Urologists Are Performing More Renal Access Procedures for PCNL

UROLOGISTS ARE increasingly performing their own initial renal access procedures for percutaneous nephrolithotomy (PCNL), with a corresponding decrease in the proportion of those procedures performed in interventional radiology (IR) departments, according to a recent study.

The proportion of urologists performing their own de novo renal access for PCNL rather than having patients undergo the procedure in an IR department rose from 12.8% in 2007 to 32.3% in 2017, Ian S. Metzler, MD, of the University of Washington School of Medicine in Seattle, and colleagues in the Journal of Endourology.

De novo renal access “is the most technically challenging aspect of the PCNL procedure and therefore remains a considerable barrier for wider adoption of PCNL,” Dr Metzler’s team wrote.

Although IR departments performed a shrinking proportion of renal access procedures during the study period, they still performed a greater proportion (40%) of the procedures in 2017 compared with urologists. In 27.7% of PCNL cases in 2017, no provider-assigned renal access CPT code for renal access was available, the investigators noted.

Use of PCNL remained stable during the 10-year study period at around 3% to 4%, whereas use of ureteroscopy (URS) use increased from 46.3% to 60.0% of procedures and extracorporeal shockwave lithotripsy (SWL) use decreased from 50% to 36.7% of procedures.

Compared with urologist-gained access, radiologist-gained access was associated with a significantly greater percentage of patients requiring a hospital stay of more than 2 days (30.8% vs 18.6%) and a significantly higher 90-day rate of hospital readmission (16.7% vs 12.8%), and 90-day blood transfusion rate (0.8% vs 0.3%), according to the investigators.

“We were encouraged to see that the uptake of urologists obtaining their own access has increased over the last decade and that their outcomes on selected patients were comparable to our IR colleagues,” Dr Metzler told Renal & Urology News. “PCNL remains a lower-volume, but critically important procedure for urologists and continued support for education and training of percutaneous access should be emphasized.”

The study also revealed trends in the use of PCNL, URS, and SWL during 2007 to 2017. Using the MarketScan insurance claims database, the investigators used CPT codes to identify PCNL, URS, and SWL cases. During the 10-year study period, the annual proportion of PCNL procedures peaked at 4.5%, with a recent decline in 2016 and 2017 to 3.2%, Dr Metzler’s team reported. While URS use increased steadily from 46.3% to 60.0% of procedures, SWL use decreased from 50.0% to 36.7% of procedures. ■

Use of PCNL, a common approach for staghorn stones, has remained stable.

In-Person CKD Visits Plummeted Early in Pandemic

BY NATASHA PERSAUD IN-PERSON VISITS among patients last known to have stage 3 to 4 chronic kidney disease (CKD) declined dramatically early in the COVID-19 pandemic compared with usual levels, and telehealth did not fully compensate for the loss in medical care, investigators revealed during the virtual National Kidney Foundation 2021 Spring Clinical Meetings.

According to data from United Health Medicare Advantage program, 2.74 million in-person visits were predicted for the early pandemic period March 1 to June 30, 2020, but only 1.56 million inperson visits occurred — a 44% loss of in-person services, Clarissa Diamantidis, MD, of Duke University in Durham, North Carolina, and colleagues reported.

Telehealth visits ramped up in April and May 2020, briefly approaching the number of in-person visits that would be expected, then declined in late May as in-person visits resumed, the investigators observed. Telehealth visits supplemented in-person care by 12.5% early in the early pandemic, the investigators reported. The overall deficit in CKD care was 30%, they said. Total visits peaked in mid-June 2020 at 86% of predicted visits. Currently, CKD care appears to be at 5% below prepandemic utilization rates according to other sources, Dr Diamantidis told Renal & Urology News.

In addition, the team observed a reduction in medication coverage early in the pandemic, such as the number of days patients were covered by antihypertensives and diabetes medications, and a reduction in procedures, particularly lab tests used to monitor CKD (such as metabolic panel, urinary albumin quantification, and assays of urinary creatinine).

“The downstream impact of CKD care reduction on health outcomes, such as hospitalizations or dialysis preparedness, requires further study, as does evaluation of which care delivery models are most effective for CKD populations,” Dr Diamantidis said. She said she hopes further research will distinguish areas of low value care from high value care.

Dr Diamantidis added that it is clear that nephrologists need to partner more with primary care physicians.

“The pandemic has taught us that digital care is possible and acceptable,” Dr Diamantidis said. “Prior to COVID19, there was a great deal of hesitation about using telehealth due to reimbursement issues — which have been mitigated due to new policies — technology issues, and the desire to interact with patients. Data are showing that telehealth visits are patient-centric, cost-effective, and efficient. Telehealth does not substitute for in-person visits, but it can supplement them. Notwithstanding, the digital divide in internet access, digital readiness, and trust remain an issue.” ■

Graft Failure Tied to Low Bicarbonate

LOW SERUM bicarbonate in kidney transplant recipients is associated with an increased risk for graft failure, according to data presented at the virtual National Kidney Foundation 2021 Spring Clinical Meetings.

