- Amihay Nevo
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, United States
| | - Scott M. Cheney
- Mayo Clinic, Department of Urology, Arizona, AZ, United States
| | - Michael Callegari
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, United States
| | | | - Karen L. Stern
- Mayo Clinic, Department of Urology, Arizona, AZ, United States
| | - Michael A. Zell
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, United States
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19
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Nevo A, Humphreys MR, Callegari M, Keddis M, Moore JP, Salih S, Stern KL. Is medical dissolution treatment for uric acid stones more cost-effective than surgical treatment? A novel, solo practice, retrospective cost-analysis of medical vs. surgical therapy. Can Urol Assoc J 2023; 17:E29-E34. [PMID: 36121885 PMCID: PMC9872829 DOI: 10.5489/cuaj.7833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Effective medical dissolution therapy (MDT) for uric acid stones is more cost-effective than surgical treatment; however, treatment failure may be associated with increased cost. We aimed to study the cost-effectiveness of MDT for uric acid stones vs. surgical management. METHODS We performed a retrospective study within our institution of all patients receiving MDT for uric acid stones from 2008-2019. All patients had a known history of uric acid stones, urine pH ≤5.5, and <500 Hounsfield units on preoperative computed tomography (CT). The cost of treatment in the dissolution group was compared to the cost of primary surgical treatment in a theoretical matched cohort. Cost was estimated using local Medicare reimbursement scales. Statistical analysis was performed with SPSS Statistics. RESULTS A total of 28 patients were identified, of which 18 were included in the study. Complete and partial dissolution occurred in six (33%) and four (22%) patients, respectively. Five (28%) patients developed symptoms and underwent ureteral stent placement. Ureteroscopy and percutaneous nephrolithotomy (PCNL) were each performed in three (17%) patients in whom dissolution treatment was not effective on followup CT. Following dissolution trial, six (33%) patients had residual stone burden requiring surgical intervention. The average cost of treatment, including surgeries, was $14 604 in the dissolution group vs. $17 680 in the surgical cohort. The average cost to achieve stone-free status in patients with complete, partial, or no response to dissolution were $1675, $10 124, and $21 584, respectively, while primary surgical treatment for the same patients would cost $15 037, $10 901, and $20 511, respectively. CONCLUSIONS Successful MDT is highly cost-effective. Incomplete response to dissolution can stem from several reasons and contributes to higher costs and likely decreased quality of life.
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Affiliation(s)
- Amihay Nevo
- University Hospitals Cleveland Medical Center – Urology Institute, Cleveland, OH, United States
| | | | - Michael Callegari
- University Hospitals Cleveland Medical Center – Urology Institute, Cleveland, OH, United States
| | - Mira Keddis
- Department of Nephrology, Mayo Clinic, Arizona, AZ, United States
| | | | - Saif Salih
- Department of Urology, Mayo Clinic, Arizona, AZ, United States
| | - Karen L. Stern
- Department of Urology, Mayo Clinic, Arizona, AZ, United States
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Wymer KM, Narang G, Slade A, Sharma V, Thao V, Borah BJ, Rivera M, Cheney S, Humphreys MR. Evaluation of the Cost-Effectiveness of Surgical Treatment Options for Benign Prostatic Hyperplasia. Urology 2023; 171:96-102. [PMID: 36270339 DOI: 10.1016/j.urology.2022.09.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/14/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare the cost-effectiveness of surgical interventions for BPH. METHODS Using a Markov model, a cost-utility analysis was performed comparing HoLEP, B-TURP, WVTT, and PUL for prostate size <80cc (index patient 1) and HoLEP and SP for prostate size >80cc (index patient 2). Model probabilities and utility values were drawn from the literature. Analysis was performed at a 5-year time horizon with extrapolation to a lifetime horizon. Primary outcomes included quality-adjusted life years (QALYs), 2021 Medicare costs, and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100,000/QALY. Univariate and probabilistic sensitivity analyses were performed. RESULTS At 5 years, costs per patient for index patient 1 were $3292 (WVTT), $6532 (HoLEP), $6670 (B-TURP), and $10,257 (PUL). HoLEP resulted in the highest QALYs (4.66), followed by B-TURP (4.60), PUL (4.38), and WVTT (4.38). This translated to HoLEP being most cost-effective (ICER $11,847). For index patient 2, HoLEP was less costly ($6,585 vs $15,404) and more effective (4.654 vs 4.650) relative to SP. On sensitivity analysis for index patient 1, B-TURP became most cost-effective if cost of HoLEP increased two-fold or chronic stress incontinence following HoLEP increased ten-fold. When follow-up time was varied, WVTT was preferred at very short follow up (<1 year), and HoLEP became more strongly preferred with longer follow up. CONCLUSION At 5 years follow up, HoLEP is a cost-effective surgical treatment for BPH- independent of gland size.
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Affiliation(s)
- Kevin M Wymer
- Department of Urology, Mayo Clinic, Phoenix, AZ; Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Austen Slade
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Viengneesee Thao
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN; Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Bijan J Borah
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN; Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Marcelino Rivera
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
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21
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Moore JP, Mauler DJ, Narang GL, Stern KL, Humphreys MR, Keddis MT. Etiology, urine metabolic risk factors, and urine oxalate patterns in patients with significant hyperoxaluria and recurrent nephrolithiasis. Int Urol Nephrol 2022; 54:2819-2825. [PMID: 35917078 DOI: 10.1007/s11255-022-03311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/17/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE American Urology Association guidelines recommend genetic testing for patients with recurrent stones and urine oxalate > 75 mg/day. The goal of this study was to examine the treatment of patients in this category in a large multidisciplinary adult stone clinic. METHODS Patients were evaluated from a single institution between 2006 and 2019. Those with at least one level of urinary oxalate excretion (uOx) above 75 mg/day were identified. A chart review identified enteric risk factors and genetic testing results. Patients without an identifiable enteric cause were considered idiopathic. RESULTS A total of 4229 separate 24-h urine collections in 1302 patients were reviewed. At least one measurement of uOx above 75 mg/day was found in 103 (7.9%) patients. Enteric hyperoxaluria (EH) was seen in 28 (27%) and idiopathic hyperoxaluria (IH) in 76 (74%). 20 (71%) patients in the EH group had undergone gastric bypass. The median uOx was significantly higher level in the EH group (121.0 vs. 93.0 mg/day). For the entire cohort, there was a drop in uOx (- 33.8 mg/day) with medical and dietary therapy after a follow-up of 46.6 months. The final oxalate was higher in EH (88.9 vs. 60.1 mg/day). Only one patient had referral for genetic testing and was found to have primary hyperoxaluria type 2. CONCLUSIONS The most common cause of significant hyperoxaluria in patients with recurrent nephrolithiasis remains idiopathic. Patients with IH have more significant improvement in uOx compared to EH; however, both groups had hyperoxaluria at last follow-up. Rate of genetic testing is low despite guideline recommendations.
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Affiliation(s)
- Jonathan P Moore
- Department of Urologic Surgery, UC Davis Medical Center, Sacramento, CA, USA
| | - David J Mauler
- Department of Urology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Gopal L Narang
- Department of Urology, University of North Carolina, Chapel Hill, NC, USA
| | - Karen L Stern
- Department of Urology, Mayo Clinic Arizona, Phoenix, AZ, USA.
| | | | - Mira T Keddis
- Department of Nephrology, Mayo Clinic Arizona, Phoenix, AZ, USA
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22
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Laughlin BS, Narang GL, Cheney SM, Humphreys MR, Vargas CE, Keole SR, Rwigema JM, Schild SE, Wong WW. Toxicity and outcomes after external beam irradiation for prostate cancer in patients with prior holmium laser enucleation of the prostate: Early experience. Cancer Rep (Hoboken) 2022; 6:e1672. [PMID: 35790091 PMCID: PMC9875616 DOI: 10.1002/cnr2.1672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/11/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
PURPOSE/OBJECTIVES Holmium laser enucleation of the prostate (HoLEP) is commonly performed in patients with significant bladder outlet obstruction. However, there are few reports on the toxicity of external beam irradiation (RT) for prostate cancer in patients after prior HoLEP. In this study, we evaluate the side effects and treatment outcomes of RT after HoLEP. MATERIALS/METHODS Eighteen patients who had HoLEP and subsequently received RT for prostate cancer were included. Data collected included patient and disease characteristics, urinary function, and radiation dose. Acute and late urinary (GU) and gastrointestinal (GI) side effects were evaluated. Disease control and survival rates were calculated using Kaplan-Meier method. RESULTS Median follow-up was 18 months (range: 4-46 months). Median prostate volume was 107 ml before HoLEP and 24 ml after HoLEP. Median International Prostate Symptom Score (IPSS) was 17 (range: 5-32) before HoLEP. Median decline in IPSS score after HoLEP was 7 (range: -2-21). On uroflow study, peak flow rate, and post-void residual were significantly improved after HoLEP. After radiation, peak flow rate and average flow rate showed a decline but remained significantly improved compared to pre-HoLEP measurements. Maximum acute Common Terminology Criteria for Adverse Events (CTCAE) adverse events were 12 grade 1 and 3 grade 2 for GU, and 3 grade 1 for GI, respectively. Maximum late adverse events were 13 grade 1 and 2 grade 2 for GU, and all grade 0 for GI, respectively. At last follow-up, there were 8 grade 1 and 1 grade 2 late GU, and 3 grade 1 late GI adverse events, respectively. There was no significant increase in urinary incontinence after RT compared to before RT. The 18-month biochemical control, local control, distant control rates were 78%, 94%, and 80%, respectively. CONCLUSIONS Patients who received RT as definitive treatment for prostate cancer after prior HoLEP had low risk of serious acute and late side effects. HoLEP can be safely performed and should be considered in patients with significant bladder outlet obstruction and large prostate volume before RT.
