A multicenter comparison of the safety and effectiveness of ureteroscopic laser lithotripsy in obese and normal weight patients.

OBJECTIVE: Surgical treatment of kidney stones in an obese patient (body mass index [BMI] >30 kg/m(2)) remains challenging as shockwave lithotripsy may not be an option due to weight limitations. We sought to determine the effectiveness of ureteroscopic laser lithotripsy in obese patients compared to nonobese controls. MATERIALS AND METHODS: Patients from 2004 to 2007 were retrospectively analyzed providing a group of 292 patients (163 obese, 76 overweight, 53 normal) who underwent ureteroscopic procedures for urolithiasis at four centers in the United States and Canada. RESULTS: The percentage of obese patients requiring flexible ureteroscopy (URS) (79%) was higher than in the other groups (P<0.0001). Flexible URS was associated with a lower stone-free rate (SFR) on multivariate analysis (P=0.034). There was no difference in SFRs of patients who required a ureteral access sheath, basket extraction, or received a postoperative stent. Complication rates did not differ between groups. CONCLUSION: SFRs using ureteroscopic lithotripsy in obese and overweight populations are the same as in the normal weight patients. A flexible ureteroscope was associated with a decreased SFR, but this likely due to a more proximal stone location in these patients. Ureteroscopic laser lithotripsy is an effective and safe technique to treat urolithiasis in the overweight/obese patient.

Ureteroscopy for transplant lithiasis.

BACKGROUND AND PURPOSE: The optimal management of renal and ureteral calculi in transplanted kidneys is not well defined. Although larger (>1.5 cm) stone burdens are generally treated with percutaneous nephrolithotomy (PCNL), smaller stones may be reasonably approached with retrograde or antegrade ureteroscopy (URS). We report our multicenter experience with URS for transplant lithiasis. PATIENTS AND METHODS: URS performed for stone disease within a transplanted kidney were retrospectively identified at three stone-referral centers between 2006 and 2011. Demographic and disease parameters were recorded, as were perioperative and postoperative details. RESULTS: Twelve patients underwent URS for a calculus in a transplant renal unit and/or ureter. For retrograde procedures (7), access to the ureteral orifice was facilitated by the use of a Kumpe catheter; a two-wire (safety and working guidewire) technique was used. For antegrade procedures (5), the ureteroscope was passed into the kidney using a two-wire technique without tract dilation. All stones but one necessitated holmium:yttrium-aluminum-garnet laser lithotripsy with extraction of stone fragments. All patients were stone free on postoperative imaging except for one patient with a 2-mm fragment that was observed. Stone analysis included calcium oxalate (6), calcium phosphate (4), and struvite (1). CONCLUSION: Antegrade and retrograde URS are safe and effective treatments for patients with simple stone burdens in a transplanted kidney. Although retrograde access to the ureter can be challenging, specialized techniques and modern endoscope technology facilitate this process. Antegrade URS for small stone burdens can be performed safely and effectively without tract dilation.

Immunotherapy in the treatment of advanced prostate cancer.

Prostate cancer is a complex disease, and treatment selection is informed by numerous variables depending on the stage of disease. Moreover, patient expectations and the impact of treatment-related adverse events may influence treatment choices. Available treatment options over the course of the disease have included surgery, radiation therapy, hormonal therapy, immunotherapy, and chemotherapy. This complexity requires an understanding of a wide range of treatment options and the support of a multidisciplinary team that involves urologists, radiation oncologists, diagnostic radiologists, pathologists, and medical oncologists. Collaboration among these physicians allows for a comprehensive treatment strategy that addresses the individual needs of the patient throughout the course of his disease. Prior to 2004, treatment options for metastatic castrate-resistant prostate cancer (CRPC) were limited to therapies for palliation of pain and reduction of skeletal-related events. Over the past 7 years, four therapeutic options-three within the last 2 years-that provide a survival benefit in this setting have been approved. These therapies have diverse mechanisms, perhaps reflecting the complex nature of advanced prostate cancer. Among them is sipuleucel-T, the first autologous immunotherapy approved for any cancer. This review will discuss the rapidly changing treatment environment for metastatic CRPC and the increased exploration of immunotherapeutic approaches to advanced prostate cancer.

New findings in localized and advanced prostate cancer: AUA 2011 review.

