Urology Practice最新文献

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

Methods: Our sample included Medicare beneficiaries with elevated PSA. The outcome variable was receipt of prostate MRI in the prediagnostic setting. A multivariate logistic regression analysis adjusting for sociodemographic factors and clustered by hospital referral region was performed to test the association between degree of rurality and receipt of MRI.

Results: Among 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 with "urban" or "rural" counties. There were 33% lower odds of obtaining MRI among rural communities compared with metro communities (adjusted OR 0.67; 95% CI: 0.59-0.74; P < .001).

Conclusions: Despite evidence that MRI is an extremely useful tool in the prediagnostic setting, fewer than 1 in 20 beneficiaries in this study 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.

Introduction: Benign scrotal conditions, including hydroceles, spermatoceles, and epididymal cysts, are frequently managed surgically under general or spinal anesthesia. Although this ensures adequate intraoperative analgesia, these methods increase perioperative risk, cost, and resource utilization. Local anesthesia (LA) offers a potential alternative, but contemporary outcome and complication data specific to benign scrotal surgery are limited.

Methods: We conducted a retrospective review of all adult patients undergoing hydrocelectomy, spermatocelectomy, epididymectomy, or testicular biopsy under LA alone at an ambulatory surgical center from October 2022 to February 2025. An equal mixture of 1% lidocaine and 0.25% bupivacaine was administered through a spermatic cord block and along the median raphe. Patient demographics, intraoperative events, postoperative complications, emergency department visits, primary care follow-up, and hospital admissions were analyzed with descriptive statistics.

Results: A total of 303 procedures were performed: 43.6% hydrocelectomies, 33.3% spermatocelectomies, 10.2% epididymectomies, and 12.2% testicular biopsies. Mean patient age was 52.5 years, and mean BMI was 30.0 kg/m². All surgeries were successfully completed under LA without conversion or procedural termination. No intraoperative complications were reported. At 4- to 6-week follow-up, no patients required family physician visits for procedure-related issues. 1.0% (n = 3) presented to the emergency department for suspected wound infections, and no hospital admissions occurred.

Conclusions: Benign scrotal procedures can be safely and effectively performed in an ambulatory setting under LA alone, with low complication rates and high procedural success. This approach offers significant potential to improve surgical efficiency, reduce health care costs, and enhance access to timely urologic care.

Introduction: Our goal was to compare rates and risk factors for infection-related hospitalizations with and without ureteral access sheath (UAS) use during ureteroscopy (URS) for renal stones.

Methods: Using the Michigan Urological Surgery Improvement Collaborative clinical registry, we identified patients who underwent single-stage unilateral URS for renal stones. We assessed variation in UAS usage across practices and surgeons. We compared demographics of cases with and without UAS. Multivariable logistic regression was used to evaluate UAS use and clinical factors on 30-day infection-related hospitalization.

Results: Six thousand one hundred forty-two patients underwent URS by 233 urologists across 34 practices and 152 (2.5%) had an infection-related hospitalization within 30 days. UAS was used in 59% of cases, with significant variation between practices (4.1%-99.5%, P < .001). Infection-related hospitalization was similar with (2.6%) and without (2.3%) UAS use (P = .5). On multivariable analysis, infection-related hospitalizations did not differ by UAS (odds ratio [OR] 0.8 [95% CI: 0.6-1.2]), but were associated with higher Charlson Comorbidity Index (CCI; CCI 1 vs 0, OR 1.9 [95% CI: 1.2-2.9]; CCI 2+ vs 0, OR 2.3 [95% CI: 1.4-3.6]), history of recurrent UTI (OR 2.4 [95% CI: 1.4-4.0]), larger stones (OR per 5 mm 1.1 [95% CI: 1.0-1.3]), and positive preoperative urinalysis and/or culture (OR 1.8 [95% CI: 1.2-2.7]).

Conclusions: UAS use in URS for renal stones varies across Michigan and was not associated with lower infection-related hospitalization. Prospective studies on the implications of intrarenal pressure are needed.

Introduction: We investigated the effect of timing to stone surgery on perioperative outcomes and costs for patients who presented with renal colic and concomitant UTI.

Methods: The 2018 Healthcare Utilization Project databases were used to identify patients who presented with renal colic and underwent upper urinary tract stone surgery within 3 months. Patients were stratified by infection status at presentation and time to surgery. Binary logit model and ordered logistic regressions with average marginal effect were used to estimate the odds of 30-day postoperative revisit based on time to surgery, evaluate surgical timing on probability of cost quartiles, and identify variables associated with surgical timing.

Results: There were 11,695 total patients, 1654 (14%) with UTI and 914 (8%) with sepsis. Time to surgery was not associated with differences in 30-day postoperative revisit for either infection group. Total episode-related costs were higher when surgery occurred > 4 weeks, and preoperative costs were higher for all groups compared with surgery within 1 week (P < .001). UTI and sepsis showed a 7.2%- and 11.4%-point increased probability, respectively, of surgery occurring at > 4 weeks (P < .001).

Conclusions: We found no benefit in delaying surgery with respect to 30-day postoperative revisits for patients presenting with renal colic and concomitant UTI. Delays led to higher total episode-related costs, largely driven by the preoperative period. UTI at presentation was associated with delays in surgery, and our findings illustrate the importance of future prospective studies evaluating the impact of surgical timing on patients with urolithiasis and UTI.