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Affiliation(s)
| | | | | | | | | | | | | | | | - William W. Wong
- Department of Radiation Oncology, Mayo ClinicPhoenixArizonaUSA
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23
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Stout TE, Lingeman JE, Krambeck AE, Humphreys MR, Zisman A, Elfering S, Large T, Dahm P, Borofsky M. A Randomized Trial Evaluating the Use of a Smart Water Bottle to Increase Fluid Intake in Stone Formers. J Ren Nutr 2022; 32:389-395. [DOI: 10.1053/j.jrn.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 06/02/2021] [Accepted: 07/19/2021] [Indexed: 11/11/2022] Open
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24
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Chew B, Wong KV, Emmott A, Paterson RF, Lange D, Lundeen CJ, Pima AN, Moore J, Knudsen BE, Humphreys MR, Eisner BH. PD26-04 FATE OF RESIDUAL FRAGMENTS AFTER PERCUTANEOUS NEPHROLITHOTOMY: RESULTS FROM THE EDGE RESEARCH CONSORTIUM. J Urol 2021. [DOI: 10.1097/ju.0000000000002019.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Shvero A, Calio B, Humphreys MR, Das AK. HoLEP: the new gold standard for surgical treatment of benign prostatic hyperplasia. Can J Urol 2021; 28:6-10. [PMID: 34453422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
UNLABELLED INTRODUCTION Transurethral resection of the prostate (TURP) was considered the "gold standard" surgical treatment for medication-refractory benign prostatic hyperplasia (BPH) for decades. With the desire to reduce hospital stay, complications, and cost, less invasive procedures gained usage in the 1990's. With the advent of a soft tissue morcellator, holmium laser enucleation of the prostate (HoLEP) was introduced as an efficacious alternative to TURP and due to its advantageous side effect profile compared to TURP, has grown in popularity ever since. HoLEP has become a size-independent guideline endorsed procedure of choice for the surgical treatment of BPH. MATERIALS AND METHODS We provide a review on the evolution of HoLEP as a gold standard compared to the historical reference procedures for BPH, and provide a review of emerging laser technologies. RESULTS A growing body of literature has shown HoLEP to be a safe and efficient procedure for the treatment of BPH for all prostate sizes. Long term studies have proven the durability of HoLEP, as a first line surgical therapy for BPH. CONCLUSIONS HoLEP is a proven modality for the surgical treatment of BPH. It can be performed on patients with high risk for postoperative bleeding, or after previous prostate reducing procedures. HoLEP is the only procedure that is AUA guideline-endorsed for all prostate sizes for the surgical treatment of BPH. Given these considerations, HoLEP has become the new gold-standard for the surgical treatment of BPH.
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Affiliation(s)
- Asaf Shvero
- Department of Urology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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26
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Wymer KM, Sharma V, Juvet T, Klett DE, Borah BJ, Koo K, Rivera M, Agarwal D, Humphreys MR, Potretzke AM. Cost-effectiveness of Retrograde Intrarenal Surgery, Standard and Mini Percutaneous Nephrolithotomy, and Shock Wave Lithotripsy for the Management of 1-2cm Renal Stones. Urology 2021; 156:71-77. [PMID: 34274389 DOI: 10.1016/j.urology.2021.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/01/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To perform a cost-effectiveness evaluation comparing the management options for mid-size (1-2cm) renal stones including percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), and shockwave lithotripsy (SWL). METHODS A Markov model was created to compare cost-effectiveness of PCNL, mini-PCNL, RIRS, and SWL for 1-2cm lower pole (index patient 1) and PCNL, RIRS, and SWL for 1-2 cm non-lower pole (index patient 2) renal stones. A literature review provided stone free, complication, retreatment, secondary procedure rates, and quality adjusted life years (QALYs). Medicare costs were used. The incremental cost-effectiveness ratio (ICER) was compared with a willingness-to-pay(WTP) threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed. RESULTS At 3 years, costs for index patient 1 were $10,290(PCNL), $10,109(mini-PCNL), $5,930(RIRS), and $10,916(SWL). Mini-PCNL resulted in the highest QALYs(2.953) followed by PCNL(2.951), RIRS(2.946), and SWL(2.943). This translated to RIRS being most cost-effective followed by mini-PCNL(ICER $624,075/QALY) and PCNL(ICER $946,464/QALY). SWL was dominated with higher costs and lower effectiveness. For index patient 2, RIRS dominated both PCNL and SWL. For index patient 1: mini-PCNL and PCNL became cost effective if cost ≤$5,940 and ≤$5,390, respectively. SWL became cost-effective with SFR ≥75% or cost ≤$1,236. On probabilistic sensitivity analysis, the most cost-effective strategy was RIRS in 97%, mini-PCNL in 2%, PCNL in 1%, and SWL in 0% of simulations. CONCLUSION For 1-2cm renal stones, RIRS is most cost-effective. However, mini and standard PCNL could become cost-effective at lower costs, particularly for lower pole stones.
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Affiliation(s)
| | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, MN; Department of Urology, David Geffen School of Medicine; University of California, Los Angeles, CA; Greater Los Angeles VA, Health Services Research and Development Program, Los Angeles, CA
| | | | - Dane E Klett
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Bijan J Borah
- Department of Health Services Research, Mayo Clinic, Rochester, MN
| | - Kevin Koo
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Marcelino Rivera
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Deepak Agarwal
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
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Carrera RV, Randall JH, Garcia-Gil M, Knudsen BE, Chew BH, Thompson JA, Humphreys MR, Molina WR. Ureteroscopic Performance of High Power Super Pulse Thulium Fiber Laser for the Treatment of Urolithiasis: Results of the First Case Series in North America. Urology 2021; 153:87-92. [PMID: 33621583 DOI: 10.1016/j.urology.2020.12.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/30/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To report the first case series of ureterorenoscopy in North America using the High Power Super Pulse Thulium Fiber Laser for the treatment of upper urinary tract stones. METHODS After Institutional Review Board approval, a multicentric retrospective chart review of patients treated with the High Power Super Pulse Thulium Fiber Laser from October 2019 to March 2020 was conducted. Basic demographic information, pre-operative, and peri-operative data were recorded. RESULTS Seventy-six patients were included with a mean age of 60.9 ± 13.3 years. 118 stones were treated including 32 within the ureter, 49 in the lower pole, 37 in mid or upper poles. Dusting technique was commonly used (67.1%) with pulse frequencies up to 2400 Hz. Mean operative time was 59.4 ± 31.5 minutes. Mean laser time and total laser energy were 10.8 ± 14.1 minutes and 12.5 ± 19.1 KJ, respectively. Intraoperative complications were limited to 7 grade 1, 3 grade 2, and 1 grade 3 ureteral injuries and one case of renal collecting system bleeding that was adequately managed with laser coagulation settings (1J-20Hz). CONCLUSION This initial case series in North America of the High Power Super Pulse Thulium Fiber Laser is promising for the treatment of urolithiasis. Sub-200 μm fibers and dusting settings up to 2400 Hz were utilized successfully. No specific complications related to use of the laser were seen.
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Affiliation(s)
- Raphael V Carrera
- University of Kansas Medical Center, Department of Urology, Kansas City, KS, United States
| | - J Hogan Randall
- University of Kansas Medical Center, Department of Urology, Kansas City, KS, United States
| | - Maurilio Garcia-Gil
- The Ohio State University Wexner Medical Center, Department of Urology, Columbus, OH, United States
| | - Bodo E Knudsen
- The Ohio State University Wexner Medical Center, Department of Urology, Columbus, OH, United States
| | - Ben H Chew
- University of British Columbia, Department of Urologic Sciences, Vancouver, BC, Canada
| | - Jeffrey A Thompson
- Department of Biostatistics & Data Science, Kansas City, KS, United States
| | | | - Wilson R Molina
- University of Kansas Medical Center, Department of Urology, Kansas City, KS, United States.
