Considerations in ureteral stent selection in order to minimize symptoms.

INTRODUCTION: Ureteral stent-related symptoms are common after stent placement. Various characteristics of stent design have been previously investigated to mitigate this issue. Our review summarizes available literature on stent design parameters (diameter, material, position, length, distal loop modifications) and their effect on stent-related symptoms, including pain. MATERIALS AND METHODS: We identified articles from PubMed, Medline, EMBASE, Web of Science, and Grey Literature using a search strategy employing MESH search headings (i.e, ureteral stent diameter, length, composition, material, durometer, and stent-related pain). RESULTS: Out of 2,970 identified studies, 26 met eligibility criteria. Most diameter studies found patients with > 6Fr stents reported significantly increased stent-related symptoms. A few did report more migration with thinner stents. Almost half of durometer studies found composition made no difference in symptoms. Distal loop modification studies found minimizing intravesical material decreased stent-related pain. All studies on positioning found patients reported more severe urinary, pain and quality of life symptoms when stents crossed the bladder midline. No difference in stent-related symptoms was seen between multi-length and standard stents patients. CONCLUSION: Adverse symptoms occur commonly after ureteral stent placement. No definitive recommendations on the model stent can be provided due to the heterogeneity of studies. Though the number of robust studies is limited, data suggest stents crossing midline, larger diameters, and those without distal material-reduction modifications may worsen stent-related symptoms. Future studies are needed to better understand the ideal stent design.

Orthotopic urinary diversions after radical cystectomy for bladder cancer: lessons learned last decade.

PURPOSE OF REVIEW: Orthotopic urinary diversion (OUD), or neobladder, is believed to be the gold standard for surgical bladder reconstruction following radical cystectomy though it is performed far less often than ileal conduits. As both a continent and intracavitary diversion, OUDs offer unique advantages for patients. Their utilization has decreased overall though, especially with the advent of robotic surgery. In this review, we will cover patient selection for OUD, functional outcomes (i.e., continence, sexual activity, quality of life [QoL]), and robotic orthotopic diversions. RECENT FINDINGS: OUDs have seen a proportionally greater decline in utilization compared with ileal conduits as the number of robotic radical cystectomies being performed with intracorporeal diversions increases. Multiple robotic series have demonstrated less perioperative blood loss and shorter hospital stays when compared with the open approach though operative times are longer, the learning curve is steeper, and overall costs may be higher in some settings. Perioperative safety and short-term oncological outcomes appear comparable. Since robotic OUDs are relatively new, functional outcomes are not yet well established. Patient satisfaction with urinary diversion is associated with informed decision-making tailored to the patient. A thorough understanding of expected short- and long-term functional outcomes and the care required to maintain an OUD improves QoL and satisfaction with diversion choice. SUMMARY: Given the potential advantages of OUD, its decreasing use is a remarkable trend. Shared decision-making and a patient-centered approach should be used when selecting the type of urinary diversion.

PTEN Hamartoma Tumor Syndrome: A Case of Renal Cell Carcinoma in a Young Female.

PTEN Hamartoma-Tumor-Syndrome (PHTS) describes a series of conditions characterized by germline-mutation of the PTEN tumor-suppressor gene. PHTS patients have an increased lifetime risk of multiple malignancies, including thyroid, breast, and endometrial cancers. PHTS patients also have 20-30 fold increased risk of renal cell carcinoma (RCC) compared to age-matched controls. As with many hereditary RCC syndromes, tumors present early and multifocally. We present a case of one of the youngest patients diagnosed with RCC in PHTS and review the urologic implications of this syndrome.

Bladder-sparing treatment of nonmetastatic muscle-invasive bladder cancer.

