Impact of Socioeconomic Status on Patient Adherence in Managing Renal Masses.

INTRODUCTION: Previous literature suggests socioeconomic status and racial disparities impact management decisions for patients with small renal masses. We aim to build upon these findings and examine how these modalities impact patient adherence to their management plan. METHODS: This retrospective study analyzed our Kidney Tumor Program database (n = 1476) containing patients from 2000 to 2020. Socioeconomic status was estimated using 2 modalities: Area Deprivation Index and household income. Patients were then evaluated for differences in adherence, nonadherence, and loss to follow-up. Adherent patients completed all recommended appointments within 6 months of their initial follow-up. Nonadherent patients did not complete all recommended appointments within 6 months of their originally scheduled follow-up but eventually did. Patients lost to follow-up were recommended to follow up but never did. RESULTS: Patient adherence was not significantly different across sex or primary treatment method but differed with respect to race/ethnicity. Black patients were significantly more likely to be nonadherent (P = .021) and lost to follow-up (P = .008). After adjusting for race/ethnicity, Area Deprivation Index and income bracket were significantly associated with adherence and loss to follow-up. Patients with a high socioeconomic status had significantly higher rates of adherence (ADI, quartile [Q] 1 vs Q4, P = .038; income, >$120,000 vs $30,000-$59,999, P < .003) and decreased loss to follow-up (ADI, Q1 vs Q4, P = .03; income, >$120,000 vs $30,000-$59,999, P = .002). CONCLUSIONS: Our results demonstrate that Black race and low socioeconomic status are associated with decreased adherence and increased loss to follow-up. Possible strategies to target these disparities include financial assistance programming, social determinants of health screening, and nurse navigator programs.

Evaluation of a novel augmented reality educational tool and its effects on patient experience: A randomized controlled trial.

Introduction: Patient education is an essential element of the treatment pathway. Augmented reality (AR), with disease simulations and three-dimensional visuals, offers a developing approach to patient education. We aim to determine whether this tool can increase patient understanding of their disease and post-visit satisfaction in comparison to current standard of care (SOC) educational practices in a randomized control study. Methods: Our single-site study consisted of 100 patients with initial diagnoses of kidney masses or stones randomly enrolled in the AR or SOC arm. In the AR arm, a physician used AR software on a tablet to educate the patient. SOC patients were educated through traditional discussion, imaging, and hand-drawn illustrations. Participants completed pre- and post-physician encounter surveys adapted from the Press Ganey® patient questionnaire to assess understanding and satisfaction. Their responses were evaluated in the Readability Studio® and analyzed to quantify rates of improvement in self-reported understanding and satisfaction scores. Results: There was no significant difference in participant education level (P = 0.828) or visit length (27.6 vs. 25.0 min, P = 0.065) between cohorts. Our data indicate that the rate of change in pre- to post-visit self-reported understanding was similar in each arm (P ≥ 0.106 for all responses). The AR arm, however, had significantly higher patient satisfaction scores concerning the educational effectiveness and understanding of images used during the consultation (P < 0.05). Conclusions: While AR did not significantly increase self-reported patient understanding of their disease compared to SOC, this study suggests AR as a potential avenue to increase patient satisfaction with educational tools used during consultations.

Impact of diabetes and chronic kidney disease on active surveillance outcomes for small renal masses: A cohort study.

Introduction: The American Cancer Society estimates 79,000 individuals will be diagnosed with kidney cancer in 2022, most of which are initially found as small renal masses (SRMs). Proper management of SRM patients includes careful evaluation of risk factors such as medical comorbidities and renal function. To investigate the importance of these risk factors, we examined their effect on crossover to delayed intervention (DI) and overall survival (OS) in patients undergoing active surveillance (AS) for SRMs. Methods: This is an Institutional Review Board-approved retrospective analysis of AS patients presented at kidney tumor conferences with SRMs between 2007 and 2017. Univariable and multivariable logistic regression analyses were performed to determine how factors including estimated glomerular filtration rate (eGFR), diabetes, and chronic kidney disease are associated with DI and OS. Results: A total of 111 cases were reviewed. In general, AS patients were elderly and had significant comorbidities. On univariate analysis, intervention was more likely to occur in patients with a younger age (P = 0.01), better kidney function (P = 0.01), and higher tumor growth rates (GRs) (P = 0.02). Higher eGFR was associated with better survival (P = 0.03), while higher tumor GRs (P = 0.014), greater Charlson Comorbidity Index (P = 0.01), and larger tumors (P = 0.01) were associated with worse OS. Of the comorbidities, diabetes was found to be an independent predictor of worse OS (P = 0.01). Conclusions: Patient-level factors - such as diabetes and eGFR - are associated with the rate of DI and OS among SRM patients. Consideration of these factors may facilitate better AS protocols and improve patient outcomes for those with SRMs.