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Sur RL, Krambeck AE, Large T, Bechis SK, Friedlander DF, Monga M, Hsi RS, Miller NL, Chew BH, Lange D, Knudsen B, Sourial MW, Humphreys MR, Stern KL, Shah O, Abbott JE, Abedi G. A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics for Percutaneous Nephrolithotomy in Moderate to High Infectious Risk Population: A Report from the EDGE Consortium. J Urol 2021; 205:1379-1386. [PMID: 33369488 DOI: 10.1097/ju.0000000000001582] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Postoperative infectious related complications are not uncommon after percutaneous nephrolithotomy. Previously, we noted that 7 days of antibiotics did not decrease sepsis rates compared to just perioperative antibiotics in a low risk percutaneous nephrolithotomy population. This study aimed to compare the same regimens in individuals at moderate to high risk for sepsis undergoing percutaneous nephrolithotomy. MATERIALS AND METHODS Patients were prospectively randomized in this multi-institutional study to either 2 days or 7 days of preoperative antibiotics. Enrolled patients had stones requiring percutaneous nephrolithotomy and had either a positive preoperative urine culture or existing indwelling urinary drainage tube. Primary outcome was difference in sepsis rates between the groups. Secondary outcomes included rate of nonseptic bacteriuria, stone-free rate and length of stay. RESULTS A total of 123 patients at 7 institutions were analyzed. There was no difference in sepsis rates between groups on univariate analysis. Similarly, there were no differences in nonseptic bacteriuria, stone-free rate and length of stay. On multivariate analysis, 2 days of antibiotics increased the risk of sepsis compared to 7 days of antibiotics (OR 3.1, 95% CI 1.1-8.9, p=0.031). Patients receiving antibiotics for 2 days had higher rates of staghorn calculus than the 7-day group (58% vs 32%, p=0.006) but post hoc subanalysis did not demonstrate increased sepsis in the staghorn only group. CONCLUSIONS Giving 7 days of preoperative antibiotics vs 2 days decreases the risk of sepsis in moderate to high risk percutaneous nephrolithotomy patients. Future guidelines should consider infectious risk stratification for percutaneous nephrolithotomy antibiotic recommendations.
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Affiliation(s)
| | - Amy E Krambeck
- Methodist Hospital Indiana University, Indianapolis, Indiana
| | - Tim Large
- Methodist Hospital Indiana University, Indianapolis, Indiana
| | | | - David F Friedlander
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - Ryan S Hsi
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Ben H Chew
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | - Ojas Shah
- Columbia University Irving Medical Center, New York, New York
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29
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Forbes CM, Lundeen C, Beebe S, Moore JP, Knudsen BE, Humphreys MR, Chew B. Device profile of the LithoVue single-use digital flexible ureteroscope in the removal of kidney stones: overview of safety and efficacy. Expert Rev Med Devices 2020; 17:1257-1264. [PMID: 33307869 DOI: 10.1080/17434440.2020.1848538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Flexible ureteroscopy is a commonly performed urologic procedure for visualization and treatment of the upper urinary tracts. Traditionally, ureteroscopy has been performed with reusable scopes, which have large initial purchasing costs. LithoVue was the first widely adopted single-use flexible ureteroscope clinically available in 2016 and has caused reevaluation of this paradigm. Areas covered: This review is an objective assessment of the LithoVue single-use ureteroscope based on available studies at the time of publication. The authors searched major databases for papers that included the term 'LithoVue' and included relevant papers. The state of the market, technical specifications, results from clinical studies and cost analyses, and competitors are discussed. Expert opinion: The LithoVue single-use flexible ureteroscope has comparable clinical performance to existing reusable ureteroscopes based on available data. Direct clinical comparisons to competing single-use ureteroscopes, many of which are relatively new, are limited. In numerous pre-clinical studies LithoVue performed favorably compared to available competitors. Cost analyses suggest that benefit of single-use ureteroscopes is institution-specific, and will likely be favorable at a low volume of cases and with high local costs for repairs of reusable scopes.
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Affiliation(s)
- Connor M Forbes
- Department of Urologic Sciences, University of British Columbia , Vancouver, Canada.,Department of Urology, Vanderbilt University Medical Center , Nashville, TN, USA
| | - Colin Lundeen
- Department of Urologic Sciences, University of British Columbia , Vancouver, Canada
| | - Sarah Beebe
- Department of Urology, Ohio State University Wexner Medical Center , Columbus, Ohio, USA
| | - Jonathan P Moore
- Department of Urology, Mayo Clinic Arizona , Phoenix, Arizona, USA
| | - Bodo E Knudsen
- Department of Urology, Ohio State University Wexner Medical Center , Columbus, Ohio, USA
| | | | - Ben Chew
- Department of Urologic Sciences, University of British Columbia , Vancouver, Canada
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30
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Nevo A, Moore JP, Humphreys MR, Salih S, Keddis MA, Rose KM, Cheney SS, Stern KL. Does bladder stone composition predict kidney stone composition? Can J Urol 2020; 27:10450-10455. [PMID: 33325347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
UNLABELLED INTRODUCTION Bladder stones have historically been associated with urinary stasis secondary to bladder outlet obstruction (BOO). Recent studies indicate that the role of BOO in bladder stone formation is minor. We evaluate the role of urinary lithogenic factors in bladder stone formation by comparing the compositions of bladder stones and kidney stones in patients with multi-site urinary calculi. MATERIALS AND METHODS We identified patients who were treated for concomitant bladder stones and kidney stones between 2008-2019, and had both stone compositions available. Patients with bladder stone size < 10 mm, urinary foreign bodies, encrusted stents or tumors were excluded. Data regarding urinary symptoms, residual volumes, stone composition and 24-hours urine data were collected. RESULTS We identified 40 males with a median age of 72 years (IQR 6-14), median residual volume of 76 mL (IQR 41-200), and a median prostate volume of 52 mL (IQR 32-102). Bladder outlet procedures were performed concomitantly with cystolitholapaxy in 21 (53%) patients. The most common bladder stone and kidney stone compositions were CaOx (47.5% and 65%), uric acid (32.5% and 22.5%), calcium phosphate (15% and 10%), and struvite (5% and 2.5%), respectively. Bladder stone and kidney stone compositions were identical in 70% of patients. Bladder stone composition was predictive of kidney stone composition, regardless of the PVR, bladder stone size, or whether an outlet procedure was performed. CONCLUSION We found a high concordance between bladder stone and kidney stone composition, suggesting that metabolic abnormalities have a significant role in bladder stone formation. Bladder stone composition can be used to guide surgical and medical treatment for kidney stones in metabolically active stone patients.
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Affiliation(s)
- Amihay Nevo
- Department of Urology, Mayo Clinic, Phoenix, Arizona, USA
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31
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Nevo A, Faraj KS, Cheney SM, Moore JP, Stern KL, Borofsky M, Gnessin E, Humphreys MR. Holmium laser enucleation of the prostate using Moses 2.0 vs non-Moses: a randomised controlled trial. BJU Int 2020; 127:553-559. [PMID: 33025749 DOI: 10.1111/bju.15265] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To compare the enucleation efficiency of Moses 2.0 with non-Moses technology in patients undergoing holmium laser enucleation of the prostate (HoLEP). PATIENTS AND METHODS A double-blinded, randomised study of patients undergoing HoLEP at the Mayo Clinic in Arizona, using the Lumenis Pulse™ 120H laser system. Patients were randomised to either right lobe enucleation using Moses 2.0 and left lobe enucleation using non-Moses, or the opposite. The primary outcome was individual lobe enucleation efficiency. Secondary outcomes included individual lobe laser time, laser energy, individual enucleation and haemostasis laser energies, and fibre burn back. Two independent reviewers watched videos of the procedures and provided a subjective evaluation of the technologies. RESULTS A total of 27 patients were included in the study. For the entire cohort, Moses 2.0 had less fibre degradation (3.5 vs 16.8 mm, P < 0.01) compared to non-Moses. When HoLEP procedures were performed by an expert, Moses 2.0 resulted in shorter enucleation time (21 vs 36.7 min, P = 0.016) and higher enucleation efficiency (1.75 vs 1.05 g/min, P = 0.05) compared to non-Moses. When HoLEP was performed by trainees, the Moses 2.0 cohort had a shorter haemostasis laser time (4.1 vs 9 min, P = 0.035) compared to the non-Moses. Fibre degradation was lower with Moses 2.0 compared to non-Moses for both experts and trainees. Moses 2.0 received a higher score than the standard technology for the incision sharpness, fibre control, tissue separation, tissue damage, haemostasis, visibility, and charring. The overall inter-observer correlation coefficient was 0.63. CONCLUSION Moses 2.0 has higher enucleation efficiency compared to non-Moses when used by experts. The subjective evaluation favoured Moses 2.0.
