Initial Observation of a Large Proportion of Patients Presenting with Clinical Stage T1 Renal Masses: Results from the MUSIC-KIDNEY Statewide Collaborative.

BACKGROUND: While surgical excision remains the principal management strategy for clinical T1 renal masses (cT1RMs), the rates of noninterventional approaches are not well known. Most single-institution and population-based series suggest rates below 10%. OBJECTIVE: To evaluate the use of observation for newly diagnosed cT1RM patients in academic and community-based practices across a statewide collaborative. DESIGN SETTING AND PARTICIPANTS: The Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) commenced data collection in September 2017 by recording clinical, radiographic, pathologic, and short-term follow-up data for cT1RM patients at 13 diverse practices. Patients with complete data were assessed at >90 d after initial evaluation as to whether observation or treatment was performed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Relationships with outcomes were analyzed using multivariable logistic regression, chi-square test, and Wilcoxon rank-sum test. RESULTS AND LIMITATIONS: Out of 965 patients, observation was employed in 48% (n = 459), with practice-level rates ranging from 0% to 68%. Patients managed with observation (vs treatment) were significantly older (71.2 vs 62.8 yr, p < 0.0001) and had smaller tumors (2.3 vs 3.4 cm, p < 0.0001). Observation was used for 53.5% of cT1a renal masses, for 29.9% of cT1b renal masses, and for 42.5%, 53.7%, and 63.9% of radiographically solid, Bosniak III-IV cystic, and indeterminate cT1RMs, respectively. Factors significantly associated with observation in multivariable analysis included lesion type (Bosniak III-IV vs solid, p = 0.017), tumor stage (cT1a vs cT1b, p < 0.001), and higher age (p < 0.001). A short duration of follow-up limits the assessment of longer-term patient management. CONCLUSIONS: Noninterventional management of cT1RMs is common across the MUSIC-KIDNEY collaborative, with wide variability across practices. Factors associated with observation were advanced age, smaller tumor size, and cystic tumor type. Durability of the initial decision for observation (delayed intervention vs active surveillance vs less active surveillance) will be a focus of subsequent study. PATIENT SUMMARY: The Michigan Urological Surgery Improvement Collaborative: Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) quality improvement collaborative assessed the current utilization of initial observation of a renal mass ≤7 cm across a diverse group of urology practices and found it to be used in 48% of patients. We found that the factors predicting observation were advanced age, smaller tumor size, and cystic tumor type.

A Case of Urinary Sepsis Secondary to Streptococcus sanguinis.

We report a case of a 71-year-old male with a history of BPH who presented with flank pain, fever, chills, abdominal pain, and nausea. He had a dental cleaning 1 month prior to admission and flosses daily. Laboratory data revealed both urine and blood cultures to be positive for streptococcus sanguinis. Computed tomography revealed a 10 mm right ureteral stone, and an ultrasound demonstrated moderate right hydronephrosis. He underwent an ureteroscopy with stent placement. A transesophageal echocardiogram was negative for endocarditis. He completed 2 weeks of IV ceftriaxone and made a complete recovery.

askMUSIC: Leveraging a Clinical Registry to Develop a New Machine Learning Model to Inform Patients of Prostate Cancer Treatments Chosen by Similar Men.

BACKGROUND: Clinical registries provide physicians with a means for making data-driven decisions but few opportunities exist for patients to interact with registry data to help make decisions. OBJECTIVE: We sought to develop a web-based system that uses a prostate cancer (CaP) registry to provide newly diagnosed men with a platform to view predicted treatment decisions based on patients with similar characteristics. DESIGN, SETTING, AND PARTICIPANTS: The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a quality improvement consortium of urology practices that maintains a prospective registry of men with CaP. We used registry data from 45 MUSIC urology practices from 2015 to 2017 to develop and validate a random forest machine learning model. After fitting the random forest model to a derivation cohort consisting of a random two-thirds sample of patients after stratifying by practice location, we evaluated the model performance in a validation cohort consisting of the remaining one-third of patients using a multiclass area under the curve (AUC) measure and calibration plots. RESULTS AND LIMITATIONS: We identified 7543 men diagnosed with CaP, of whom 45% underwent radical prostatectomy, 30% surveillance, 17% radiation therapy, 5.6% androgen deprivation, and 1.8% watchful waiting. The personalized prediction for patients in the validation cohort was highly accurate (AUC 0.81). CONCLUSIONS: Using clinical registry data and machine learning methods, we created a web-based platform for patients that generates accurate predictions for most CaP treatments. PATIENT SUMMARY: We have developed and tested a tool to help men newly diagnosed with prostate cancer to view predicted treatment decisions based on similar patients from our registry. We have made this tool available online for patients to use.

