Management of large kidney stones in the geriatric population.

PURPOSE: The aim of this review is to highlight the unique factors that predispose geriatric patients to nephrolithiasis and to compare the utility and efficacy of surgical techniques in this specific patient population. METHODS: PubMed and EMBASE databases were reviewed, and studies were organized according to surgical treatments. RESULTS: Few prospective studies exist comparing kidney stone removal in the elderly to younger cohorts. In addition, various age cut-offs were used to determine who was considered elderly. Most studies which analyzed Percutaneous Nephrolithotomy (PCNL) found a slightly higher rate of minor complications but comparable stone free rate and operative time. For ureteroscopy (URS) and extracorporeal shockwave lithotripsy (ESWL), there were minimal complications observed and no difference in clinical success in the elderly. All surgical techniques were presumed to be safe in the elderly and most found no difference in stone-free rates. CONCLUSIONS: Unique attributes of the geriatric population contribute to stone formation and must be considered when determining appropriate management modalities. This review provides an overview of the utility and efficacy of PCNL, URS and ESWL in the elderly, as well as a porposed algorithm for management in this population.

The Impact of Holistic Review of Urology Residency Applications on Selection for Interview During the COVID-19 Pandemic.

OBJECTIVE: To investigate the impact of a holistic review of urology residency applications on interview selection at our institution during the COVID-19 pandemic. METHODS: In the 2019-2020 cycle, applicants were filtered by a Step 1 score of 230 and whether they applied from selected east coast medical schools. For the 2020-2021 and 2021-2022 cycles, we implemented a scoring system which focused on desirable attributes based on our program training needs and resources. We compared applicant and interviewee demographics and United States Medical Licensing Examination (USMLE) scores using descriptive statistics and 1-way analysis of variance tests. RESULTS: A total of 282, 300, and 367 students applied to our residency program with 50, 45, and 52 selected for interviews during the 2019-2020, 2020-2021, and 2021-2022 cycles, respectively. Compared to 2019-2020, the 2020-2021 and 2021-2022 interviewee cohorts comprised of more non-tri-state applicants (36%, 55.6%, and 46.2%, respectively). Underrepresented minority representation increased for the 2020-2021 interviewee cohort; however, this was not observed in 2021-2022 (16%, 24.4%, 15.4%, respectively). Additionally, USMLE Step 1 and 2 scores were similar between interviewee cohorts in 2019-2020, 2020-2021 and 2021-2022, respectively (Step 1: 244.2 ± 8.8, 242 ± 12.1, 242.8 ± 12.4, P = .624) (Step 2: 249.1 ± 11.5, 251.5 ± 10.5, 254.4 ± 10.8, P = .143). CONCLUSION: Utilizing a comprehensive review resulted in a geographically diverse interview pool and no significant difference in academic performance among interviewees. Holistic review provides an alternative, balanced evaluation of residency applicants which may increase diversity in urology.

Assessment of Patient Understanding Prior to Urological Procedures.

OBJECTIVE: To evaluate patient understanding of risks, benefits, and alternatives (R/B/A) prior to urological procedures using the teachback method. METHODS: Using a preprocedural phone interview, patients recalled general knowledge and R/B/A of a scheduled procedure. A scoring system compared patient responses to a standardized R/B/A list to analyze the level of understanding, graded as incomplete (<25%), partial (25-75%), or complete (>75%). Following the interview, additional education was provided if understanding was inadequate, and patients were queried regarding their satisfaction. RESULTS: Patients (n = 99) comprised 46% women; 32% Spanish speaking; Mean age was 64 ± 10.9 years. Procedures included were: intravesical botulinum toxin injection (24), mid-urethral sling (9), colpocleisis (4), prostate biopsy (24), ureteroscopy (16), transurethral resection prostate (11), transurethral resection bladder tumor (11). Across all procedures, the average percent of risks identified was 12%, benefits 63%, and alternatives 35%. No patients had complete understanding, but most had partial (73.7%). Patients had significantly higher level of understanding if they were female (P = 0.02), underwent the same procedure previously (P < 0.01) or any surgery within a year (P = 0.02), and were undergoing an in-office procedures (P = 0.03). After the teachback interview, most patients (90%) were satisfied with their understanding. CONCLUSION: In our cohort, patient understanding was alarmingly incomplete and there was substantial benefit in pre-procedural interviews. Our findings highlight the need for improvement in patient education prior to surgery and offers a potential solution using a teachback-based telephone interview.

