Adoption of robot-assisted radical nephroureterectomy permits a minimally invasive option for management of upper tract urothelial carcinoma in geriatric patients: comparison with non-geriatric patients with intermediate-term oncologic follow-up.

To assess the oncologic efficacy and safety of robot-assisted approach to radical nephroureterectomy (RARNU) in geriatric versus younger patients with upper tract urothelial carcinoma (UTUC). A single-center, retrospective cohort study was conducted from 2009 to 2022 of 145 patients (two cohorts: < 75 and ≥ 75 years old) with non-metastatic UTUC who underwent RARNU. Primary endpoint was UTUC-related recurrence of disease during surveillance (bladder-specific and metastatic). Safety was assessed according to 30-day, modified Clavien-Dindo (CD) classifications (Major: C.D. III-V). Survival estimates were performed using Kaplan-Meier method. There were 89 patients < 75 years (median 65 years) and 56 patients ≥ 75 years (median 81 years). Comparing the young versus geriatric cohorts: median follow-up 38 vs 24 months (p = 0.03, respectively) with similar 3-year bladder-specific recurrence survival (60% vs 67%, HR 0.70, 95% CI [0.35, 1.40], p = 0.31) and metastasis-free survival (79% vs 70%, HR 0.71, 95% CI [0.30, 1.70], p = 0.44). Expectedly, the younger cohort had a significant deviation in overall survival compared to the geriatric cohort at 1-year (89% vs 76%) and 3-years (72% vs 41%; HR 3.29, 95% CI [1.88, 5.78], p < 0.01). The 30-day major (1% vs 0) and minor complications (8% vs 14%, p = 0.87). Limitations include retrospective study design of a high-volume, single-surgeon experience. Compared to younger patients with UTUC, geriatric patients undergoing RARNU have similar oncologic outcomes at intermediate-term follow-up with no increased risk of 30-day perioperative complications. Thus, age alone should not be used to disqualify patients from definitive surgical management of UTUC with RARNU.

Refined step-by-step narrative review of robotic radical nephroureterectomy in the management of upper tract urothelial carcinoma.

Background and Objective: Upper tract urothelial carcinoma (UTUC) is a challenging clinical entity to diagnose and manage. Recent advances in robotic technology have permitted optimization of surgical technique in robot-assisted radical nephroureterectomy with bladder cuff excision (RNU/BCE), regional lymphadenectomy, and intra or perioperative instillation of intravesical chemotherapy. This has optimized the management of bulky upper tract disease and high-grade disease not amenable to segmental ureterectomy or nephron-sparing surgery. The purpose of this article is to highlight and review the surgical technique if RNU/BCE and regional lymphadenectomy utilized in our high-volume clinical practice. Methods: A review of our surgical approach was summarized for this narrative article. This technique has been refined over a course of more than 150 cases and 12 years of local experience with the procedure, as well as through multiple da Vinci® robotic surgical systems over the years. Key Content and Findings: RNU/BCE, regional template-based lymphadenectomy, and intra or perioperative instillation of intravesical chemotherapy is technically feasible and the procedure has been optimized via multiple iterations with a decade of local experience. The appropriate steps are outlined in this review. Conclusions: RNU/BCE, regional template-based lymphadenectomy, and intra or perioperative instillation of intravesical chemotherapy provides a refined, standardized, efficient approach for management of UTUC in appropriately selected patients. This surgical technique has also been undertaken in elderly patients including those with advanced age (>80 years old) with significant medical co-morbidities due to imperative, symptomatic indications. Further, this approach may be facilely adapted by urologists familiar with all forms of robotic renal surgery.

Safety and complications of continuation of aspirin therapy in patients undergoing robot-assisted laparoscopic simple prostatectomy.