A study of a real-world population of 1722 renal transplant recipients who had a functioning graft at 1 year showed that each 1 mEq/L increase in serum bicarbonate over time was associated with a 10% reduction in graft failure risk in adjusted analyses, Vandana Mathur, MD, a nephrologist and president of MathurConsulting in Woodside, California, and colleagues reported in a poster presentation.

In addition, each 1 mEq/L increase in serum bicarbonate was associated with a 4% increased risk for a composite of major cardiovascular (CV) events (MACE+) that included the first occurrence of myocardial infarction, stroke, new-onset heart failure (HF), a HF inpatient admission in patients with comorbid HF, or CV death.

“Since metabolic acidosis is a risk factor for [chronic kidney disease] progression, we examined its role in predicting long-term graft loss in kidney transplant recipients in a large US community-based cohort,” Dr Mathur’s team explained.

They concluded, “The role of metabolic acidosis as a modifiable risk factor for chronic allograft nephropathy and MACE+ deserves further examination.”

The investigators analyzed data from the Optum EHR+Integrated dataset of US patients (2007-2019) with a kidney transplant preceded by 1 year or more of data and no graft loss during the first year.

The study cohort, which had a mean age of 51.1 years, consisted of 1034 male (60%) and 688 (40%) female patients. At baseline, patients had a mean estimated glomerular filtration rate of 63.4 mL/min/1.73 m2 and mean baseline serum bicarbonate level of 24.6 mEq/L. ■

No ADT-CV mortality link

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Comprehensive Cancer Network criteria (clinical T2b-T4, Gleason score 7-10, or PSA level greater than 10 ng/mL). They defined CV mortality as death from cardiac causes, stroke, or other vascular causes.

In an acknowledgment of study limitations, Dr Mualidhar’s team said it is possible that a difference in CV mortality by ADT use exists and that the study was underpowered to detect it. In addition, the PLCO trial lacked important clinical data endpoints, including development of nonlethal myocardial infarction, CVD, and diabetes, all of which have been associated with ADT use in prior studies, they noted.

Commenting on the new study, Sanoj Punnen, MD, MAS, associate professor of urology at the University of Miami Miller School of Miami, said the new findings add to the literature showing similar CV mortality risk between RT alone and RT plus ADT.

In his view, he said, the biggest study limitation was that the decision regarding who received RT alone or in combination with ADT was based on routine clinical practice and did not follow a scientific protocol, a possible source of selection bias. The study authors, however, did

acknowledge that “the trial did not specifically dictate medical practice, implement uniform diagnostic and treatment protocols, or record data on clinician reasoning behind management decisions— all of which may create the potential for selection bias in our study.” The authors noted that men with more than 1 comorbidity were less likely to receive ADT.

Dr Punnen, who is co-chair of the Genitourinary Site Disease Group at the University of Miami’s Sylvester Comprehensive Cancer Center, pointed out that the new findings “are pertinent to those who are undergoing current ADT as part of radiation and may not be generalizable to those placed on longer durations of continuous ADT for recurrence or metastatic disease.”

The study by Dr Muralidhar’s group adds to a growing body of research examining the CV safety of ADT. A recent study conducted in South Korea found that ADT might even decrease the risk for ischemic CVD and cerebrovascular disease. In a propensity-scorematched cohort that included 61,722 men with PCa, men who received ADT, compared with those who did not, had a significant 11.0% and 13.1% reduced risk for ischemic CVD and cerebrovascular disease, respectively. ■

In a study, adding ADT to radiotherapy did not significantly up CV death risk.

Early PCa rarely fatal

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was the most common noncancer cause of death (23.3%).

During follow-up, the risk of death overall was 10% lower for men with local or regional PCa compared with the general population, and, in particular, in the first year after diagnosis (42% lower).

Among the 27,535 men with distant PCa who died, PCa was the cause of death in 20,451 cases (74.3%). Another 1709 (6.2%) died from other cancers and 5375 (19.5%) died from noncancer causes. Also, 90% of deaths among men with distant PCa occurred within 5 years of diagnosis. Compared with the general population, men with distant PCa were 1.5-fold more likely to die from noncancer causes, notably suicide and sepsis.

“Overall, our work highlights new opportunities to optimize overall health care management for men with distant PCa,” the authors wrote.

