Journal of Urology最新文献

Purpose: Ureteral stents are commonly placed intraoperatively during radical cystectomy, although their efficacy in reducing complications is unproven. We compared clinical outcomes among patients undergoing robot-assisted radical cystectomy with intracorporeal ileal conduit (RARC-IC) with or without ureteral stents to determine if omission of ureteral stents affects postoperative complications.

Materials and methods: All RARC-IC surgeries performed at our institution between November 2017 and June 2023 were reviewed. Beginning August 2021, ureteral stents were routinely omitted. Primary outcome was ureteroenteric anastomosis complications (urine leak, UTI, abscess, and/or sepsis) within 30 and 90 days of RARC-IC. Secondary outcomes included rates of wound infections, urgent care center visits, inpatient readmissions, and ureteral stricture.

Results: Among 133 patients included, 90 patients (68%) received a ureteral stent and 43 (32%) did not. Composite ureteroenteric anastomosis complications were higher in the stented group (20% vs 9.5%, 10% difference, 95% CI, -3.4% to 24%, P = .2), though not statistically significant. The stented group had a significantly higher 30-day UTI rate (19% difference, 95% CI, 9.0%-29%, P = .007). The 30-day readmission rates were higher in the stented group, although differences did not meet statistical significance (19% vs 9.8%, 9.1% difference, 95% CI, -4.8% to 23%, P = .3). Limitations include lack of randomization and inability to evaluate some outcomes, including ureteral obstruction or strictures.

Conclusions: Omission of ureteral stent placement at RARC-IC is safe and feasible. Randomized trials are warranted to determine the effects of stents on risk of postoperative complications after RARC-IC.

Purpose: Postoperative prognostic tools allow for improved prediction of future recurrence risk, patient counseling, assessment of eligibility for adjuvant treatments, and appropriate follow-up surveillance. The purpose of this analysis was to validate prognostic models for patients with kidney cancer.

Materials and methods: The Canadian Kidney Cancer information system is a prospective cohort of patients managed at 14 institutions since January 1, 2011, to present. The Canadian Kidney Cancer information system was used to assess 15 predictive models for kidney cancer recurrence, 6 for cancer-specific mortality, and 4 for all-cause mortality in patients with a solitary, nonmetastatic kidney tumor treated with surgery (partial or radical nephrectomy). Discrimination was measured using C statistics, 5-year calibration plots for calibration, and decision curve analysis at 5 years after surgery for net benefit when considering adjuvant therapy.

Results: Seven thousand one hundred seventy-four patients were included. For kidney cancer recurrence, C statistics ranged from 0.62 to 0.83, depending on whether the model was derived and applied to all patients without further stratification, specific risk groups, or specific histologic subtypes. Cancer-specific mortality models had C statistics ranging from 0.60 to 0.89 and all-cause mortality models from 0.60 to 0.73. Using decision curve analysis in patients with clear-cell renal cell carcinoma, the best models for choosing adjuvant therapy to prevent recurrence and cancer-related death were the Mayo Clinic prediction models.

Conclusions: Model performance varied considerably with some suitable for clinical use. If using prediction models to select adjuvant therapy, the Mayo Clinic models were best when applied to a large contemporary cohort of Canadian patients.

Purpose: We describe and develop predictors for spontaneous resolution of primary obstructive megaureter (POM) from early ultrasound (US) measures.

Materials and methods: Children referred to our institution between 2007 and 2023 for POM were reviewed. POM was defined as hydroureteronephrosis with ureteral dilation > 7 mm. We excluded patients with other etiologies for upper tract dilation. Resolution was defined as decrease in hydronephrosis to < 10 mm anteroposterior diameter (APD) or Society for Fetal Urology grade ≤ 2 or ≤ 7 mm in hydroureter. Patients were censored if they underwent surgical intervention or were lost to follow-up before documenting resolution. Kaplan-Meier curves were drawn to illustrate the cumulative resolution rate and determine univariate associations. Cox proportional hazards regression was performed to identify significant predictors for early resolution, and C index was calculated.

Results: A total of 159 patients were included, with a median index age of 2 months and a median follow-up of 30 months. Of these, 89 patients reached spontaneous resolution during monitoring, and likelihood of surgical indication at 1 year from US was 30%. APD > 15 mm, high-grade hydronephrosis, ureteral dilation > 10 mm, and ureter tortuosity at presentation were associated with a lower likelihood of resolution for individual Kaplan-Meier curves. A Cox regression model trained on these predictors achieved an adjusted C index of 0.68, and low APD remained associated with a higher likelihood of resolution.

Conclusions: Early sonographic features in POM, specifically APD, are associated with the likelihood of spontaneous resolution. Patients with high-risk features at first US warrant closer follow-up.

Purpose: We developed prediction models for severe pain and urinary symptoms after ureteroscopy with ureteral stent placement.

Materials and methods: The development cohort included 424 adults and adolescents enrolled in the multicenter STENTS prospective cohort study who underwent ureteroscopy with stent placement for urinary stones. The validation cohort was an independent prospective cohort of 115 adults. The outcomes were severe pain intensity and pain interference, measured by the Patient-Reported Outcomes Measurement Information System, and severe urinary symptoms, measured by the Ureteral Stent Symptom Questionnaire. The top quartile of symptoms on postoperative days 1 and 3 was defined as severe. Generalized estimating equation models were used to predict severe symptoms on postoperative days 1, 3, 5, and 7 to 9 in the development cohort and severe pain interference on days 1 and 7 in the validation cohort.

Results: Female sex, younger age, higher BMI, baseline pain interference, number of chronic pain conditions, renal stone location, and history of anxiety predicted severe pain. In the development cohort, the C statistics were 0.83 (95% CI 0.80-0.85) for severe pain interference and 0.82 (95% CI 0.79-0.84) for severe pain intensity. A model in which baseline urinary symptoms replaced pain interference had excellent discrimination for severe urinary symptoms (C statistic 0.83; 95% CI 0.81-0.85). In the validation cohort, the C statistic was 0.7 for severe pain interference (95% CI 0.54-0.78).

Conclusions: Preoperative characteristics accurately predicted severe pain and urinary symptoms after ureteroscopy with stent placement. On further validation, these models could guide clinical decisions to improve surgical outcomes.