To evaluate the safety and feasibility of continued perioperative aspirin at the time of robotic assisted simple prostatectomy (RASP). We performed a retrospective review of our IRB approved institutional database of patients who underwent RASP between 2013 and 2022. Comparative groups included patients taking aspirin in the perioperative period and those not taking aspirin pre-operatively. The primary outcome was any post-operative bleeding related complication using the modified Clavien-Dindo classification. Secondary outcomes included the identification of risk factors for increased blood loss in the entire study population, operative time, and blood transfusion requirement. 143 patients underwent RASP of which 55 (38.5%) patients continued perioperative aspirin therapy and 88 (61.5%) patients did not. Baseline demographics were similar between groups. Patients taking perioperative aspirin had a higher rate of hypertension (74.5% vs 58.0%, p = 0.04) and other cardiovascular disease (30.9% vs 11.4%, p = 0.007). Postoperative complications were similar between the groups (Clavien-Dindo ≥ 3; p = 0.43). Median blood loss (150 cc vs 150 cc, p = 0.38), percentage drop in hemoglobin (13.4 vs 13.2, p = 0.94) and blood transfusion rate (3.6 vs 1.1, p = 0.56) were also similar between groups. The median blood loss was 150 ml for the whole study population. On regression analysis, neither aspirin nor any other variable was associated with increased blood loss (> 150 ml). Aspirin can be safely continued perioperatively in patients undergoing RASP without any risk of bleeding related complications, blood loss, or increased transfusion rate.

A levator ani midurethral support via single vaginal incision technique to treat stress urinary incontinence: A case report.

Stress urinary incontinence affects more than one-fourth of adult women. The recommended surgical treatment involves the use of a synthetic mesh sling. Upon unsuccessful treatment using a mesh sling or when patients decline mesh, surgical treatments, including an autologous fascia sling, colposuspension, or bulking injections, are used. After unsuccessful treatment using three mesh slings, an autologous fascia sling, and a midurethral bulking agent, a patient was successfully treated with our modified Kelly plication technique. A 51-year-old woman with recurrent stress urinary incontinence had had three previous mesh midurethral sling exposures with complete mesh removals followed by one autologous fascia sling with severe infection. We initially treated her with a set of urethral bulking injections, which was also unsuccessful. She was successfully treated with our modified Kelly plication technique, which plicates levator ani muscles to support the midurethral instead of plicating the vesicovaginal fascia at the bladder neck. The patient remained continent four years after the performance of this technique and had reported no pelvic pain or dyspareunia. The technique is detailed in this paper. This single vaginal incision native tissue technique may be considered when mesh slings or alternative native tissue procedures are not feasible for patients, as in this case.

Technologic advances in robot-assisted nephron sparing surgery: a narrative review.

Background and Objective: Nephron sparing surgery (NSS) is the preferred management for clinical stage T1 (cT1) renal masses. In recent years, indications have expanded to larger and more complex renal tumors. In an effort to provide optimal patient outcomes, urologists strive to achieve the pentafecta when performing partial nephrectomy. This has led to the continuous technologic advancement and technique refinement including the use of augmented reality, ultrasound techniques, changes in surgical approach and reconstruction, uses of novel fluorescence marker guided imaging, and implementation of early recovery after surgery (ERAS) protocols. The aim of this narrative review is to provide an overview of the recent advances in pre-, intra-, and post-operative management and approaches to managing patients with renal masses undergoing NSS. Methods: We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010 to 2022 without limitation on study design. We included only full-text English articles published in peer-reviewed journals. Key Content and Findings: Partial nephrectomy is currently prioritized for cT1a renal masses; however, indications have been expanding due to a greater understanding of anatomy and technologic advances. Recent studies have demonstrated that improvements in imaging techniques utilizing cross-sectional imaging with three-dimensional (3D) reconstruction, use of color doppler intraoperative ultrasound, and newer studies emerging using contrast enhanced ultrasound play important roles in certain subsets of patients. While indocyanine green administration is commonly used, novel fluorescence-guided imaging including folate receptor-targeting fluorescence molecules are being investigated to better delineate tumor-parenchyma margins. Augmented reality has a developing role in patient and surgical trainee education. While pre-and intra-operative imaging have shown to be promising, near infrared guided segmental and sub-segmental vessel clamping has yet to show significant benefit in patient outcomes. Studies regarding reconstructive techniques and replacement of reconstruction with sealing agents have a promising future. Finally, ERAS protocols have allowed earlier discharge of patients without increasing complications while improving cost burden. Conclusions: Advances in NSS have ranged from pre-operative imaging techniques to ERAS protocols Further prospective investigations are required to determine the impact of novel imaging, in-vivo fluorescence biomarker use, and reconstructive techniques on achieving the pentafecta of NSS.