Impact of dedicated renal enhanced recovery after surgery (RERAS) program on postoperative opioid consumption and evaluation of surgeon-specific compliance to the program.

INTRODUCTION AND OBJECTIVE: Enhanced Recovery After Surgery (ERAS) protocols have been increasingly applied to urologic surgeries such as cystectomy and prostatectomy, though research defining protocols and outcomes for renal ERAS programs (RERAS) for nephrectomy remains limited. We aim to assess perioperative outcomes following implementation of our RERAS protocol modified from ERAS society cystectomy guidelines, as well as describe compliance with protocol guidelines. METHODS: We performed a retrospective cohort analysis of 400 patients who underwent partial or radical nephrectomy between October 2017 and August 2020. RERAS protocol was initiated September 30, 2018, and patients were categorized into pre- and post-RERAS implementation cohorts based on surgery date. Perioperative outcomes including complications, 30-day readmissions, length of stay, and opioid consumption were compared across pre- and post-RERAS cohorts. Protocol compliance was reported based on adherence to program recommendations. RESULTS: Among 400 patients included in analysis, the pre-RERAS cohort included 133 patients and the post-RERAS cohort included 267 patients. There were no differences in overall complications (P = 0.354) and 30-day readmissions (P = 0.078). Length of stay (P < 0.001) and postoperative opioid consumption (P < 0.001) were significantly reduced post-RERAS. We observed an increase in compliance with RERAS recommendations over time (P< 0.001). CONCLUSION: RERAS implementation was associated with decreased length of stay and opioid usage, underscoring the benefits of program adoption in an era of opioid dependence and strained hospital capacity. Successful initiation of a RERAS protocol requires intentional organization and buy in from all providers involved.

Lessons Learned: Social Determinants of Health Screening Pilot in 2 Urology Clinics.

INTRODUCTION: Unmet social needs lead to adverse health outcomes and contribute to health inequities. Efforts to screen for social determinants of health (SDOH) have occurred primarily within primary care. Here, we describe the feasibility of implementing a workflow for SDOH screening within 2 urology clinics in Charlotte, North Carolina. METHODS: Our pilot was adapted from the WE CARE Model, which integrates a referral to community resources for patients identified with social needs and an optional followup with a navigator for additional assistance. Patients were screened with the validated Healthy Opportunities SDOH tool to assess food, housing, utilities, transportation and physical safety needs; 40 patients were screened at 2 urology clinics, totaling 80 patients. Surveys were sent to 16 clinicians and staff who participated in the pilot to assess feasibility of implementation. RESULTS: In all, 24/80 patients (30%) were screened for 1 or more social needs, with food and housing being the most frequent; 20/24 patients with social need (83%) successfully received a community resource guide, and 13 of those patients also requested a referral. All survey respondents either agreed or strongly agreed that screening was valuable and allowed them to better understand the needs of their patients. They also felt that understanding SDOH aligns with departmental goals and mission. CONCLUSIONS: Our results suggest that SDOH screening within a urological setting is feasible, and dedicated support staff should be available to ensure adequate followup for patients with unmet needs. Future work is needed to expand resources for patients and optimize workflow for clinicians.

Demographic and Socioeconomic Factors Associated with Urinary Stone Disease Management in a Large Urban US Population.

OBJECTIVE: To determine the influence of socioeconomic parameters on urinary stone surgeries. METHODS: A retrospective cohort study analyzed patients undergoing urolithiasis surgery in our community network hospital in North Carolina from 2005-2018. RESULTS: Of 7731 patients, 2160 (28%), 5,174 (67%), and 397 (5%) underwent SWL, URS, and PCNL, respectively. A higher proportion of Whites underwent URS (67%) and SWL (74%) than PCNL (56%); whereas a larger percentage of Blacks underwent PCNL (24%) than URS (20%) and SWL (15%) groups (P <.001). Private insurance payers were greater in the SWL (95%) group than URS (80%) and PCNL (81%) (P <.001). The distribution of median income was significantly different amongst the 3 surgeries with higher income classes overutilizing SWL and underutilizing PCNL compared to lower income classes (P <.001). In linear regression modeling, the proportion of SWL in a postal code was positively associated with median income (R2=0.55, P <.001); URS and PCNL were negatively associated with median income (R2=0.40, P <.001 and R2=0.41, P <.001, respectively). On multivariate logistic regression modeling, Blacks were significantly more likely to undergo PCNL than Whites (aOR 1.32, 95% CI 1.01-1.74 P <.050). Private insurance payers were more likely to undergo SWL (aOR 11.0, 95% CI 7.26-16.8, P <.0001) than public insurance payers. Patients in higher median income brackets are significantly less likely to undergo PCNL than those in the <$40,000 income bracket (P <.0001). CONCLUSION: Our study suggests that socioeconomic status impacts urolithiasis surgical management, underscoring disparity recognition importance in endourologic care and ensuring appropriate surgical care regardless of socioeconomic status.