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Affiliation(s)
- Amihay Nevo
- Department of Urology, Mayo Clinic in Arizona, Phoenix, AZ, USA
| | - Kassem S Faraj
- Department of Urology, Mayo Clinic in Arizona, Phoenix, AZ, USA
| | - Scott M Cheney
- Department of Urology, Mayo Clinic in Arizona, Phoenix, AZ, USA
| | | | - Karen L Stern
- Department of Urology, Mayo Clinic in Arizona, Phoenix, AZ, USA
| | - Michael Borofsky
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Ehud Gnessin
- Department of Urology, Shamir Medical Center, Be'er Ya'akov, Israel
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Nevo A, Muchtar E, Stern KL, Moore JP, Cheney SM, Humphreys MR, Grogan M, Stanton ML. The Clinical Implication of Incidental Prostatic Amyloidosis. Urology 2020; 145:253-257. [PMID: 32961226 DOI: 10.1016/j.urology.2020.08.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/24/2020] [Accepted: 08/30/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To describe the clinicopathologic features of patients with incidental prostatic amyloidosis. PATIENTS AND METHODS We queried the genitourinary pathology database at Mayo Clinic Arizona for prostate specimens which showed amyloid deposits. Congo red stain was used for the diagnosis of amyloidosis and amyloid subtype was performed analysis using Liquid chromatography tandem mass spectrometry. We reviewed the patient's medical charts for past or subsequent diagnosis of systemic amyloidosis and clinical course. RESULTS Prostatic amyloidosis was identified in 7 patients between 2008-2018. Median age was 79 years (range 69-84) and median follow-up was 5 years (range 0-11). Benign prostate tissue was found in 4 patients, and prostate cancer was diagnosed in 3 patients. Amyloid subtyping was available in 6 patients and was consistent with Amyloid transthyretin Amyloidosis. Liquid chromatography tandem mass spectrometry did not detect an amino acid sequence abnormality in the transthyretin protein in any of the patients. Five of 6 patients were diagnosed with cardiac amyloidosis, which preceded and followed the diagnosis of prostatic amyloidosis in 1 and 4 patients, respectively. Of these 4 patients, 2 were diagnosed immediately and as a consequence of the diagnosis of prostatic amyloidosis, and the remaining 2 3 and 4 years later. CONCLUSION Incidental prostatic amyloidosis should prompt systemic and cardiac evaluation for amyloidosis. In patients with suspected cardiac amyloidosis, prior prostate specimens should be reviewed for the presence of amyloidosis.
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Affiliation(s)
- Amihay Nevo
- Department of Urology, Mayo Clinic, Phoenix, AZ.
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Martha Grogan
- Department of Cardiovascular diseases, Mayo Clinic, MN
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Nevo A, Stern KL, Moore JP, Humphreys MR, Tyson MD, Keddis MT. The impact of phone counseling on urinary stone prevention. World J Urol 2020; 39:1625-1629. [PMID: 32588206 DOI: 10.1007/s00345-020-03320-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/16/2020] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE We compared the effect of standard office-based consultation (OC) and phone correspondences (PC) on dietary 24-h urinary parameters. METHODS The medical record of all patients treated between January and April 2019 was reviewed. Only patients who had at least two consecutive 24-h urine collections were included. Linear and logistic regressions were used to investigate the difference between the changes in urinary parameters after OC and PC. RESULTS Forty-three patients underwent 135 OC and 34 PC. Twenty-one received OC and PC, and 22 had only OC. Gender, age, the distance to stone clinic, the number of previous stone episodes, and baseline urinary parameters were similar between the groups. Patients who had both OC and PC had a longer follow-up time (51.7 vs 18.5 months, p < 0.0001) as well as more consults (Median 5.4 vs 2.5, p < 0.0001). Six (27%) patients who had only OC, and eight (38%) patients who had both OC and PC, experienced stone recurrence during the study period (p = 0.52). Following PC, there was a greater improvement in urine volume in comparison to OC (0.27 l/day vs -0.06 l/day, p = 0.034), but there was no difference in the absolute values after the consults between the groups. CONCLUSION In established stone-clinic patients, PC was associated with a better adherence with follow-up. The 24-h urine results were similar between PC and OC. PC may be an effective alternative for urinary stone management.
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Affiliation(s)
- Amihay Nevo
- Department of Urology, Mayo Clinic, Arizona, USA.
| | | | | | | | - Mark D Tyson
- Department of Urology, Mayo Clinic, Arizona, USA
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Faraj KS, Mi L, Eversman S, Singh R, DeLucia NM, Blodgett G, Swanson SK, Andrews PE, Ferrigni RG, Humphreys MR, Castle EP, Tyson MD. The effect of urinary diversion on long-term kidney function after cystectomy. Urol Oncol 2020; 38:796.e15-796.e21. [PMID: 32482512 DOI: 10.1016/j.urolonc.2020.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/26/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Cystectomy with urinary diversion is associated with decreased long-term kidney function due to several factors. One factor that has been debated is the type of urinary diversion used: ileal conduit (IC) vs. neobladder (NB). We tested the hypothesis that long-term kidney function will not vary by type of urinary diversion. METHODS AND MATERIALS We retrospectively identified all patients who underwent cystectomy with urinary diversion at our institution from January 1, 2007, to January 1, 2018. Data were collected on patient demographics, comorbid conditions, perioperative radiotherapy, and complications. Creatinine values were measured at several time points up to 120 months after surgery. Glomerular filtration rate (GFR) (ml/min per 1.73 m2) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed model with inverse probability of treatment weighting (IPTW) was used to compare GFR between the IC and NB cohorts over time. Multiple sensitivity analyses were performed based on 2 different calculations of GFR (Chronic Kidney Disease Epidemiology Collaboration equation vs. Modification of Diet in Renal Disease), with and without excluding patients with preoperative GFR less than 40 ml/min per 1.73 m2. RESULTS Among 563 patients who underwent cystectomy with urinary diversion, a NB was used for 72 (12.8%) individuals. Patients who had a NB were significantly younger, had a lower American Society of Anesthesiologists score, greater baseline GFR, better Eastern Cooperative Oncology Group performance status, lower median Charlson comorbidity index, and were less likely to have received preoperative abdominal radiation (all P < 0.05). Both NB and IC patients had decreased kidney function over time, with mean GFR losses at 5 years of 17% and 14% of baseline values, respectively. The IPTW-adjusted linear mixed model revealed that IC patients had slightly more deterioration in kidney function over time, but this was not statistically significant (estimate, 0.12; P = 0.06). The sensitivity analyses yielded a similar trend, in that GFR decrease appeared to be greater in the IC cohort. This trend was statistically significant when using Modification of Diet in Renal Disease (P = 0.04). CONCLUSIONS Among highly selected patients with an NB, deterioration of kidney function may potentially be lower over time than among IC patients. However, the statistical significance varied between analyses and we cautiously attribute these observed differences to patient selection.
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Affiliation(s)
- Kassem S Faraj
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Lanyu Mi
- Biostatistics (Ms Mi), Mayo Clinic, Scottsdale, Arizona
| | - Sarah Eversman
- Ms Eversman is a student, Creighton University, Omaha, Nebraska
| | - Rohan Singh
- Mr Singh is a student, Arizona State University, Tempe, Arizona
| | - Noel M DeLucia
- Division of Research Administrative Services (Ms DeLucia), Mayo Clinic Hospital, Phoenix, Arizona
| | - Gail Blodgett
- Patient Collaborator (Ms Blodgett), Mayo Clinic Hospital, Phoenix, Arizona
| | - Scott K Swanson
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Paul E Andrews
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Robert G Ferrigni
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Mitchell R Humphreys
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Erik P Castle
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Mark D Tyson
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona.
