Immunotherapy has revolutionized the treatment of metastatic renal cell carcinoma (RCC). This case evaluates the use of neoadjuvant immunotherapy for localized RCC in a patient with solitary functioning kidney. A retrospective chart review was conducted between September 2019 and January 2020 on a single patient. Before treatment, the tumor was 7 cm × 8 cm × 8.5 cm. The patient trialed nivolumab + ipilimumab then cabozantinib. The tumor shrunk to 6.3 cm × 5.5 cm and was removed via partial nephrectomy. This case demonstrates the efficacy of immunotherapy in neoadjuvant treatment of RCC. Expansion of guidelines could allow for patients with RCC to undergo partial nephrectomy.
With increasing treatment options available, the management of locally advanced and metastatic prostate cancer (PCa) is growing more complex, nuanced, and individualized. Strategies for combining surgery, radiation, chemotherapy, and androgen deprivation therapy (ADT) continue to evolve, as do ADT and immunotherapy options. Additionally, multiple adjunctive agents for metastatic PCa have been recently approved or are pending approval. As the number of locally advanced and metastatic prostate cancers being diagnosed rises, so does the need to consider patients' clinical situations and personal preferences. This review discusses current and potential future approaches to managing locally advanced and metastatic PCa.
The management of small, non-obstructing renal stones in adults with recurrent lower urinary tract infections remains unclear. Whereas for larger or obstructing stones the decision to intervene becomes clearer, for stones smaller than 5 to 6 mm the decision to intervene requires consideration of multiple factors. This review describes these factors, including history, imaging, laboratory studies, as well as a comprehensive review of the literature. It remains of utmost importance that patients have additional possible etiologies appropriately evaluated and managed prior to intervention for their small renal stones.
We evaluated the impact of safety protocols, including rapid testing and contact tracing, on coronavirus disease 2019 (COVID-19) risk exposure and transmission rates amongst healthcare workers in the outpatient care setting. Over an 11-week period, a total of 254 employees representing 38% of our total workforce had potential COVID-19 exposure and underwent voluntary COVID-19 testing. Data was stratified based on severity of risk exposure and job description. During this period, the probability of a COVID exposure being high risk decreased in Administrative (-93.0%; P < 0.01) and Clinical (-77.0%; P < 0.01) staff; simultaneously, viral transmission rates declined in Administrative (-73.4%; P = 0.03) and Clinical (-69.9%; P = 0.04) staff as well. Systematic safety protocols effectively reduce exposure risk and transmission rates in outpatient healthcare workers and should be ubiquitously adopted.
Transwomen may elect to pursue fertility preservation prior beginning hormonal treatment or proceeding with gender-affirming surgery. To date, there has been little research specifically investigating factors influencing fertility and preservation thereof among transwomen. Here, we review the case of a transwoman who engaged in genital tucking behavior presenting with severe oligospermia, and we review the literature regarding transgender fertility preservation and the role of the heat stress hypothesis with regards to this common behavior.
To assess the usefulness and applications of machine vision (MV) and machine learning (ML) techniques that have been used to develop a single cell-based phenotypic (live and fixed biomarkers) platform that correlates with tumor biological aggressiveness and risk stratification, 100 fresh prostate samples were acquired, and areas of prostate cancer were determined by post-surgery pathology reports logged by an independent pathologist. The prostate samples were dissociated into single-cell suspensions in the presence of an extracellular matrix formulation. These samples were analyzed via live-cell microscopy. Dynamic and fixed phenotypic biomarkers per cell were quantified using objective MV software and ML algorithms. The predictive nature of the ML algorithms was developed in two stages. First, random forest (RF) algorithms were developed using 70% of the samples. The developed algorithms were then tested for their predictive performance using the blinded test dataset that contained 30% of the samples in the second stage. Based on the ROC (receiver operating characteristic) curve analysis, thresholds were set to maximize both sensitivity and specificity. We determined the sensitivity and specificity of the assay by comparing the algorithm-generated predictions with adverse pathologic features in the radical prostatectomy (RP) specimens. Using MV and ML algorithms, the biomarkers predictive of adverse pathology at RP were ranked and a prostate cancer patient risk stratification test was developed that distinguishes patients based on surgical adverse pathology features. The ability to identify and track large numbers of individual cells over the length of the microscopy experimental monitoring cycles, in an automated way, created a large biomarker dataset of primary biomarkers. This biomarker dataset was then interrogated with ML algorithms used to correlate with post-surgical adverse pathology findings. Algorithms were generated that predicted adverse pathology with >0.85 sensitivity and specificity and an AUC (area under the curve) of >0.85. Phenotypic biomarkers provide cellular and molecular details that are informative for predicting post-surgical adverse pathologies when considering tumor biopsy samples. Artificial intelligence ML-based approaches for cancer risk stratification are emerging as important and powerful tools to compliment current measures of risk stratification. These techniques have capabilities to address tumor heterogeneity and the molecular complexity of prostate cancer. Specifically, the phenotypic test is a novel example of leveraging biomarkers and advances in MV and ML for developing a powerful prognostic and risk-stratification tool for prostate cancer patients.