The state of PSA counseling in male-to-female transgender patients in the U.S.

BACKGROUND: Morbidity and mortality from prostate cancer (PCa) are known to vary heavily based on socioeconomic and demographic risk factors. We sought to describe prescreening PSA (prostate-specific antigen) counseling (PPC) rates amongst male-to-female transgender (MtF-TG) patients and non-TG patients using the behavioral risk factor surveillance system (BRFSS). METHODS: We used the survey data from 2014, 2016, and 2018 BRFSS and included respondents aged 40-79 years who completed the "PCa screening" and "sexual orientation and gender identity" modules. We analyzed differences in age, education level, income level, marital status, and race/ethnicity using Pearson's χ2 tests. The association of PPC with MtF-TG status and other patient characteristics was evaluated using multivariate logistic regression. RESULTS: A total of 175,383 respondents were included, of which 0.3% identified as MtF-TG. Overall, 62.4% of respondents reported undergoing PPC. On univariate analysis, PPC rates were lower among MtF-TG respondents when compared to the non-TG group (58.3% vs. 62.4%, p = 0.03). MtF-TG respondents were also more likely to report lower education level (p < 0.01), lower-income level (p < 0.01), and were less likely to be white (p < 0.01) than non-TG respondents. However, multivariate analysis adjusting for these respondent features demonstrated an association between higher income and higher education levels with increased odds of PPC, but no association was demonstrated between MtF-TG status and PPC rates. PPC rates for the MtF-TG and non-TG populations did not change significantly over time. CONCLUSIONS: Although PPC was less frequently reported among MtF-TG respondents than in the non-TG group on univariate analysis, this association was not demonstrated when controlling for confounders, including education and income levels. Instead, on multivariate analysis, low education and income levels were more predictive of PPC rates. Further research is needed to ensure equivalent access to prescreening counseling for patients across the socioeconomic and gender identity spectrum.

The Urologist and the Appendix: A Review of Appendiceal Use in Genitourinary Reconstructive Surgery.

Recently, genitourinary reconstruction has experienced a renaissance. Over the past several years, there has been an expansion of the literature regarding the use of buccal mucosa for the repair of complex ureteral strictures and other pathologies. The appendix has been an available graft utilized for the repair of ureteral stricture disease and has been infrequently reported since the early 1900s. This review serves to highlight the use of the appendix for reconstruction in urology, particularly focusing on the anatomy and physiology of the appendix, historical use, and current applications, particularly in robotic upper tract reconstruction.

Direct Oral Anticoagulants for Venous Thromboembolism Prophylaxis Following Robot-assisted Radical Cystectomy: A Retrospective Feasibility Study at a Single Academic Medical Center.

OBJECTIVES: To evaluate the use of direct oral anticoagulants following radical cystectomy for venous thromboembolism prophylaxis. We compared the experience of those who received venous thromboembolism prophylaxis following a robot-assisted radical cystectomy with either a direct oral anticoagulant or enoxaparin. METHODS: Medical records of 66 patients who underwent robot-assisted radical cystectomy between July 2017 and May 2020 at a single academic institution were reviewed retrospectively. Patients received extended prophylaxis with either a direct oral anticoagulant or enoxaparin before or following surgical discharge. Venous thromboembolic events and complications resulting in emergency department visits and readmissions were reviewed over a 90-day postoperative period. RESULTS: A total of 4 venous thromboembolic events within 90 days of surgery were observed. Among patients taking enoxaparin, 5% (2/37) developed a deep vein thrombosis and 3% (1/37) developed a pulmonary embolism. Among patients taking direct oral anticoagulants, 3% (1/29) developed a deep vein thrombosis. Zero patients in the enoxaparin group and 3% (1/29) of patients in the direct oral anticoagulant group experienced bleeding that required an emergency department visit. CONCLUSION: Direct oral anticoagulants performed comparably to enoxaparin in this feasibility study following robot-assisted radical cystectomy in 66 patients. No significant differences in the number of venous thromboembolisms or bleeding complications were observed. These data encourage future studies and support the prospect of direct oral anticoagulants as a potentially suitable oral alternative to injectable low molecular weight heparins for venous thromboembolism prophylaxis following radical cystectomy.