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Faraj KS, Judge NZ, Rose KM, Eversman S, Richards J, Blodgett G, Singh V, DeLucia NM, Humphreys MR, Castle EP, Tyson MD. How the Beneficial Effects of Alvimopan Differ With Surgical Approach for Radical Cystectomy. Urology 2020; 140:107-114. [DOI: 10.1016/j.urology.2019.12.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 12/30/2022]
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Kleinmann N, Matin SF, Pierorazio PM, Gore JL, Shabsigh A, Hu B, Chamie K, Godoy G, Hubosky S, Rivera M, O'Donnell M, Quek M, Raman JD, Knoedler JJ, Scherr D, Stern J, Weight C, Weizer A, Woods M, Kaimakliotis H, Smith AB, Linehan J, Coleman J, Humphreys MR, Pak R, Lifshitz D, Verni M, Adibi M, Amin MB, Seltzer E, Klein I, Konorty M, Strauss-Ayali D, Hakim G, Schoenberg M, Lerner SP. Primary chemoablation of low-grade upper tract urothelial carcinoma using UGN-101, a mitomycin-containing reverse thermal gel (OLYMPUS): an open-label, single-arm, phase 3 trial. Lancet Oncol 2020; 21:776-785. [PMID: 32631491 DOI: 10.1016/s1470-2045(20)30147-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Most patients with low-grade upper tract urothelial cancer are treated by radical nephroureterectomy. We aimed to assess the safety and activity of a non-surgical treatment using instillation of UGN-101, a mitomycin-containing reverse thermal gel. METHODS In this open-label, single-arm, phase 3 trial, participants were recruited from 24 academic sites in the USA and Israel. Patients (aged ≥18 years) with primary or recurrent biopsy-proven, low-grade upper tract urothelial cancer (measuring 5-15 mm in maximum diameter) and an Eastern Cooperative Oncology Group performance status score of less than 3 (Karnofsky Performance Status score >40) were registered to receive six instillations of once-weekly UGN-101 (mitomycin 4 mg per mL; dosed according to volume of patient's renal pelvis and calyces, maximum 60 mg per instillation) via retrograde catheter to the renal pelvis and calyces. All patients had a planned primary disease evaluation 4-6 weeks after the completion of initial therapy, in which the primary outcome of complete response was assessed, defined as negative 3-month ureteroscopic evaluation, negative cytology, and negative for-cause biopsy. Activity (complete response, expected to occur in >15% of patients) and safety were assessed by the investigator in all patients who received at least one dose of UGN-101. Data presented are from the data cutoff on May 22, 2019. This study is registered with ClinicalTrials.gov, NCT02793128. FINDINGS Between April 6, 2017, and Nov 26, 2018, 71 (96%) of 74 enrolled patients received at least one dose of UGN-101. 42 (59%, 95% CI 47-71; p<0·0001) patients had a complete response at the primary disease evaluation visit. The median follow-up for patients with a complete response was 11·0 months (IQR 5·1-12·4). The most frequently reported all-cause adverse events were ureteric stenosis in 31 (44%) of 71 patients, urinary tract infection in 23 (32%), haematuria in 22 (31%), flank pain in 21 (30%), and nausea in 17 (24%). 19 (27%) of 71 patients had study drug-related or procedure-related serious adverse events. No deaths were regarded as related to treatment. INTERPRETATION Primary chemoablation of low-grade upper tract urothelial cancer with intracavitary UGN-101 results in clinically significant disease eradication and might offer a kidney-sparing treatment alternative for these patients. FUNDING UroGen Pharma.
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Affiliation(s)
- Nir Kleinmann
- Department of Urology, Sheba Medical Center, Ramat Gan, Israel
| | - Surena F Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - John L Gore
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA
| | - Ahmad Shabsigh
- Department of Urology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Brian Hu
- Department of Urology, Loma Linda University, Loma Linda, CA, USA
| | - Karim Chamie
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Guilherme Godoy
- Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Scott Hubosky
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Marcelino Rivera
- Department of Urology, Mayo Clinic Health System, Rochester, MN, USA
| | | | - Marcus Quek
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | - Jay D Raman
- Division of Urology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - John J Knoedler
- Division of Urology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Douglas Scherr
- Department of Urology, Weill Medical College of Cornell University, New York, NY, USA
| | - Joshua Stern
- Department of Urology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christopher Weight
- Department of Urology, University of Minnesota Health, Minneapolis, MN, USA
| | - Alon Weizer
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Michael Woods
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | - Hristos Kaimakliotis
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Angela B Smith
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jennifer Linehan
- Department of Urology, John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Jonathan Coleman
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Raymond Pak
- Department of Urology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - David Lifshitz
- Department of Urology, Rabin Medical Center, Tel Aviv, Israel
| | | | - Mehrad Adibi
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mahul B Amin
- Department of Pathology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | | | | | | | - Mark Schoenberg
- Department of Urology, Albert Einstein College of Medicine, Bronx, NY, USA; UroGen Pharma, New York, NY, USA
| | - Seth P Lerner
- Department of Urology, Baylor College of Medicine, Houston, TX, USA.
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Desai M, Bidair M, Bhojani N, Trainer A, Arther A, Kramolowsky E, Doumanian L, Elterman D, Kaufman RP, Lingeman J, Krambeck A, Eure G, Badlani G, Plante M, Uchio E, Gin G, Goldenberg L, Paterson R, So A, Humphreys MR, Roehrborn CG, Kaplan S, Motola J, Zorn KC. Aquablation for benign prostatic hyperplasia in large prostates (80-150 cc): 2-year results. Can J Urol 2020; 27:10147-10153. [PMID: 32333733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION To report 2-year safety and effectiveness of the Aquablation procedure for the treatment of men with symptomatic benign prostatic hyperplasia (BPH) and large-volume 80-150 cc prostates. MATERIALS AND METHODS Between September-December 2017, 101 men with moderate-to-severe BPH symptoms and prostate volumes of 80-150 cc underwent an ultrasound-guided robotically executed Aquablation procedure in a prospective multicenter international clinical trial (WATER II). Baseline, procedural and follow up parameters were recorded at baseline and scheduled postoperative visits. Herein we report 2-year safety and efficacy for this cohort. RESULTS Mean prostate volume was 107 cc (range 80-150 cc). Mean IPSS improved from 23.2 at baseline to 5.8 at 2 years (17-point improvement, p < .0001). Mean IPSS quality of life improved from 4.6 at baseline to 1.1 at 2 years (p < .0001). Maximum urinary flow increased from 8.7 to 18.2 cc/sec. Two subjects underwent a repeat procedure for BPH symptoms over the 2-year follow up period. By 2 years or study exit, all but 2 of 74 subjects stopped taking alpha blockers. Similarly, all but 4 of 32 subjects stopped taking 5α-reductase inhibitors. CONCLUSIONS Two-year prospective multicenter follow up demonstrated that the Aquablation procedure is safe and effective in the treatment of men with LUTS due to BPH and prostates 80-150 cc with durable treatment efficacy, acceptable safety profile and a low retreatment rate. ClinicalTrials.gov number, NCT03123250.
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Affiliation(s)
- Mihir Desai
- University of Southern California, Institute of Urology, Los Angeles, California, USA
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Zell MA, Abdul-Muhsin H, Navaratnam A, Cumsky J, Girardo M, Cornella J, Nevo A, Cheney S, Humphreys MR. Holmium laser enucleation of the prostate for very large benign prostatic hyperplasia (≥ 200 cc). World J Urol 2020; 39:129-134. [PMID: 32206890 DOI: 10.1007/s00345-020-03156-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 03/03/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Patients presenting with prostate gland sizes greater than 200 cc pose a unique surgical challenge to both patients and surgeons. The objective of this study is to critically assess the efficacy and risks associated with performing holmium laser enucleation of the prostate (HoLEP) on glands ≥ 200 cc. MATERIALS AND METHODS Using a prospective maintained database, all consecutive benign prostatic hyperplasia (BPH) patients with gland size ≥ 200 cc who underwent HoLEP were included. We reported patient preoperative, intraoperative, postoperative outcomes and complications. Subgroup analysis of outcomes was stratified by gland sizes 200-299 cc and ≥ 300 cc. Univariate analysis using Kruskal-Wallis and Fisher exact test was performed to compare the two groups. RESULTS There were 88 patients with a mean preoperative gland size of 255.9 cc (200-770 cc). Mean operative (171 vs 182 min) and enucleation time (77 vs 83 min) were not different between the two subgroups (200-299 cc vs ≥ 300 cc). Enucleation efficiency was greater for glands ≥ 300 cc (2.6 cc/min vs 2.0 cc/min, p = 0.04). Morcellation time was longer in the ≥ 300 cc group (74.5 min vs 46.8 min, p = 0.021). Mean length of stay was 1.8 ± 1.2 days and catheter duration was 2.6 ± 2.7 days. 1 (1.1%) patient required retreatment of BPH at last follow-up. The main limitation of this study is the retrospective data analysis. CONCLUSIONS Holmium laser enucleation for prostate glands volume > 200 cc is feasible with minimal morbidity. These data further reinforce the size independence success of this procedure for BPH.