Bladder-sparing therapies for the treatment of nonmetastatic muscle-invasive bladder cancers are included in both American and European guidelines. Numerous treatment approaches have been described, including partial cystectomy, radiation monotherapy, and radical transurethral resection. However, the most oncologically favorable and well-studied regimen employs a multimodal approach that consists of maximal transurethral resection of the bladder tumor followed by concurrent radiosensitizing chemotherapy and radiotherapy. This sequence, referred to as trimodal therapy (TMT), has been evaluated with robust retrospective comparative studies and prospective series, although a randomized trial comparing TMT with radical cystectomy has not been performed. Despite promising reports of 5-year overall survival rates of 50% to 70% in well-selected patients, relatively few patients qualify as ideal candidates for TMT. Specifically, contemporary series exclude patients who have clinical stage T3 disease, multifocal tumors, coexisting carcinoma in situ, or hydronephrosis. Herein, we review all forms of bladder-preserving therapies with an emphasis on TMT, highlighting the rationale of each component, survival outcomes, and future directions.

Systemic Comorbidity Burden Using the ACTIONS Phenotype Predicts Urologic Medication Discontinuation Following Transurethral Resection of the Prostate.

OBJECTIVE: To assess the impact of systemic comorbidities on a validated health phenotype score (ACTIONS: Anxiety, Cardiovascular, Testosterone, Insulin/diabetes, Obesity, Neurologic, Sleep apnea) on outcomes of transurethral resection of prostate (TURP) for benign prostatic hyperplasia (BPH) for symptoms and medication discontinuation. MATERIALS AND METHODS: Comorbidities of men undergoing TURP for BPH from 2004 to 2015 were assessed with the validated ACTIONS phenotype totaling a score from 0 to 2 for each domain (Anxiety, Cardiovascular, Testosterone, Insulin/diabetes, Obesity, Neurologic, Sleep apnea). BPH medication discontinuation, change in International Prostate Symptom Score, postvoid residual, and patient satisfaction were assessed. Descriptive and comparative statistics were calculated with significance set at P <.05. RESULTS: The 319 men had a median age of 74.0 (interquartile range 67-78). Mean ACTIONS score was significantly lower in men who discontinued alpha-blockers or 5-alpha reductase inhibitors compared to those who did not (3.37 ± 2.14vs 4.79 ± 2.75, P <.0001). ACTIONS score <4 was significantly associated with medication discontinuation (P = .0014). Lower scores in Testosterone (P = .04), Neurologic (P = .003), and Sleep apnea (P = .04) domains were significantly associated with medication discontinuation. Total ACTIONS score was not independently associated with changes in International Prostate Symptom Score or postvoid residual. CONCLUSION: Lower ACTIONS score was associated with BPH medication discontinuation after TURP, suggesting men with lower comorbidity burdens do better after the procedure. The ACTIONS phenotype score is easily calculated and may aid the preoperative counseling of men undergoing TURP for BPH.

Postoperative Pain and Analgesia: Is There a Genetic Basis to the Opioid Crisis?

BACKGROUND: Multiple factors have been implicated in determining why certain patients have increased postoperative pain, with the potential to develop chronic pain. The purpose of this study was to: 1) identify and describe genes that affect postoperative pain perception and control; 2) address modifiable risk factors that result in epigenetic altered responses to pain; and 3) characterize differences in pain sensitivity and thresholds between opioid-naïve and opioid-dependent patients. MATERIALS AND METHODS: Three electronic databases were used to conduct the literature search: Pubmed, EBSCO host, and SCOPUS. A total of 372 abstracts were reviewed, of which 46 studies were deemed relevant and are included in this review. RESULTS: Specific gene alterations that were shown to affect postoperative pain control included single nucleotide polymorphisms in the mu, kappa, and delta opioid receptors, ion channel genes, cytotoxic T-cells, glutamate receptors and cytokine genes, among others. Alcoholism, obesity, and smoking were all linked with genetic polymorphisms that altered pain sensitivity. Opioid abuse was found to be associated with a poorer response to analgesics postoperatively, as well as a risk for prescription overdose. CONCLUSION: Although pain perception has multiple complex influences, the greatest variability seen in response to opioids among postoperative patients known to date can be traced to genetic differences in opioid metabolism. Further study is needed to determine the clinical significance of these genetic associations.