Safety and effectiveness of percutaneous renal cryoablation with conscious sedation.

OBJECTIVE: To investigate complications and treatment failure rates of percutaneous renal cryoablation (PRC) for small renal masses under local anaesthesia and conscious sedation (LACS), to assess the safety and effectiveness of this approach, as PRC is typically performed under general anaesthesia (GA). PATIENTS AND METHODS: We retrospectively reviewed PRC under LACS from 2003 to 2017. We analysed perioperative parameters between patients who successfully underwent PRC under LACS and patients with post-procedural complications or treatment failure (renal mass enhancement after successful intraoperative tumour ablation). Two-sided non-parametric and Fisher's exact tests were performed to compare uncomplicated or disease-free PRC with the complication or treatment failure group, respectively. RESULTS: A total of 100 PRCs under LACS were performed during the study period. Of these patients, six patients had at least one postoperative complication (6%), and treatment failure was diagnosed in nine patients (9%) after PRC [mean (SD) follow-up of 42.7 (26.6) months]. The procedural failure rate was 1%. No ablations were converted to GA. The mean tumour size was smaller in patients who had no complications during PRC compared to those who did, at a mean (SD) of 2.2 (0.6) cm vs 3.0 (1.0) cm (P = 0.039). The use of more intraoperative probes during the PRC was also associated with complications, at a mean (SD) 3.0 (1.4) vs 1.8 (0.8) (P = 0.021). CONCLUSIONS: PRC under LACS is an effective and safe procedural approach for managing small renal masses with low complication, treatment failure, and procedural failure rates. Larger renal masses and intraoperative use of multiple probes is associated with an increased risk of PRC complications. ABBREVIATIONS: BMI: body mass index; CCI: Charlson Comorbidity Index; GA: general anaesthesia; LACS: local anaesthesia and conscious sedation; PRC: percutaneous renal cryoablation; R.E.N.A.L.: Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location.

Tortuous Duplicated Collecting System Complicated by Ureterovesical Junction Compression.

Duplex collecting system of the kidney is a common congenital anomaly of the urinary tract and is less reported in the adult population. Rarely, this anomaly can result in ureterovesical junction compression. Herein, we present a case of ureterovesical junction compression occurring in an adult patient with a duplex collecting system and describe the surgical management.

Reducing the Incidence of Retained Double-J Ureteral Stents: A Multidisciplinary Approach.

INTRODUCTION: Double-J® ureteral stents are temporary tubes used for ureteral patency that can cause serious complications if left beyond the allotted time. We developed a streamlined framework that allows for Double-J stent tracking to alert patients to the need for removal. METHODS: By creating a multidisciplinary committee we developed a database of patients with Double-J stents who presented to our facility between 2012 and 2014. The database was populated by a query of the billing system, generating HIPAA compliant stent removal reminder letters. Three queries (A, B and C) were developed using a combination of billing codes and each query was compared to a gold standard list. RESULTS: The ICD-9 ureteral catheterization code used to perform query A was only 28% sensitive. Query B (using CPT or HCPCS codes) was 98% sensitive. However, it incorrectly captured many patients with nonureteral stents. Our final query method, query C, rectified this issue by using the ICD-9 code with CPT or HCPCS codes, resulting in the highest sensitivity (78%) while minimizing undesired stent capture. CONCLUSIONS: We developed an automated and reproducible program that correctly identifies and alerts a high percentage of patients to the need to remove their stent. Repeated audits of our query methods combined with regular meetings of a multidisciplinary Double-J stent committee were integral to developing and maintaining this system. By promoting proactive awareness for patients as well as physicians, we are working to minimize the incidence of retained Double-J stents and associated complications.

Impact of tumour location and surgical approach on recurrence-free and cancer-specific survival analysis in patients with ureteric tumours.