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Affiliation(s)
- Michael A Zell
- Department of Urology, Mayo Clinic in Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Haidar Abdul-Muhsin
- Department of Urology, Mayo Clinic in Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Anojan Navaratnam
- Department of Urology, Mayo Clinic in Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Jameson Cumsky
- Department of Urology, Mayo Clinic in Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Marlene Girardo
- Department of Biostatistics, Mayo Clinic in Arizona, 5777 E Mlvd, Phoenix, AZ, 85054, USA
| | - Joseph Cornella
- Department of Urology, Mayo Clinic in Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Amihay Nevo
- Department of Urology, Mayo Clinic in Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Scott Cheney
- Department of Urology, Mayo Clinic in Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Mitchell R Humphreys
- Department of Urology, Mayo Clinic in Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
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Faraj K, Chang YHH, Rose KM, Habermann EB, Etzioni DA, Blodgett G, Castle EP, Humphreys MR, Tyson Ii MD. Single-dose perioperative mitomycin-C versus thiotepa for low-grade noninvasive bladder cancer. Can J Urol 2019; 26:9922-9930. [PMID: 31629441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Mitomycin-C (MMC) and thiotepa are intravesical agents effective in reducing the recurrence of low-grade noninvasive bladder cancer when instilled perioperatively. No studies have compared these agents as a single-dose perioperative instillation. This study tests whether there is a difference in recurrence-free survival in patients with low-grade noninvasive bladder cancer who received intravesical MMC versus thiotepa. MATERIALS AND METHODS A retrospective review was performed of patients who underwent cystoscopic excision of a bladder mass identified as a small, low-grade, treatment-naïve, noninvasive, wild-type urothelial carcinoma of the bladder and who received either intravesical thiotepa (30 mg/15 cc) or MMC (40 mg/20 cc) between January 1, 2002, and January 1, 2016. Data were collected for demographic characteristics, comorbid conditions, operative information, surveillance, and recurrence. The primary outcome was disease-free survival. Cohorts were compared via the doubly robust estimation approach, which used logistic regression to model the probability of recurrence. RESULTS Of 154 total patients, 84 received intravesical MMC; 70, thiotepa. No statistical differences were shown between groups for age, sex, race, body mass index, smoking status, or baseline comorbid conditions; mass size, tumor multifocality, or tumor grade; and unadjusted recurrence rates (MMC, 36.0%; thiotepa, 46.0%; p = .33) at similar median follow up (MMC, 20.4; thiotepa, 22.8 months; p = .46). The robust logistic regression analysis yielded no differences in recurrence rates between MMC and thiotepa (OR, 0.65 [95% CI, 0.33-1.31]; p = .23). No episodes of myelosuppression or frozen pelvis were identified. CONCLUSIONS As single-dose perioperative agents, both thiotepa and MMC were associated with similar recurrence-free survival rates.
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Affiliation(s)
- Kassem Faraj
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Navaratnam A, Cumsky J, Abdul-Muhsin H, Gagneur J, Shen J, Kosiorek H, Golafshar M, Kawashima A, Wong W, Ferrigni R, Humphreys MR. Assessment of Polyethylene Glycol Hydrogel Spacer and Its Effect on Rectal Radiation Dose in Prostate Cancer Patients Receiving Proton Beam Radiation Therapy. Adv Radiat Oncol 2019; 5:92-100. [PMID: 32051895 PMCID: PMC7004937 DOI: 10.1016/j.adro.2019.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 07/15/2019] [Accepted: 08/13/2019] [Indexed: 12/31/2022] Open
Abstract
Purpose To assess the efficacy of placing a polyethylene glycol (PEG) spacing hydrogel in patients undergoing proton beam radiation therapy for prostate cancer. This study also aims to assess the effect on rectal radiation dose of prostate-rectum separation in various anatomic planes. Methods and Materials Seventy-two consecutive prostate cancer patients undergoing conventionally fractionated pencil beam scanning proton radiation therapy with and without hydrogel placement were compared. Magnetic resonance images taken after hydrogel placement measured prostate-rectum separation and were correlated to rectal dosing and rectal toxicity. Univariate analysis of clinical variables and radiation dosing was conducted using nonparametric Wilcoxon rank-sum test with continuity correction between groups (hydrogel spacer vs controls). Spearman's rank correlation coefficient assessed relationships between the various anatomic dimensions of perirectal space and rectal radiation dosing. Results Fifty-one patients had hydrogel placement before therapy and 21 did not. There was a 42.2% reduction in rectal dosing (mL3 rectum) in hydrogel patients (P < .001). Increasing midline sagittal lift resulted in a greater mitigation of total rectal dose (P = .031). The degree of prostate surface area coverage on coronal plane did not correlate with further reductions in rectal radiation dose (P = .673). Patients who had PEG hydrogels placed reported more rectal side effects during treatment compared with those patients who did not (35.3% vs 9.5%, P = .061). At median 9.5-month follow-up, there was no difference in reporting of grade ≤2 rectal toxicity between the 2 groups (7.7% vs 7.1%, P = .145). Conclusions Polyethylene glycol hydrogel placement before pencil proton beam radiation therapy for prostate cancer reduced rectal radiation dose. The most important factor reducing total rectal dose was the degree of sagittal midline separation created by the PEG hydrogel. This is the largest study with the longest follow-up to investigate hydrogel placement in the proton beam radiation setting.
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Affiliation(s)
| | - Jameson Cumsky
- Department of Urology, Mayo Clinic in Arizona, Phoenix, Arizona
| | | | - Justin Gagneur
- Department of Radiation Oncology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Heidi Kosiorek
- Department of Biostatistics, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Michael Golafshar
- Department of Biostatistics, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Akira Kawashima
- Department of Radiology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - William Wong
- Department of Radiation Oncology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Robert Ferrigni
- Department of Urology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Mitchell R. Humphreys
- Department of Urology, Mayo Clinic in Arizona, Phoenix, Arizona
- Corresponding author: Mitchell R. Humphreys, MD
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Blaine SA, Abdul-Muhsin HM, Jakob NJ, Andrews PE, Ferrigni RG, Cha SS, Golshani A, Silva AC, Kawashima A, Humphreys MR. MRI - ultrasound fusion guided biopsy of the prostate: lesion volume as a predictor of cancer in patients with repeat biopsies. Indian J Urol 2019; 35:208-212. [PMID: 31367072 PMCID: PMC6640000 DOI: 10.4103/iju.iju_49_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction The objective was to analyze the diagnostic value of multiparametric magnetic resonance imaging (MRI) prostate lesion volume (PLV) and its correlation with the subsequent MRI-ultrasound (MRI-US) fusion biopsy results. Materials and Methods Between March 2014 and July 2016, 150 men underwent MRI-US fusion biopsies at our institution. All suspicious prostate lesions were graded according to the Prostate Imaging Reporting and Data System (PIRADS) and their volumes were measured. These lesions were subsequently biopsied. All data were prospectively collected and retrospectively analyzed. The PLV of all suspicious lesions was correlated with the presence of cancer on the final MRI-US fusion biopsy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results There were 206 suspicious lesions identified in 150 men. The overall cancer detection rate was 102/206 (49.5%). The mean PLV for benign lesions was 0.63 ± 0.94 cm3 versus 1.44 ± 1.76 cm3 for cancerous lesions (P < 0.01). There was a statistically significant difference between the PLV of PIRADS 5 lesions when compared to PIRADS 4, 3, and 2 lesions (P < 0.0001, < 0.0001, and 0.006, respectively). The area under the curve for volume in predicting prostate cancer (PCa) was 0.66. The optimal volume for predicting PCa was 0.26 cm3 with a sensitivity, specificity, PPV, and NPV of 80.7%, 42.7%, 41.2%, and 74.6%, respectively. Conclusion PLV may serve as a useful measure to triage patients prior to MRI-US fusion biopsy and help better understand the limits of this technology for individual patients.
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Affiliation(s)
| | | | | | - Paul E Andrews
- Department of Urology, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Stephen S Cha
- Department of Research Biostatistics, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Alvin C Silva
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
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Das AK, Teplitsky S, Humphreys MR. Holmium laser enucleation of the prostate (HoLEP): a review and update. Can J Urol 2019; 26:13-19. [PMID: 31481144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is one of the most common diseases affecting the aging man, with almost 80% of men greater than 70 affected. Historically, transurethral resection of the prostate (TURP) has been considered the historical gold standard in the treatment of LUTS due to BPH for many years, contemporary literature indicates that holmium laser enucleation of the prostate (HoLEP) has replaced TURP and open simple prostatectomy as the size independent surgical gold standard for BPH treatment. MATERIALS AND METHODS In this review, we discuss the current techniques utilized, outcomes and safety, as well as the long term durability of results. Adverse events associated with the HoLEP procedure, both enucleation and morcellation, are covered as well. RESULTS HoLEP has a robust body of literature supporting the technique, which demonstrates its ability to surpass other surgical BPH procedures, including TURP and open simple prostatectomy. Additionally, there is long term durability of both subjective and objective outcomes greater than 10 years associated with this procedure. One randomized trial showed specific postoperative outcome measures that were superior to TURP at 7 years of follow up, including Qmax (4.36 mL/s improvement), erectile function (2.39 points improvement on the IIEF erectile function section), and weight of prostate removed (15.7 grams greater), while other studies have shown greater reduction in postoperative PSA, lower detrusor pressure at Qmax, and more. CONCLUSIONS Overall, HoLEP has proven to be an extremely durable and effective treatment for patients suffering from LUTS due to BPH. Both the Europeans and AUA guidelines on the surgical treatment of BPH recommend HoLEP as a size-independent treatment option for those men with moderate to severe symptoms. HoLEP is an excellent option for many patients who may not be good candidates for other procedures based on prostate size, age, or bleeding risk.