A 64-year-old woman was referred for recurrent urinary tract infections (UTIs). She presented with progressive complaints of vaginal dryness, sensitivity, and pain at the introitus with associated dyspareunia despite the use of over-the-counter vaginal lubricants. She reported having 3 or 4 UTIs per year since entering menopause, often occurring postcoitally. She was finding wearing tight pants and bike riding increasingly difficult because of her introital discomfort. She was avoiding sexual activity with her husband because of pain and fear of UTIs.
Broad-based prostate-specific antigen (PSA) screening has saved lives but at a substantial human and financial cost. One way of mitigating this harm, while maintaining and possibly improving the benefit, is by focusing screening efforts on men at higher risk. With age, race, and family history as the only risk factors, many men lack any reliable data to inform their prostate cancer (PCa) screening decisions. Complexities including history of previous negative biopsies, interpretation of negative and/or equivocal mpMRI findings, and patient comorbidities further compound the already complicated decisions surrounding PCa screening and early detection. The authors present cases that provide real-world examples of how a single nucleotide polymorphism-based test can provide patients and providers with personalized PCa risk assessments and allow for development of improved risk-stratified screening regimens.
Urethral stricture disease (USD) is a progressive scar-forming disease commonly encountered by urologists and is challenging to manage. USD most frequently occurs in the bulbar urethra. Patients typically present with chronic obstructive voiding symptoms but may develop recurrent urinary tract infections, detrusor failure, or renal disease. The authors review the pathophysiology, diagnostic workup, and evidence-based management of bulbar urethral strictures (BUS). There are multiple surgical options to treat BUS. Endoscopic techniques (eg, dilation and urethrotomy) are suitable for the initial management of short strictures but new evidence-based guidelines recommend against repeated endoscopic treatment. Urethroplasty is the gold standard treatment for BUS of all lengths, with anastomotic techniques appropriate for strictures <2 cm and tissue substitution performed for longer strictures. New techniques, such as non-transecting urethroplasty, lack long-term data but may represent a paradigm shift in the field. Future treatments may utilize tissue-engineered grafts and agents that inhibit inflammation and scar formation.
A 31-year-old woman presented to NYU Langone with intermittent right flank pain of 6 months’ duration. The pain was sharp, non-radiating, and worsened with fluid intake. The patient had originally been in Italy, where she was diagnosed with kidney stones and underwent 3 ureteroscopic treatments, but her pain persisted. She was unable to provide prior medical records delineating what operations and perioperative care she had been provided in Italy. A recent CT urogram showed a 4-cm right posterior upper pole calyceal diverticulum (CD) with a 9-mm stone (Figure 1). There was no hydronephrosis and the left kidney appeared normal. She had had one prior episode of urinary tract infection (UTI) and had been treated to effect. In the office on presentation, she complained of persistent and intermittent right flank pain but did not display costovertebral angle (CVA) tenderness on examination. Her renal function was normal, with Cr 0.8 mg/ dL and office urinalysis dipstick negative for UTI.
A 37-year-old man presented with primary infertility of 12 months’ duration. His current partner wife was 30 years old and had not undergone a fertility evaluation. The couple had been having properly timed and unprotected intercourse for 12 months. The patient denied any sexual dysfunction. He had no past medical history, never had surgery, and did not take any medications. He denied smoking or using illicit drugs and had no relevant family history. He worked as a physician and denied genital trauma or exposure to toxic or radioactive agents.
A 70-year-old man was referred for penile urethral stricture and vesicourethral anastomotic stenosis (VUAS) after robot-assisted radical prostatectomy at an outside institution. There was no evidence of cancer recurrence, but over the last 5 years, he had had multiple episodes of urinary retention. He had received 10 endoscopic treatments for recurrent VUAS. His surgical history was also notable for bilateral inguinal hernia repair with mesh. He was placed on intermittent catheterization in an effort to maintain urethral patency, but he became unable to catheterize because of the development of the penile urethral stricture from repeated catheter trauma.
[This corrects the article on p. 126 in vol. 22, PMID: 33239972.].