Indigenous Preferences for Inpatient Rooms in Australian Hospitals: A Mixed-Methods Study in Cross-Cultural Design.

AIM: This mixed-method study aimed to establish preliminary evidence for spatial and design features that can improve the experience and participation of Indigenous inpatients in healthcare. BACKGROUND: Disadvantaged across a range of health measures, a disproportionately high number of Indigenous people leave hospital without receiving appropriate medical care. Australian government policies to improve cultural safety of Indigenous patients have largely ignored physical settings and their potential to improve health outcomes. Despite increasing evidence on the potential of design to reduce patient stress, there is minimal research on cross-cultural design in health facilities, including for Indigenous Australians. METHODS: A cross-sectional, area-based survey elicited design preferences of four healthcare settings from Indigenous participants (n = 602). On the screen-based survey, participants selected from paired images that indicated their preferences for room layout and features of inpatient rooms. Semistructured in-depth interviews (n = 55) explored meanings behind preferences. RESULTS: Participants showed majority preferences for the two-bed patient room, for a balcony rather than a window only, Indigenous art, and view of a park over an urban environment. Analysis of qualitative data shifted the focus from Ulrich's three supportive design components to cultural recognition, the desire for company of family members, and connection to life outdoors. CONCLUSIONS: Social and cultural factors were highly significant to patients for sense of control, family support, and positive distraction. In response, inpatient room size and type, views, access to outdoors and Indigenous art need to be considered in hospital design for Indigenous patients and families.

Brown Urology: A Historical Perspective.

The first Urology Residency Program in the United States was founded at the Johns Hopkins Hospital in the wake of the first structured surgery residency as established by Dr. William Halsted in the early 20th Century.1 Dr. Hugh Hampton Young was selected to lead the Genitourinary Division and the foundation for the first urology residency training program was established.2 The Brown University Medical School, initially opened in 1811, effectively closed circa 1827, and re-established in the 1970s, has a long tradition in training surgeons.3,4 The Rhode Island Hospital Urology Residency Training Program was organized in the early 1950s and will be explored in this article. Brown University affiliated with the residency program in the mid-1980s to establish the first and only academic urology residency program in Rhode Island. Today, this program provides state-of-the-art urologic care for thousands of patients in the state.

Personal Protective Equipment for Common Urologic Procedures Before and During the United States COVID-19 Pandemic: A Single Institution Study.

OBJECTIVE: To evaluate the personal protective equipment (PPE) utilized in common urologic procedures before and during the COVID-19 outbreak in the United States. As elective urologic procedures are being reduced to conserve resources, we sought to quantify the PPE used per case to determine the impact on potentially limited resources needed for protecting healthcare providers treating COVID-19 patients. METHODS: An IRB approved retrospective analysis of all urologic procedures in March 2019 and March 2020 was performed. Additionally, all urologic procedures performed by vascular interventional radiology (VIR) in May 2019 and March 2020 were included in the analysis. Case length, surgical and operating room staff present and number of articles of PPE were quantified. Articles of PPE were defined as surgical bonnet/hat and mask, and disposable or reusable gown with 1 pair of surgical gloves. RESULTS: Four hundred and thirty-seven urologic and VIR procedures were included in the analysis. The mean PPE per case varied significantly between endoscopic and robotic categories. Robotic assisted laparoscopic cystectomy required the most hats and masks (14.5 per case in March 2019) whereas percutaneous nephrostomy tube placement by VIR required the fewest (3.1 in May 2019 and March 2020). CONCLUSION: PPE consumption varied significantly across urologic procedures. Robotic-assisted cases require the most PPE and percutaneous nephrostomy placement by VIR requires the fewest. While PPE shortages are currently being addressed national and internationally, our results provide a baseline benchmark for articles of PPE required should another pandemic or global disaster requiring careful attention to resource allocation occur in the future.