Evaluation of Prostate Cancer Risk Calculators for Shared Decision Making Across Diverse Urology Practices in Michigan.

OBJECTIVE: To compare the predictive performance of a logistic regression model developed with contemporary data from a diverse group of urology practices to that of the Prostate Cancer Prevention Trial (PCPT) Risk Calculator version 2.0. MATERIALS AND METHODS: With data from all first-time prostate biopsies performed between January 2012 and March 2015 across the Michigan Urological Surgery Improvement Collaborative (MUSIC), we developed a multinomial logistic regression model to predict the likelihood of finding high-grade cancer (Gleason score ≥7), low-grade cancer (Gleason score ≤6), or no cancer on prostate biopsy. The performance of the MUSIC model was evaluated in out-of-sample data using 10-fold cross-validation. Discrimination and calibration statistics were used to compare the performance of the MUSIC model to that of the PCPT risk calculator in the MUSIC cohort. RESULTS: Of the 11,809 biopsies included, 4289 (36.3%) revealed high-grade cancer; 2027 (17.2%) revealed low-grade cancer; and the remaining 5493 (46.5%) were negative. In the MUSIC model, prostate-specific antigen level, rectal examination findings, age, race, and family history of prostate cancer were significant predictors of finding high-grade cancer on biopsy. The 2 models, based on similar predictors, had comparable discrimination (multiclass area under the curve = 0.63 for the MUSIC model and 0.62 for the PCPT calculator). Calibration analyses demonstrated that the MUSIC model more accurately predicted observed outcomes, whereas the PCPT risk calculator substantively overestimated the likelihood of finding no cancer while underestimating the risk of high-grade cancer in this population. CONCLUSION: The PCPT risk calculator may not be a good predictor of individual biopsy outcomes for patients seen in contemporary urology practices.

Drainage characteristics and differential function of the horseshoe kidney: what is typical?

PURPOSE: To describe the drainage and differential function of the horseshoe kidney. PATIENTS AND METHODS: A retrospective review of mercaptoacetyltriglycine (MAG3) nuclear renograms from 1991 to 2007 was performed. Nineteen patients with horseshoe kidney who had not undergone previous renal surgery were identified. All studies were reviewed, and patient information was gathered. Drainage characteristics and differential function were determined. RESULTS: Nineteen primary MAG3 studies were found, representing 38 evaluable renal units. For these units altogether, the median t1/2 was 11 minutes. A t1/2 of 10 minutes or less was found in 18 units (47%), while 12 units (32%) showed a t1/2 longer than 20 minutes. The relative function difference mean was 24.6%. The number of patients with a relative function difference greater than 10% was 11 (57%), and those with a relative function difference greater than 20% was 7 (37%). CONCLUSION: Horseshoe kidney is associated with fairly high rates of poor renal drainage and elevated differential function.

Open versus laparoscopic simultaneous bilateral adrenalectomy.