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Affiliation(s)
- Akhil K Das
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Tay K, Navaratnam A, McAdams S, Keddis M, Neville M, Humphreys MR. Predictive Factors for Achieving the Recommended AUA Daily Urine Production in Patients With Nephrolithiasis. Mayo Clin Proc Innov Qual Outcomes 2019; 3:141-148. [PMID: 31193855 PMCID: PMC6543444 DOI: 10.1016/j.mayocpiqo.2019.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Objective To identify factors that predict kidney stone patient's ability to produce 2.5 L urine volume per day on metabolic evaluation. Patients and Methods In a retrospective chart review, the first analysis evaluated initial 24-hour urine collections with respect to those who achieved or did not achieve a urine volume of 2.5 L/day. The second analysis evaluated those who achieved or did not achieve a daily urine volume of 2.5 L on their subsequent collection. Several variables were assessed. Results Patients' initial collections (n=1100) that achieved 2.5 L/day (n=274) were of younger age and had a higher body mass index, increased urine sodium, phosphorus, calcium levels, increased protein catabolic rate, and decreased supersaturation of calcium oxalate. In the second analysis (n=273), decreased supersaturation of calcium oxalate, increased urine urea nitrogen level, and increased protein catabolic rate were observed in subsequent collections with a urine volume of 2.5 L/day or more. Patients with a diagnosis of hyponatremia were less likely to achieve 2.5 L/day urine volume. Collection date, other comorbidities, and diuretic use were not associated with achieving 2.5 L/day urine volume. Patients' mean creatinine per kilogram for all study cohorts were within the range of adequate collection. Conclusion Predictive factors for a urine volume of 2.5 L/day or more include increased fluid intake, higher salt and animal protein diet, elevated body mass index, and male sex. Patients with these factors may require interventions other than hydration recommendations to optimize their prevention of future kidney.
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Affiliation(s)
| | | | | | - Mira Keddis
- Department of Urology, Mayo Clinic, Phoenix, AZ
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Faraj K, Chang YHH, Neville MR, Blodgett G, Etzioni DA, Habermann EB, Andrews PE, Castle EP, Humphreys MR, Tyson MD. Robotic vs. open cystectomy: How length-of-stay differences relate conditionally to age. Urol Oncol 2019; 37:354.e1-354.e8. [PMID: 30770298 DOI: 10.1016/j.urolonc.2019.01.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/20/2018] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The length-of-stay (LOS) benefit of minimally invasive cystectomy varies in the published literature, potentially because of subgroup effects. Here, we investigated the effect of minimally invasive cystectomy on LOS among different age groups. METHODS AND MATERIALS Adult patients who underwent cystectomy (open or minimally invasive) from January 1, 2012, to December 31, 2016, were identified from the National Surgical Quality Improvement Program database. Multivariable linear regression was used to evaluate the adjusted association between the surgical approach and LOS after stratifying patients by age (40-64, 65-79, and ≥80 years). A sensitivity analysis was performed after multiple imputation by using age as a continuous variable with a third-order polynomial term. RESULTS Of the 5,561 patients identified, 640 underwent minimally invasive cystectomy and 4,921 had open cystectomy. The unadjusted analysis showed that minimally invasive cystectomy was associated with a shorter mean LOS compared with the open approach (8.0 vs. 9.7 days; P < 0.001). The predicted difference in LOS between the 2 approaches was 0.72 days (95% confidence interval (CI), -0.28 to 1.72; P = 0.16) for patients aged 40 to 64 years, 1.48 days (95% CI, 0.73-2.23; P < 0.001) for 65 to 79 years, and 2.56 days (95% CI, 0.84-4.29; P = 0.01) for ≥80 years favoring the minimally invasive approach. The sensitivity analysis did not materially change the results. CONCLUSIONS Older patients may derive more LOS benefit from minimally invasive approaches than younger patients. Given the greater expense associated with the minimally invasive approach, an age-adapted strategy to using this technology may be reasonable.
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Affiliation(s)
- Kassem Faraj
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ
| | | | | | - Gail Blodgett
- Biostatistics, and Patient Collaborator, Mayo Clinic, Scottsdale, AZ
| | - David A Etzioni
- Department of Urology, Division of Colon and Rectal Surgery, Mayo Clinic Hospital, Phoenix, AZ
| | | | - Paul E Andrews
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ
| | - Erik P Castle
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ
| | | | - Mark D Tyson
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ.
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Chew BH, Miller NL, Abbott JE, Lange D, Humphreys MR, Pais VM, Monga M, Krambeck AE, Sur RL. A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics Prior to Percutaneous Nephrolithotomy in a Low Infectious Risk Population: A Report from the EDGE Consortium. J Urol 2018; 200:801-808. [PMID: 29684391 DOI: 10.1016/j.juro.2018.04.062] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Single institution studies suggest a benefit of a week of preoperative antibiotics prior to percutaneous nephrolithotomy. These studies are limited by lower quality methodology, such as the inclusion of heterogeneous populations or nonstandard definitions of sepsis. The AUA (American Urological Association) Best Practice Statement recommends less than 24 hours of intravenous antibiotics but to our knowledge no other data exist on the duration or benefit of preoperative antibiotics. Using CONSORT (Consolidated Reporting of Trials) guidelines we sought to perform a rigorous multi-institutional trial to assess preoperative antibiotics in patients in whom percutaneous nephrolithotomy was planned and who were at low risk for infection. MATERIALS AND METHODS This randomized controlled trial enrolled patients undergoing percutaneous nephrolithotomy who were at low risk, defined as negative preoperative urine cultures and no urinary drain. Of the subjects 43 were randomized to nitrofurantoin 100 mg twice daily for 7 days preoperatively while a control arm of 43 received no oral antibiotics. All subjects received perioperative doses of ampicillin and gentamicin. Prone percutaneous nephrolithotomy was performed by urologists blinded to randomization. The primary outcome was the development of sepsis. RESULTS A total of 86 subjects were enrolled. Preoperative patient characteristics were similar in the treatment and control cohorts with a stone size of 19 and 17 mm, respectively (p = 0.47). Intraoperative characteristics also did not differ. The sepsis rate was not statistically different between the treatment and control groups (12% and 14%, respectively, 95% CI -0.163-0.122, p = 1.0). Other infectious parameters and complications were similar, including intensive care admission, fever, hypotension and leukocytosis. CONCLUSIONS Our study demonstrated no advantage to providing 1 week of preoperative oral antibiotics in patients at low risk for infectious complications who undergo percutaneous nephrolithotomy. Perioperative antibiotics according to the AUA Best Practice Statement appear sufficient.
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Affiliation(s)
- Ben H Chew
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Dirk Lange
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Vernon M Pais
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | | | - Roger L Sur
- University of California-San Diego, San Diego, California.
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Flannigan RK, Battison A, De S, Humphreys MR, Bader M, Lellig E, Monga M, Chew BH, Lange D. Evaluating factors that dictate struvite stone composition: A multi-institutional clinical experience from the EDGE Research Consortium. Can Urol Assoc J 2017; 12:131-136. [PMID: 29319486 DOI: 10.5489/cuaj.4804] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Struvite stones account for 15% of urinary calculi and are typically associated with urease-producing urinary tract infections and carry significant morbidity. This study aims to characterize struvite stones based on purity of stone composition, bacterial speciation, risk factors, and clinical features. METHODS Retrospective data was collected from patients diagnosed with infection stones between 2008 and 2012. Stone analysis, perioperative urine cultures, bacterial speciation, and clinical data were collected and analyzed. The purity of struvite stones was determined. Statistical comparisons were made among homogeneous and heterogeneous struvite stones. RESULTS From the four participating centres, 121 struvite stones were identified. Only 13.2% (16/121) were homogenous struvite. Other components included calcium phosphate (42.1%), calcium oxalate (33.9%), calcium carbonate (27.3%), and uric acid (5.8%). Partial or full staghorn calculi occurred in 23.7% of cases. Urease-producing bacteria were only present in 30% of cases. Proteus, E. coli, and Enterococcus were the most common bacterial isolates from perioperative urine, and percutaneous nephrolithotomy was the most common modality of treatment. Only 40% of patients had a urinalysis that was nitrite-positive, indicating that urinalysis alone is not reliable for diagnosing infection stones. The study's limitation is its retrospective nature; as such, the optimal timing of cultures with respect to stone analysis or treatment was not always possible, urine cultures were often not congruent with stone cultures in the same patient, and our findings of E. coli commonly cultured does not suggest causation. CONCLUSIONS Struvite stones are most often heterogeneous in composition. Proteus remains a common bacterial isolate; however, E. coli and Enterococcus were also frequently identified. This new data provides evidence that patients with struvite stones can have urinary tract pathogens other than urease-producing bacteria, thus challenging previous conventional dogma.