The 2011 American Urological Association (AUA) annual meeting took place in Washington, DC, USA, on May 14-19. It is the largest gathering of urologists in the world, providing unparalleled access to groundbreaking research, new guidelines and the latest advances in urologic medicine. The opportunity to exchange knowledge among urologists on a worldwide level was provided by participation of more than 80 countries in this scientific meeting. As one of the most important subjects, there were more than 500 presented studies in prostate cancer. In this review we will highlight some of the findings and the clinical significance of a few of these abstracts concerning prostate cancer staging and markers.

Heterogeneity in the reporting of disease characteristics and treatment outcomes in studies evaluating treatments for nephrolithiasis.

BACKGROUND AND PURPOSE: There is no standardization in the nephrolithiasis literature regarding preoperative or postoperative evaluation of patients who are undergoing treatment for stone disease. This may hinder comparisons of efficacy of different treatment modalities. We evaluated heterogeneity in the literature of preoperative and postoperative evaluations of patients who were undergoing surgical treatment for nephrolithiasis. MATERIALS AND METHODS: A systematic PubMed search was performed for 2006 to 2008 using search terms kidney stones, ureteral stones, nephrolithiasis, ureterolithiasis, ureteroscopy (URS), shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL). Articles that evaluated treatment outcomes were included, and information regarding preoperative and postoperative evaluation was collected. RESULTS: One hundred and fifty-four studies were included. Preoperative stone burden was evaluated using CT (42), ultrasonography (US) (42), plain radiography of the kidneys, ureters, and bladder (KUB) (92), multiple modalities (52), and no mention (45). Stone burden was reported as maximum diameter (105), surface area (32), volume (6), other (1), and no mention (10). Treatment modalities included URS (46), PCNL (71), SWL (50), and multiple modalities (9). Postoperative imaging included CT (37), US (67), KUB (115), multiple modalities (70), other (11) and no mention (19). Radiographic outcomes included strict stone free (114) and presence of residual fragments (RF) (64). There was wide variation in the size of RF reported (<1 mm through <7 mm). "Stone free" included the presence of RF in 18 studies. Treatment "success" was defined to include RF of various sizes. Reported clinical outcomes included stone-related events (46) and surgery (90). CONCLUSIONS: There is extensive variability in the reporting of preoperative disease characteristics and postoperative outcomes in studies that evaluate treatments for nephrolithiasis. Standardization of these criteria is essential for more meaningful comparisons of treatment modalities and outcomes for different disease subgroups.

Trends in the use of gross and frozen section pathological consultations during partial or radical nephrectomy for renal cell carcinoma.

PURPOSE: There is no consensus regarding the role of intraoperative pathological consultation during kidney cancer surgery. Accordingly intraoperative pathological consultation use is susceptible to variation based on nonclinical factors. We explored this hypothesis by evaluating national trends in the use of intraoperative pathological consultation during radical or partial nephrectomy with time, across regions, and by patient and provider characteristics. MATERIALS AND METHODS: Using linked Surveillance, Epidemiology and End Results-Medicare data we identified a cohort of patients who underwent partial or radical nephrectomy from 1991 to 2002. In each case we ascertained corresponding Medicare claims for gross and/or frozen section intraoperative pathological consultation. We assessed variations in the use of intraoperative pathological consultation by year of treatment and geographic region as well as by patient and provider characteristics. RESULTS: We identified 7,507 cases treated with partial (600 or 8.0%) or radical (6,907 or 92.0%) nephrectomy from 1991 through 2002. Of cases treated with radical nephrectomy 744 (10.8%) and 843 (12.2%) received gross and frozen section intraoperative pathological consultation, respectively. Of cases treated with partial nephrectomy 67 (11.2%) had an intraoperative gross consultation and 323 (53.8%) had a frozen section evaluation. Use of intraoperative pathological consultation (gross or frozen section) during partial and radical nephrectomy varied based on patient demographics, United States Census region, and Surveillance, Epidemiology and End Results registry (p <0.05). Intraoperative pathological consultation during radical nephrectomy differed by year of treatment (p <0.05). Intraoperative pathological consultation use also varied based on provider characteristics (p <0.05). CONCLUSIONS: Intraoperative pathological consultation use during kidney cancer surgery varies with time, across geographic regions and based on patient demographics and broadly defined provider characteristics. These data provide context for future studies seeking to refine the use of intraoperative pathological consultation in this clinical setting.