OBJECTIVES: To compare our experience with synchronous bilateral adrenalectomy using laparoscopic and open techniques. Laparoscopic adrenalectomy has become the reference standard for management of benign unilateral adrenal pathologic findings. METHODS: This was a nonrandomized retrospective chart review of 12 known patients who underwent simultaneous bilateral adrenalectomy, comparing five laparoscopic and seven open procedures. One urologic surgeon performed all laparoscopic cases, and one general surgeon performed all open procedures. RESULTS: All patients had Cushing's disease or syndrome. The average patient age was 47.4 years (range 24 to 71) and 42.4 years (range 19 to 70), with an average body mass index of 38.2 kg/m2 and 36.0 kg/m2 for the laparoscopic and open groups, respectively. The operating time was on average 60 minutes longer for the laparoscopic group. No open conversions were necessary. The median blood loss (100 versus 500 mL, P < 0.01) and hematocrit drop (8.5% versus 12.6%, P = 0.05) were lower for the laparoscopic group. The transfusion rates and hospital stay trended lower in the laparoscopic group (20% versus 57% and 3 versus 8.5 days, respectively). Specimen weights for both the right and left glands trended larger for the laparoscopic group. The complication rates were similar between groups at 60% for the laparoscopic versus 71% for the open groups. CONCLUSIONS: Simultaneous laparoscopic bilateral adrenalectomy is safe and effective. Compared with the open approach, it resulted in decreased blood loss, lower transfusion rate, and a trend toward a shorter hospital stay, although the operating time was longer. The laparoscopic approach should be the treatment of choice for bilateral adrenalectomy.

Robotic-assisted laparoscopic prostatectomy in overweight and obese patients.

OBJECTIVES: To assess outcomes of robotic laparoscopic radical prostatectomy (RLRP) in overweight and obese patients, defined as those with a body mass index (BMI) of 25 to 30 kg/m2 and greater than 30 kg/m2, respectively. METHODS: This was a nonrandomized study evaluating all of our RLRP patients. Patients were divided into three groups: BMI of 25 kg/m2 or less (group 1), BMI greater than 25 kg/m2 and less than 30 kg/m2 (group 2), and BMI of 30 kg/m2 or more (group 3). Patients were evaluated prospectively with the validated Rand 36-Item Health Survey (version 2) and with the University of California, Los Angeles Prostate Cancer Index questionnaire. RESULTS: Between February 2003 and November 2004, 150 RLRPs were performed at our center. Average follow-up was 8 months. Groups 1, 2, and 3 had 39, 65, and 46 patients, respectively. Average BMIs for all three groups were statistically different (P < 0.01). When compared with group 1, open conversion rates, hospital stay, positive margin, and complication rates were not statistically different for groups 2 or 3. Operative time (P < 0.004) and estimated blood loss (P < 0.03), however, were statistically greater for group 3 compared with group 1. Transfusion rate was highest in group 2 (P = 0.04 compared with group 1). Prostate weights were also statistically greater in groups 2 (P = 0.003) and 3 (P = 0.02) compared with group 1. Overall, BMI did not increase perioperative and postoperative morbidity. CONCLUSIONS: Robotic laparoscopic radical prostatectomy is safe in overweight and obese patients and might be the surgical management of choice in this subset of patients. Further long-term follow-up with more patients is required to verify this initial observation.

Laparoscopy.

Urologists around the world are doing more laparoscopy, with renal surgery being the most common procedure. Almost a third devote more than 20% of their practices to laparoscopy. Among those who do not use laparoscopy, lack of training and equipment are the most common reasons.

Laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: With continuing rapid changes in endourology, we conducted a new survey of practice trends and expanded our sampling to include non-American urologists. MATERIALS AND METHODS: The survey was done via the Internet using the database for the 2003 World Congress of Endourology. Approximately 1100 surveys were sent, and responses were received from 193 urologists, who had been in practice for a mean of 9.9 years (median 8 years). Of these, 52% spend >50% in endourology, and 48% devote >20% of their practice to laparoscopy. RESULTS: More than half of the respondents (56%) perform laparoscopic partial nephrectomy (LPN), and 65% chose LPN as the procedure of choice for patients with an uncomplicated 3-cm renal mass. The majority obtain vascular control, most commonly by clamping the renal artery only. Most respondents do not use ureteral stents unless the collecting system is entered. CONCLUSIONS: These results and a review of the literature indicate a growing acceptance among endourologists of LPN as the procedure of choice for patients with small renal masses who are to undergo nephron-sparing surgery. Disagreement remains concerning the role and type of vascular control, the use of hemostatic agents, and the value of stents when the collecting system is entered.