Aboriginal and Torres Strait Islander preferences for healthcare settings: effective use of design images in survey research.

Objective The aim of this study was to develop an effective digital survey instrument incorporating images to investigate Aboriginal and Torres Strait Islander preferences for health clinics and hospitals, design of healthcare settings and the differences between inner regional and remote locations. Methods Design-related constructs developed from qualitative interviews informed the construction of healthcare setting images. These images were embedded in an online survey instrument to elicit data on design preferences and an area-based recruitment strategy ensured participation by Indigenous Australians from three Queensland locations. Logistic regression analyses were used to estimate the odds of preference for a healthcare setting design by location. Results Statistical analysis of data from 602 participants showed a preference for health care at an Aboriginal and Torres Strait Islander clinic. The odds of preference for an in-patient room with a two- versus single-bed design was greater for participants with less education, and lower for participants with a long-term health problem. Conclusions The multidisciplinary approach to developing an online survey instrument with images and the willingness of Indigenous people of all ages to engage with the images demonstrated the effectiveness of this method in providing robust evidence for the design of culturally appropriate healthcare spaces for Indigenous users. What is known about the topic? Evidence-based research influences the design of healthcare buildings, yet the field currently provides negligible evidence on cross-cultural perceptions or experiences of conventional modern hospitals and clinics. Although recent healthcare buildings show signs of acknowledging Indigenous users, general principles in the Australian Health Facility Guidelines give limited specific information about how cultural requirements may translate into architectural design. What does this paper add? The multidisciplinary approach to research design has enabled the development of healthcare design-related constructs from consultation with Indigenous people, the presentation of these constructs as images and the inclusion of these images for comparison and selection in a digital survey instrument. Combined with a culturally appropriate recruitment strategy, this survey provides evidence from a large sample of the Indigenous population. Selected results from analyses of survey responses show the capacity of the methodological approach to address broader questions about Indigenous preferences for healthcare settings by location, age and sex. What are the implications for practitioners? A focus on individual preferences related to healthcare clinics and the combined significance of design and setting can give practitioners a better understanding of Aboriginal and Torres Strait Islander people's preferences and suggest ways to reduce the incidence of poor engagement with healthcare services.

Nebulizer cleaning and disinfection practices in families with cystic fibrosis: The relationship between attitudes, practice and microbe colonization.

BACKGROUND: The daily burden of health maintenance for children and families with cystic fibrosis (CF) is immense with respect to time and complexity of care. Infection control practices, specifically nebulizer cleaning and disinfection, are a recommended component of home health care for CF families due to colonization of home respiratory equipment with lung pathogens. To better inform education interventions at our center, we were interested in studying how families' views on infection prevention and awareness of CF Foundation infection prevention and control (IP&C) guidelines correlate with actual home nebulizer care and the presence of microorganisms on their nebulizers. METHODS: Twenty families who have children with CF were surveyed to better understand attitudes toward infection prevention, awareness of CFF IP&C guidelines and nebulizer cleaning and disinfection practices in the home. Their nebulizers were also cultured for microbes to correlate recovery with infection control behaviors. RESULTS: A subset of families recognizes the importance of germ avoidance but do not recognize nebulizer cleaning and disinfection as very important for infection control practices. Decreased frequency of disinfection, but not cleaning, was correlated with the recovery of organisms on the nebulizers. CONCLUSIONS: The study questionnaire results identify a gap between recognizing the importance of infection prevention and consistently implementing CFF IP&C guidelines in the home. This demonstrates the need at our center for new educational interventions to promote cleaning and disinfection of home nebulizers after each use as recommended by the CFF.

First-in-Human, First-in-Class Phase I Trial of the Anti-CD47 Antibody Hu5F9-G4 in Patients With Advanced Cancers.