With regard to study limitations, the authors noted the SEER dataset for active surveillance (AS) and watchful waiting (WW) only extends back to 2010 and does not distinguish between these management approaches. AS involves disease monitoring with intent to provide curative treatment if signs of disease progression emerge, whereas WW often describes potential future treatment to palliate symptoms, they pointed out. “Patients managed with active surveillance or watchful waiting would likely greatly differ in that men managed with watchful waiting often elect watchful waiting because other comorbid health concerns which may limit life expectancy take priority over PCa,” Dr Weiner’s team wrote. “Thus, the heterogeneity of this subgroup within SEER would limit interpretability.”

In an accompanying editorial, Joseph E. Bauer, PhD, of the Levine Cancer Institute/Atrium Health in Charlotte, North Carolina, praised the new study by Dr Weiner and his colleagues.

“Their detailed account presents an increased awareness/sensitivity for clinical practitioners, including oncologists, radiation oncologists, urologists, and primary care physicians, among others.”

Dr Bauer added, “Think of their research findings as placing a bit more focus on noncancer causes of death in PCa survivors; this gives clinical practitioners the chance to affect the current mortality patterns by prioritizing health care management decisions.” ■

Inflammatory diet

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China Hospital, Sichuan University in China, reported in The Journal of Urology. The odds of testosterone deficiency increased 4.0% for every unit increase in DII. In a fully adjusted model, men in tertiles 2 and 3 had significant 19% and 30% increased odds of testosterone deficiency compared with men in tertile 1. Obese men with more pro-inflammatory diets (tertiles 2 and 3) had 15.91 and 26.75 ng/mL lower total testosterone than men with an anti-inflammatory diet (tertile 1). Results showed that obese men in the higher DII tertiles had significant 31% and 59% increased odds of testosterone deficiency, respectively. “Our results suggest men who eat a pro-inflammatory diet, particularly those who are obese, are more likely to have testosterone deficiency,” Dr Qiu stated in a press release from the journal’s publisher. “Since men with obesity likely already experience chronic inflammation, physicians should be aware of contributing factors, like diet, that could likely worsen this inflammation and contribute to the risk of other health conditions, such as diabetes and heart disease.” The authors acknowledged study limitations, the main one being that the NHANES database provides only cross-sectional data, “which severely hinders our ability to a make a causal inference.” They had to rely on selfreported dietary intake, which is subject to recall bias and is estimated from a 24-hour history, which cannot reflect the day-to-day variability in intake. The investigators were unable to directly exclude patients diagnosed with hypogonadism because those data are not available in the NHANES database, they noted. In addition, serum testosterone was only assayed at a single time point, and American Urological Association guidelines recommend obtaining 2 measurements because of intra-individual and diurnal variations in serum testosterone, they pointed out. ■

GG5 Pattern Influences PCa Mortality Risk

PROSTATE CANCER (PCa) mortality differs by specific Gleason grade group (GG) 5 pattern, according to a new study.

Men with Gleason pattern 5+4 and 5+5 had significantly increased risks for cancer-specific mortality (CSM) compared with those with Gleason pattern 4+5, Mike Wenzel, MD, of the University Hospital Frankfurt in Germany and colleagues reported in a paper published in European Urology Focus.

“Ideally, individual Gleason patterns should be considered in pretreatment risk stratification,” they wrote.

Using the 2004-2016 data from the Surveillance, Epidemiology and End Results (SEER) database, the researchers identified 17,263 men with GG 5 cancer at biopsy, including 12,705 with Gleason 4+5, 3302 with Gleason 5+4, and 1256 with Gleason 5+5 disease. All patients underwent radical prostatectomy (RP) or external beam radiation therapy (EBRT).

The 5- and 10-year CSM rates were 7.3% and 18.2% for Gleason 4+5, 11.7% and 28.0% for Gleason 5+4, and 19.8% and 39.1% for Gleason 5+5, respectively, Dr Wenzel and his colleagues reported.

In multivariable analyses, Gleason 5+4 and Gleason 5+5 were associated with 1.6- and 2.2-fold higher CSM risks, respectively, compared with Gleason 4+5. The risks varied by treatment subgroup. Compared with Gleason 4+5, Gleason 5+4 was significantly associated with approximately 1.6- and 2.5-fold increased CSM risks among patients who underwent RP and EBRT, respectively. Gleason 5+5 was significantly associated with approximately 1.5- and 2.1-fold increased risks, respectively.

“Prostate cancer characteristics were increasingly unfavorable with increasingly aggressive Gleason pattern from 4+5 to 5+4 to 5+5,” Dr Wenzel’s team observed. They noted that the death risk associated with Gleason pattern 5+5 cancer was even higher for patients undergoing RP than EBRT, perhaps partly due to use of androgen deprivation therapy. ■