Background Hematuria is a common clinical finding and represents the most frequent presenting sign of bladder cancer. The American Urological Association recommends cystoscopy and abdomino-pelvic imaging for patients over 35 years. Nonetheless, fewer than half of patients presenting with hematuria undergo proper evaluation. We sought to identify clinical and non-clinical factors associated with evaluation of persons with newly diagnosed hematuria. Methods Retrospective cohort study, using claims data and laboratory values. The primary exposure was practice site, as a surrogate for non-clinical, potentially modifiable sources of variation. Primary outcomes were cystoscopy and/or abdomino-pelvic imaging within 180 days following hematuria diagnosis. We modeled the association between clinical and non-clinical factors and appropriate hematuria evaluation. Results We identified 2,455 primary care patients 40 years of age or older diagnosed with hematuria between 2004 and 2012 in the absence of other explanatory diagnosis. 13.7% of patients underwent cystoscopy within 180 days. Multivariate logistic regression revealed significant variation between those who did and did not undergo evaluation in age, gender and anti-coagulant use (p<0.001, p=0.036, p=0.028). Addition of practice site improved the predictive discrimination of each model (p<0.001). Evaluation was associated with higher rates of genitourinary neoplasia diagnosis. Conclusions Patients with hematuria rarely underwent complete evaluation. While established risk factors for malignancy were associated with increasing use of diagnostic testing, factors unassociated with risk, such as practice site, also accounted for significant variation. Inconsistency across practice sites is undesirable and may be amenable to quality improvement interventions.

Monocytes/macrophages are thought to be recruited to the renal interstitium during calcium oxalate (CaOx) kidney stone disease for crystal clearance. Mitochondria play an important role in monocyte function during the immune response. We recently determined that monocytes in patients with CaOx kidney stones have decreased mitochondrial function compared to healthy subjects. The objective of this study was to determine whether oxalate, a major constituent found in CaOx kidney stones, alters cell viability, mitochondrial function, and redox homeostasis in THP-1 cells, a human derived monocyte cell line. THP-1 cells were treated with varying concentrations of CaOx crystals (insoluble form) or sodium oxalate (NaOx; soluble form) for 24 h. In addition, the effect of calcium phosphate (CaP) and cystine crystals was tested. CaOx crystals decreased cell viability and induced mitochondrial dysfunction and redox imbalance in THP-1 cells compared to control cells. However, NaOx only caused mitochondrial damage and redox imbalance in THP-1 cells. In contrast, both CaP and cystine crystals did not affect THP-1 cells. Separate experiments showed that elevated oxalate also induced mitochondrial dysfunction in primary monocytes from healthy subjects. These findings suggest that oxalate may play an important role in monocyte mitochondrial dysfunction in CaOx kidney stone disease.

There were no significant differences in overall prostate cancer detection when comparing MRI-targeted biopsies to standard systematic biopsies (P = 0.39). Furthermore, there were no significant differences in the distribution of severity of cancers based on grade groups in cases with cancer detection (P = 0.68). However, significantly fewer needle cores were taken during the MRI/US fusion-guided biopsy compared with systematic biopsy (63% less cores sampled, P < 0.001) CONCLUSION: In biopsy-naive men, MRI/US fusion-guided prostate biopsy offers equal prostate cancer detection compared with systematic TRUS-guided biopsy with significantly fewer tissue cores using the targeted technique. This approach can potentially reduce morbidity in the future if used instead of systematic biopsy without sacrificing the ability to detect prostate cancer, particularly in cases with higher grade disease.

