Urology Practice最新文献

Introduction: Minimally invasive therapies (MITs) for overactive bladder (OAB) are effective for patients who have failed or cannot tolerate medical management. Despite this, rates of MIT are low and have remained stagnant. Using the AQUA database, we examine trends in utilization of MIT over time with a focus on patient and provider factors that affect selection of sacral neuromodulation (SNM) over other MITs for OAB.

Methods: The AQUA Registry was queried for adults with idiopathic OAB who received MIT from 2014 to 2023. Patients were analyzed by age, race, sex, insurance, and MIT trends over time. Multivariable logistic regression was used to evaluate patient and provider factors associated with SNM selection.

Results: Of 2,006,684 patients with idiopathic OAB, 58,840 (2.9%) received MIT; 19,582 (0.98%) SNM; 28,463 (1.4%) bladder onabotulinum toxin injection (BTX-A); and 17,045 (0.85%) percutaneous tibial nerve stimulation. There was an increase in those undergoing BTX-A and a decline in those undergoing SNM and percutaneous tibial nerve stimulation over time. Patients receiving SNM vs other MITs were more likely to be younger than 51 years, male, in a rural area, and seen in a high-volume OAB practice. Patients in the Southeastern and South Central sections were more likely to receive SNM.

Conclusions: Overall utilization of MIT was 2.9% over a 9-year period. While SNM has seen a decline in relative utilization compared with BTX-A, overall MIT use has stayed stagnant. Patient and provider demographics impact choice of SNM over other MITs. These findings highlight an opportunity to better understand trends and limitations when providing MITs.

Introduction: Patients with autosomal dominant polycystic kidney disease (ADPKD) frequently require nephrectomy before renal transplant or for clinical symptoms. We encountered no population-based data on perioperative outcomes for nephrectomy in patients with ADPKD, indicating a knowledge gap for patient counseling and quality benchmarking.

Methods: We analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2015-2022) to identify patients undergoing nephrectomy with a diagnosis of ADPKD. The primary outcome was major complications. Multivariable logistic regression was used to identify predictors of outcomes.

Results: The cohort comprised 823 patients with a median age of 54 years (range 19-87). Preoperative hypertension (79.3%), dialysis (49.2%), and steroid use (44.8%) were common. Major complications occurred in 7.0% of patients. Minimally invasive surgery was associated with lower major complication risk (odds ratio 0.269; P < .001), reduced length of stay (3 vs 6 days), and decreased transfusion rates (7.8% vs 29.1%). Preoperative steroid use was also associated with reduced risk. Dialysis status and bilateral nephrectomy were not significant predictors. Thirty-day mortality was noted in 4 patients (0.5%).

Conclusions: Major complications and death are rare after nephrectomy for ADPKD despite the high rate of dialysis and renal transplantation in this population. When technically feasible, minimally invasive surgery may be beneficial in nephrectomy for ADPKD.

Introduction: Nephrectomy remains the curative standard for localized renal cell carcinoma. Partial nephrectomy (PN) is generally favored over radical nephrectomy (RN) for patients with chronic kidney disease (CKD) stage 3a or worse to preserve renal function. However, evidence stratifying CKD progression risk by preoperative stage is limited. We aimed to compare stage-specific postoperative CKD progression by nephrectomy type.

Methods: We reviewed prospectively maintained nephrectomy databases from 2 academic institutions (2000-2024) for adults with localized renal cell carcinoma (T1-3N0M0), preoperative CKD2-4, and available demographic and clinical data. CKD stage was classified using CKD-Epidemiology (CKD-EPI) 2009 and 2021 equations. Multivariable logistic regression adjusted for age, gender, obesity, race, and nephrectomy type evaluated CKD stage progression within 2 to 6 months postoperatively. Ratio-of-odds analysis quantified relative deterioration risk by stage.

Results: Using CKD-EPI 2009 and 2021, 1257 and 1180 patients met criteria, respectively; ∼69% underwent RN. RN was associated with significantly higher odds of 1-stage deterioration across all CKD stages except CKD4 and 2-stage deterioration in CKD2 and CKD3a patients. No significant end-stage renal disease risk difference was observed in any stage. Ratio-of-odds analysis showed CKD2 patients had 2-fold to 3-fold higher deterioration risk than CKD3a following RN.

Conclusions: RN confers greater risk of CKD progression vs PN across preoperative CKD stages except CKD4, independent of estimated glomerular filtration rate equation. CKD2 patients demonstrated the highest relative deterioration risk. These findings suggest nephrectomy type may disproportionately affect patients with greater renal reserve, supporting broader use of PN above current guideline thresholds.

Introduction and objectives: MRI as an initial test for elevated PSA increases detection of clinically significant prostate cancer while reducing overdiagnosis. Despite its proven benefit, access to MRI in rural areas is limited. Prior studies on utilization of prostate MRI use cancer registries and therefore have limited ability to assess MRI use in the pre-diagnostic setting. We assess rural/urban disparities in MRI use among Medicare beneficiaries with elevated PSA.

Materials & methods: Our sample included Medicare beneficiaries with elevated PSA. The outcome variable was receipt of prostate MRI in the pre-diagnostic setting. A multivariate logistic regression analysis adjusting for sociodemographic factors and clustered by hospital referral region (HRR) was performed to test the association between degree of rurality and receipt of MRI.

Results: Amongst the 1,009,040 beneficiaries with elevated PSA, 4.87% (n=49,128) obtained an MRI. We observed significant differences in receipt of MRI by degree of rurality. Beneficiaries in the highest population density "metro" centers were more likely to receive an MRI as compared to "urban" or "rural" counties. There was 33% lower odds of obtaining MRI among "rural" communities compared to "metro" communities (aOR 0.67; 95% CI 0.59-0.74; p<0.001).

Conclusion: Despite evidence that MRI is an extremely useful tool in the pre-diagnostic setting, fewer than 1 in 20 beneficiaries in this studied received an MRI. Rural patients were less likely than their more urban counterparts to receive MRI for evaluation of elevated PSA. Barriers such as equipment, logistical expertise and workforce limitations may represent unique challenges for rural patients.