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Affiliation(s)
- Ryan K Flannigan
- The Stone Centre at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, Vancouver BC, Canada
| | - Andrew Battison
- The Stone Centre at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, Vancouver BC, Canada
| | - Shubha De
- Stevan Streem Centre of Endourology & Stone Disease, The Cleveland Clinic, Cleveland, OH, United States
| | - Mitchell R Humphreys
- Department of Urology, Mayo Clinic, Phoenix, Arizona, Mayo Clinic, Phoenix, AZ, United States
| | | | | | - Manoj Monga
- Stevan Streem Centre of Endourology & Stone Disease, The Cleveland Clinic, Cleveland, OH, United States
| | - Ben H Chew
- The Stone Centre at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, Vancouver BC, Canada
| | - Dirk Lange
- The Stone Centre at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, Vancouver BC, Canada
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York NE, Borofsky MS, Chew BH, Dauw CA, Paterson RF, Denstedt JD, Razvi H, Nadler RB, Humphreys MR, Preminger GM, Nakada SY, Krambeck AE, Miller NL, Terry C, Rawlings LD, Lingeman JE. Randomized Controlled Trial Comparing Three Different Modalities of Lithotrites for Intracorporeal Lithotripsy in Percutaneous Nephrolithotomy. J Endourol 2017; 31:1145-1151. [PMID: 28859485 DOI: 10.1089/end.2017.0436] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To compare the efficiency (stone fragmentation and removal time) and complications of three models of intracorporeal lithotripters in percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS Prospective, randomized controlled trial at nine centers in North America from 2009 to 2016. Patients were randomized to one of three lithotripter devices: the Cyberwand, a dual-probe ultrasonic device; the Swiss Lithoclast Select, a combination pneumatic and ultrasonic device; and the StoneBreaker, a portable pneumatic device powered by CO2 cartridges. Since the StoneBreaker lacks an ultrasonic component, it was used with the LUS-II ultrasonic lithotripter to allow fair comparison with combination devices. RESULTS Two hundred seventy patients were enrolled, 69 were excluded after randomization. Two hundred one patients completed the study: 71 in the Cyberwand group, 66 in the Lithoclast Select group, and 64 in the StoneBreaker group. The baseline patient characteristics of the three groups were similar. Mean stone surface area was smaller in the StoneBreaker group at 407.8 mm2 vs 577.5 mm2 (Lithoclast Select) and 627.9 mm2 (Cyberwand). The stone clearance rate was slowest in the StoneBreaker group at 24.0 mm2/min vs 28.9 mm2/min and 32.3 mm2/min in the Lithoclast Select and Cyberwand groups, respectively. After statistically adjusting for the smaller mean stone in the StoneBreaker group, there was no difference in the stone clearance rate among the three groups (p = 0.249). Secondary outcomes, including complications and stone-free rates, were similar between the groups. CONCLUSIONS The Cyberwand, Lithoclast Select, and the StoneBreaker lithotripters have similar adjusted stone clearance rates in PCNL for stones >2 cm. The safety and efficacy of these devices are comparable.
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Affiliation(s)
- Nadya E York
- 1 Department of Urology, Indiana University School of Medicine , Indianapolis, Indiana
| | - Michael S Borofsky
- 2 Department of Urology, University of Minnesota , Minneapolis, Minnesota
| | - Ben H Chew
- 3 Urologic Sciences, Faculty of Medicine, University of British Columbia , Vancouver, Canada
| | - Casey A Dauw
- 4 Department of Urology, University of Michigan , Ann Arbor, Michigan
| | - Ryan F Paterson
- 3 Urologic Sciences, Faculty of Medicine, University of British Columbia , Vancouver, Canada
| | - John D Denstedt
- 5 Division of Urology, Western University , London, Ontario, Canada
| | - Hassan Razvi
- 5 Division of Urology, Western University , London, Ontario, Canada
| | - Robert B Nadler
- 6 Department of Urology, Northwestern University , Chicago, Illinois
| | | | | | - Stephen Y Nakada
- 9 Department of Urology, University of Wisconsin , Madison, Wisconsin
| | - Amy E Krambeck
- 1 Department of Urology, Indiana University School of Medicine , Indianapolis, Indiana.,10 Mayo Clinic , Rochester, Minnesota
| | - Nicole L Miller
- 11 Department of Urology, Vanderbilt University , Nashville, Tennessee
| | - Colin Terry
- 12 Methodist Research Institute , Indianapolis, Indiana
| | - Lori D Rawlings
- 1 Department of Urology, Indiana University School of Medicine , Indianapolis, Indiana
| | - James E Lingeman
- 1 Department of Urology, Indiana University School of Medicine , Indianapolis, Indiana
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McAdams S, Nunez-Nateras R, Martin CJ, Cha S, Humphreys MR. Morcellation Efficiency in Holmium Laser Enucleation of the Prostate: Oscillating Morcellator Outperforms Reciprocating Morcellator With no Apparent Learning Curve. Urology 2017; 106:173-177. [DOI: 10.1016/j.urology.2017.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 05/08/2017] [Accepted: 05/10/2017] [Indexed: 12/22/2022]
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McAdams S, Funk JT, Navetta AF, El Tayeb MM, Humphreys MR. Holmium Laser Enucleation of the Prostate After Prostatic Urethral Lift Surgery: Feasibility and Technical Considerations from a Multi-Institutional Case Series. J Endourol 2017; 31:774-779. [PMID: 28586247 DOI: 10.1089/end.2017.0224] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Ten percent of patients undergoing prostatic urethral lift (PUL) require repeat surgical treatment within 3 years. We describe the feasibility and considerations of performing holmium laser enucleation of the prostate (HoLEP) as a salvage therapy after previous PUL. METHODS Men who had undergone HoLEP after PUL were retrospectively identified from three institutions with surgeons experienced in HoLEP. Subjects were characterized by age, time from PUL procedure (months) to HoLEP surgery, indication for retreatment, and pre-operative prostate volume by ultrasound. Outcomes of interest included enucleation time, morcellation time, morcellator type, weight of tissue resected, and Clavien complications. We also summarize findings related to the location of PUL device implants, and the effect of the implants on the enucleation and morcellation portions of the procedure. RESULTS From December 15, 2015 to October 31, 2016, seven men aged 51-78 years underwent HoLEP at a median of 8.6 months (range 3-18) after PUL. The median prostate volume by transrectal ultrasound was 80 cm3 (range 56-160 cm3). For the 7 patients, 6 out of the 22 device implants were found in aberrant locations. Auxiliary maneuvers were required in five cases. Morcellation devices tended to jam with each implant, requiring a pause for withdrawal of the morcellator and manual removal from the blade or requiring grasper retrieval of device components. There were no Clavien complications. CONCLUSIONS HoLEP can be performed safely and effectively post-PUL; however, device implants may be found in areas other than the intended location, and morcellation of the adenoma tissue is complicated by metallic implants of the PUL device.
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Affiliation(s)
- Sean McAdams
- 1 Department of Urology, Mayo Clinic , Phoenix Arizona
| | - Joel T Funk
- 2 Division of Urology, Department of Surgery, Banner University Medical Group , Tuscon, Arizona
| | - Andrew F Navetta
- 3 Division of Urology, Department of Surgery, Baylor Scott & White Health , Temple, Texas
| | - Marawan M El Tayeb
- 3 Division of Urology, Department of Surgery, Baylor Scott & White Health , Temple, Texas
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Marien T, Kadihasanoglu M, Tangpaitoon T, York N, Blackburne AT, Abdul-Muhsin H, Borofsky MS, Krambeck AE, Humphreys MR, Lingeman JE, Miller NL. Outcomes of Holmium Laser Enucleation of the Prostate in the Re-Treatment Setting. J Urol 2017; 197:1517-1522. [DOI: 10.1016/j.juro.2016.12.098] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Tracy Marien
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Nadya York
- Indiana University School of Medicine, Indianapolis, Indiana
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