Diet has been associated with several metabolic diseases and may impact immunity. Increased consumption of meals with high oxalate content may stimulate urinary calcium oxalate (CaOx) crystals, which are precursors to CaOx kidney stones. We previously reported that CaOx stone formers have decreased monocyte cellular bioenergetics compared to healthy participants and oxalate reduces monocyte metabolism and redox status in vitro. The purpose of this study was to investigate whether dietary oxalate loading impacts monocyte cellular bioenergetics, mitochondrial complex activity, and inflammatory signaling in humans. Healthy participants (n = 40; 31.1 ± 1.3 years) with a BMI of 24.9 ± 0.6 kg/m2 consumed a controlled low oxalate diet for 3 days before drinking a blended preparation of fruits and vegetables containing a large amount of oxalate. Blood and urine were collected before (pre-oxalate) and for 5 h after the oxalate load to assess urinary oxalate levels, monocyte cellular bioenergetics and mitochondrial complex activity, and plasma cytokine/chemokine levels. Urinary oxalate levels significantly increased in post-oxalate samples compared to pre-oxalate samples. Monocyte cellular bioenergetics, mitochondrial complex I activity, and plasma cytokine and chemokine levels were altered to varying degrees within the study cohort. We demonstrate for the first time that dietary oxalate loading may impact monocyte metabolism and immune response in a cohort of healthy adults, but these response are variable. Further studies are warranted to understand oxalate mediated mechanisms on circulating monocytes and how this potentially influences CaOx kidney stone formation.Clinical Trial RegistrationClinicalTrials.gov, identifier NCT03877276.

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Objectives: To develop a preoperative nomogram that would predict the risk of a postoperative complication for pheochromocytoma patients undergoing adrenalectomy using an international database. Methods: We retrospectively analyzed preoperative variables and postoperative outcomes in patients who underwent adrenalectomy for pheochromocytoma in three institutions from 2000 to 2017. Internal validation of a generated nomogram was carried out with receiver operating characteristics, calibration plots, and decision curve analyses. Results: A total of 153 patients who had undergone 166 adrenalectomies were included in the study. Overall, post-adrenalectomy complications were seen in 30% of patients, whereas 9.6% of patients sustained a Clavien ≥3a complication. Independent predictors of a complication were a history of hypertension, body mass index, tumor size, and Charlson Comorbidity Index score. On internal validation, the multivariable model generated a nomogram that predicted a postoperative complication or clinically hemodynamic event with an area under the curve of 0.86, showed good calibration and had an overall net benefit. Conclusions: An internally validated nomogram combining body mass index, Charlson Comorbidity Index score and tumor size can predict the probability of a postadrenalectomy complication in those with and without hypertension. The model, the first of its kind in pheochromocytoma surgery, identifies patients at risk of a postoperative complication at the time of their presentation with pheochromocytoma.

To present the feasibility and technical details of robot-assisted single port partial nephrectomy with a retroperitoneal approach, using da Vinci SPÒ platform.METHODS: Between April and July 2019, 2 patients (1 male) with renal mass (both right side) underwent robot-assisted single port retroperitoneal partial nephrectomy. Both patients had organ confined disease with lower pole 24 and 25 mm renal masses (Nephrometry score: 4p and 6p). Patients were positioned in 90 degree flank position and a 30 mm transverse incision was made between the 12th rib and the iliac crest at the level of the mid axillary line. The retroperitoneal space is initially identified and created by digital exploration, followed by balloon dilation to create an appropriate working space. The inner ring of the alexis wound retractor was inserted in the retroperitoneal space, and the GelPOINT Mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA) was assembled. A 25 mm multichannel robot port and a 12-mm accessory laparoscopic port were passed through the GelPOINT and the da Vinci SPÒ Surgical System (Intuitive Surgical, Sunnyvale, CA) was docked. Standard partial nephrectomy with early unclamping technique and renorrhaphy in two layers was performed. The specimen was extracted through the trocar site and no drain was placed.RESULTS: Patients' age was 58 and 78 years. Both cases were completed successfully without any need for conversion, blood transfusion or intraoperative complications. Operative times were 155 and 240 minutes, with warm ischemia times of 26 and 29 minutes. Postoperative course was uneventful and patients were discharged after 26 and 42 hours of hospital stay. In-hospital analgesia included exclusively nonsteroidal anti-inflammatory drugs. Histopathological examination of specimens showed a 21 mm clear cell renal cell carcinoma and a 26 mm benign papillary adenoma, both with negative margins.CONCLUSIONS: Single-port partial nephrectomy through retroperitoneal approach is feasible in selected patients by Using da Vinci SPÒ platform is feasible. This system has features such as double-jointed articulating robotic instruments and the articulating camera that allow to optimize the work in a smaller environment such the retroperitoneal space. With avoiding violation of the peritoneum, promising results regarding pain control, the need for opioid usage and postoperative recovery can be expected. Further comparative studies with larger sample and long-term follow-up data are recommended to corroborate these initial findings.

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