The Development of Non-Invasive Diagnostic Tools in Bladder Cancer.

Bladder cancer is a common urinary tract cancer with a difficult clinical course. With frequent recurrence, patients with a history of bladder cancer often undergo surveillance that involves invasive cystoscopies and biopsies. Not only is this financially burdensome for patients but it is also mentally and physically intensive. Given this predicament, the field has shifted towards the use of non-invasive urinary tests to detect bladder cancer earlier in the disease course and to avoid unnecessary procedures. The first non-invasive test developed was urine cytology; however, that was found to have a low sensitivity, especially for low-grade lesions. There are many tests that are available that utilize common protein biomarkers to enhance the sensitivity of detection. However, many of these tests lack the specificity seen with cytology. With recent technological and research advancements, there are newer detection systems such as RNA sequencing and microfluidics along with novel bladder cancer biomarkers including mRNAs, methylation patterns and exosomes, which have potential to be used in clinical practice. The aim of this review is to highlight established non-invasive bladder cancer diagnostic tests as well as innovative methodologies that are on the horizon for use in bladder cancer detection.

Medical Treatment of Overactive Bladder.

Overactive bladder is a disruptive urinary condition composed of urgency, frequency, and nocturia, which affects a large proportion of men and women. Symptoms are often associated with a decreased quality of life. After optimizing behavioral strategies, pharmacologic intervention is the next consideration for treatment. Therapeutic agents consist primarily of antimuscarinic and ß-agonist medications, as well as off-label use of antidepressants in some cases. These medications, although effective, can be associated with considerable adverse side effects. Combination therapies along with novel therapeutics and drug targets are under investigation.

AXL Mediates Cetuximab and Radiation Resistance Through Tyrosine 821 and the c-ABL Kinase Pathway in Head and Neck Cancer.

PURPOSE: Radiation and cetuximab are therapeutics used in management of head and neck squamous cell carcinoma (HNSCC). Despite clinical success with these modalities, development of both intrinsic and acquired resistance is an emerging problem in the management of this disease. The purpose of this study was to investigate signaling of the receptor tyrosine kinase AXL in resistance to radiation and cetuximab treatment. EXPERIMENTAL DESIGN: To study AXL signaling in the context of treatment-resistant HNSCC, we used patient-derived xenografts (PDXs) implanted into mice and evaluated the tumor response to AXL inhibition in combination with cetuximab or radiation treatment. To identify molecular mechanisms of how AXL signaling leads to resistance, three tyrosine residues of AXL (Y779, Y821, Y866) were mutated and examined for their sensitivity to cetuximab and/or radiation. Furthermore, reverse phase protein array (RPPA) was employed to analyze the proteomic architecture of signaling pathways in these genetically altered cell lines. RESULTS: Treatment of cetuximab- and radiation-resistant PDXs with AXL inhibitor R428 was sufficient to overcome resistance. RPPA analysis revealed that such resistance emanates from signaling of tyrosine 821 of AXL via the tyrosine kinase c-ABL. In addition, inhibition of c-ABL signaling resensitized cells and tumors to cetuximab or radiotherapy even leading to complete tumor regression without recurrence in head and neck cancer models. CONCLUSIONS: Collectively, the studies presented herein suggest that tyrosine 821 of AXL mediates resistance to cetuximab by activation of c-ABL kinase in HNSCC and that targeting of both EGFR and c-ABL leads to a robust antitumor response.