PURPOSE: To evaluate the safety, pharmacokinetics, and pharmacodynamics of Hu5F9-G4 (5F9), a humanized IgG4 antibody that targets CD47 to enable phagocytosis. PATIENTS AND METHODS: Adult patients with solid tumors were treated in four cohorts: part A, to determine a priming dose; part B, to determine a weekly maintenance dose; part C, to study a loading dose in week 2; and a tumor biopsy cohort. RESULTS: Sixty-two patients were treated: 11 in part A, 14 in B, 22 in C, and 15 in the biopsy cohort. Part A used doses that ranged from 0.1 to 3 mg/kg. On the basis of tolerability and receptor occupancy studies that showed 100% CD47 saturation on RBCs, 1 mg/kg was selected as the priming dose. In subsequent groups, patients were treated with maintenance doses that ranged from 3 to 45 mg/kg, and most toxicities were mild to moderate. These included transient anemia (57% of patients), hemagglutination on peripheral blood smear (36%), fatigue (64%), headaches (50%), fever (45%), chills (45%), hyperbilirubinemia (34%), lymphopenia (34%), infusion-related reactions (34%), and arthralgias (18%). No maximum tolerated dose was reached with maintenance doses up to 45 mg/kg. At doses of 10 mg/kg or more, the CD47 antigen sink was saturated by 5F9, and a 5F9 half-life of approximately 13 days was observed. Strong antibody staining of tumor tissue was observed in a patient at 30 mg/kg. Two patients with ovarian/fallopian tube cancers had partial remissions for 5.2 and 9.2 months. CONCLUSION: 5F9 is well tolerated using a priming dose at 1 mg/kg on day 1 followed by maintenance doses of up to 45 mg/kg weekly.

Prevention, identification, and management of post-operative penile implant complications of infection, hematoma, and device malfunction.

Penile prosthesis implant surgery is an effective management approach for a number of urological conditions, including medication refractory erectile dysfunction (ED). Complications encountered post-operatively include infection, bleeding/hematoma, and device malfunction. Since the 1970s, modifications to these devices have reduced complication rates through improvement in antisepsis and design using antibiotic coatings, kink-resistant tubing, lock-out valves to prevent autoinflation, and modified reservoir shapes. Device survival and complication rates have been investigated predominately by retrospective database-derived studies. This review article focuses on the identification and management of post-operative complications following penile prosthetic and implant surgery. Etiology for ED, surgical technique, and prosthesis type are variable among studies. The most common post-operative complications of infection, bleeding, and device malfunction may be minimized by adherence to consistent technique and standard protocol. Novel antibiotic coatings and standard antibiotic regimen may reduce infection rates. Meticulous hemostasis and intraoperative testing of devices may further reduce need for revision surgery. Additional prospective studies with consistent reporting of outcomes and comparison of surgical approach and prosthesis type in patients with variable ED etiology would be beneficial.

Ezrin links CFTR to TLR4 signaling to orchestrate anti-bacterial immune response in macrophages.

Macrophages (MΦs) with mutations in cystic fibrosis transmembrane conductance regulator (CFTR) have blunted induction of PI3K/AKT signaling in response to TLR4 activation, leading to hyperinflammation, a hallmark of cystic fibrosis (CF) disease. Here, we show that Ezrin links CFTR and TLR4 signaling, and is necessary for PI3K/AKT signaling induction in response to MΦ activation. Because PI3K/AKT signaling is critical for immune regulation, Ezrin-deficient MΦs are hyperinflammatory and have impaired Pseudomonas aeruginosa phagocytosis, phenocopying CF MΦs. Importantly, we show that activated CF MΦs have reduced protein levels and altered localization of the remaining Ezrin to filopodia that form during activation. In summary, we have described a direct link from CFTR to Ezrin to PI3K/AKT signaling that is disrupted in CF, and thus promotes hyper-inflammation and weakens phagocytosis.

Advances in the diagnosis of hereditary kidney cancer: Initial results of a multigene panel test.