UNLABELLED: What's known on the subject? and What does the study add? Pathological stage, lymph node metastasis and tumour grade have been established as prognostic factors for upper-tract urothelial carcinoma, but there are few studies to date assessing location within the ureter as a prognostic factor. There are also few studies comparing surgical approaches to radical nephroureterectomy (NU), partial ureterectomy and endoscopic resection (ENDO) with regard to oncological outcomes. This study did not find any prognostic significance for tumour location or surgical approach with regard to outcomes in patients with ureteric tumours. Although NU is the standard treatment for invasive ureteric tumours, partial ureterectomy and ENDO can safely be performed in selected patients. Despite the risk of a shorter time to recurrence, ENDO can be recommended in low grade, non-invasive ureteric tumours but only with close, thorough surveillance practices. OBJECTIVE: • To assess the impact of tumour location within the ureter and the impact of surgical approach on recurrence-free survival (RFS) and cancer-specific survival (CSS) with regard to ureteric tumours. PATIENTS AND METHODS: • Data were retrospectively reviewed from 60 patients with isolated primary ureteric tumours, treated at a single tertiary referral centre. • Patients were treated with radical nephroureterectomy (NU, n= 33), partial ureterectomy (n= 17) or endoscopic resection (ENDO, n= 10). • Kaplan-Meier curves were used for the analysis of RFS and CSS after surgery, stratified by tumour location and surgical approach. RESULTS: • With a median follow-up of 29 months, tumour location was not associated with disease recurrence (P= 0.423). • The ENDO group had shorter time to disease recurrence. • There were no significant differences in the probability of CSS with regard to either tumour location or surgical approach (P= 0.523 and P= 0.904, respectively). CONCLUSIONS: • Tumour location or surgical approach were not significant predictors of oncological outcomes in patients with ureteric tumours. • Although NU is standard treatment for invasive ureteric tumours, partial ureterectomy and ENDO can safely be performed in selected patients. Despite the risk of a shorter time to recurrence, ENDO can be recommended in low grade, non-invasive ureteric tumours. • All urothelium-preserving approaches require thorough surveillance.

Cone beam computed tomography for percutaneous nephrolithotomy: initial evaluation of a new technology.

BACKGROUND AND PURPOSE: Cone beam CT (CBCT) is a novel imaging modality that combines the versatility of conventional C-arm imaging with the functionality of cross-sectional imaging. This is a pilot study to evaluate the capabilities of this new technology to obtain percutaneous access and for the immediate postoperative evaluation of residual fragments in percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: A retrospective analysis of all PCNL cases performed between April 2007 and November 2007 was performed. One urologist (NSS) and one radiologist (JFA) reviewed the studies postoperatively. Preoperative films were evaluated to see if CBCT influenced or improved percutaneous access. Postoperative films were evaluated that compared CBCT with conventional noncontrast CT to determine efficacy in finding postoperative stone fragments. Parameters of stone size, location, and quantity of fragments were compared. RESULTS: For preoperative access, CBCT was used in 52 cases of PCNL between April 2007 and November 2007. In eight of these cases, CBCT altered the percutaneous access. In postoperative evaluation, 26 cases had both CBCT and conventional CT for comparison. In 11 cases with residual stones, conventional CT identified a greater number of fragments, but these were less than 2 mm. The postoperative recommendation for a secondary procedure concurred in 22 of 26 studies. CONCLUSIONS: CBCT may provide advantages of improved preoperative imaging, which may result in better percutaneous access, and improved postoperative imaging, which allows surgeons to have "real-time" access to CT quality images. The intraoperative availability of these high quality tomographic images may obviate the need for other postoperative imaging and subsequent adjunctive procedures for residual fragments.

Minimally invasive retroperitoneal lymph node dissection for testicular cancer.

Testicular cancer is the most common solid organ malignancy in young men between the ages of 15 and 35. Although much of this increase in survival can be attributed to improvements in systemic chemotherapy, surgery retains a critical role in the diagnostic and therapeutic management of testicular cancer. Laparoscopic retroperitoneal lymph node dissection is an effective staging and therapeutic procedure in patients with low-stage testicular cancer. It is an attractive alternative to the open approach, with faster recovery, improved cosmesis, and reduced post-operative morbidity driving its application. In experienced hands, it can be used in postchemotherapy patients.

Biomagnetic detection of injury currents in rabbit ischemic intestine.

The presence of direct current (DC) injury currents in ischemic tissue is an important diagnostic indicator of pathophysiology in cortical spreading depression and particularly in myocardial infarction. To date, no measurements of DC injury currents in the alimentary tract have been reported. We used a SQUID magnetometer to measure changes in the baseline of the magnetic field of intestinal electrical activity during induced segmental ischemia. We computed the magnetic field DC baseline by subtracting sequential recordings made while the bowel segment was first directly beneath the SQUID and then pulled away. We observed a significant baseline decrease of 38% +/- 4% in experimental animals, while the control group decreased by only 1% +/- 6%. This magnetic field baseline decrease is consistent with the flow of injury currents between normally perfused and hypoxic tissue regions. This study is the first report of DC injury currents in ischemic smooth muscle of the alimentary tract.