BACKGROUND: Panel testing has been recently introduced to evaluate hereditary cancer; however, limited information is available regarding its use in kidney cancer. METHODS: The authors retrospectively reviewed test results and clinical data from patients who underwent targeted multigene panel testing of up to 19 genes associated with hereditary kidney cancer from 2013 to 2016. The frequency of positive (mutation/variant likely pathogenic), inconclusive (variant of unknown significance), and negative results was evaluated. A logistic regression analysis evaluated predictive factors for a positive test. RESULTS: Patients (n = 1235) had a median age at diagnosis of 46 years, which was significantly younger than the US population of individuals with kidney cancer (P < .0001). Overall, 6.1%, 75.5%, and 18.4% of individuals had positive, negative, and inconclusive results, respectively. The most commonly altered genes included folliculin (FLCN) and fumarate hydratase (FH), which were altered in 1.8% and 1.3% of patients, respectively. Tuberous Sclerosis Complex 2 (TSC2), mesenchymal epithelial transition factor proto-oncogene (MET), and PMS1 homolog 2 (PMS2) had the highest rates of variants of unknown significance, which were identified in 2.7%, 2.2%, and 1.7% of patients, respectively. Early age of onset was the only factor that was identified as predictive of a positive test on multivariate analysis (odds ratio, 0.975; P = .0052) and may be the only identifying characteristic of low-penetrant syndromes, such as those associated with MITF (melanogenesis-associated transcription factor) mutations, which do not have singular histology or a family history of kidney cancer. CONCLUSIONS: Panel tests may be particularly useful for patients who lack distinguishing clinical characteristics of known hereditary kidney cancer syndromes. The current results support the use of early age of onset for genetic counseling and/or testing. Cancer 2017;123:4363-71. © 2017 American Cancer Society.

Effect of single agent high-dose methotrexate-related acute kidney injury on length of hospitalization and relative dose intensity in adult patients with central nervous system lymphoma.

Purpose Grade ≥3 adverse effects prolong hospitalization and reduce chemotherapy dose intensity. The purpose of this study was to evaluate the rate and severity of high-dose methotrexate-related acute kidney injury and analyze its effect on hospital length of stay and relative chemotherapy dose intensity. Methods This was a retrospective cohort analysis. Patients receiving ≥1 dose of high-dose methotrexate were analyzed for acute kidney injury and length of stay. Patients receiving ≥6 cycles of induction therapy were included in the analysis of relative chemotherapy dose intensity. Chi squared analysis was used to determine the differences between dichotomous data; Student's t-test for parametric data and Mann-Whitney U test for non-parametric data for continuous variables. Statistical analyses were performed with IBM SPSS Statistics (version 21). Results Twenty-six patients and 194 treatment encounters were identified. Thirteen patients were evaluated for relative chemotherapy dose intensity. Grade ≥3 acute kidney injury occurred in four patients (15% of patients; 2% of encounters). There were no grade 5 adverse events. Mean length of stay for encounters with grade ≥3 acute kidney injury was almost three times longer than for those with ≤ grade 2 acute kidney injury (p = 0.041). Mean relative chemotherapy dose intensity was reduced approximately in half for patients experiencing grade ≥3 acute kidney injury (p < 0.01). The most common adverse events were hypokalemia and nausea. Proton pump inhibitors were the most frequently co-administered medications with the potential to affect high-dose methotrexate pharmacokinetics. Conclusion At our cancer program, the rate of grade ≥3 acute kidney injury with high-dose methotrexate is similar to that reported by others. Grade ≥3 acute kidney injury following high-dose methotrexate administration significantly prolonged length of stay and reduced relative chemotherapy dose intensity.

Opioid-Induced Androgen Deficiency (OPIAD): Diagnosis, Management, and Literature Review.

Opioid-induced androgen deficiency (OPIAD) was initially recognized as a possible consequence of opioid use roughly four decades ago. Long-acting opioid use carries risks of addiction, tolerance, and systemic side effects including hypogonadotropic hypogonadism with consequent testosterone depletion leading to multiple central and peripheral effects. Hypogonadism is induced through direct inhibitory action of opioids on receptors within the hypothalamic-pituitary-gonadal (HPG) and hypothalamic-pituitary-adrenal (HPA) axes as well as testosterone production within the testes. Few studies have systematically investigated hormonal changes induced by long-term opioid administration or the effects of testosterone replacement therapy (TRT) in patients with OPIAD. Clomiphene citrate, a selective estrogen receptor modulator (SERM), is a testosterone enhancement treatment which upregulates endogenous hypothalamic function. This review will focus on the pathophysiology, diagnosis, and management of OPIAD, including summary of literature evaluating OPIAD treatment with TRT, and areas of future investigation.