Trost, Landon

Objectives To model renal function after radical nephroureterectomy ( RNU ) for upper tract urothelial carcinoma ( UTUC ). To identify predictors of renal function decline after surgery, thereby allowing the identification of patients likely to be ineligible for cisplatin‐based chemotherapy in the adjuvant setting. Patients and Methods We retrospectively identified 374 patients treated with RNU for UTUC at three centres between 1995 and 2010. Estimated glomerular filtration rate ( eGFR ) was calculated using Chronic Kidney Disease Epidemiology Collaboration equation before RNU and at early (1–5 months after RNU ) and late (>5 months) time points after RNU . Only patients deemed eligible for cisplatin‐based chemotherapy before RNU (preoperative glomerular filtration rate [ GFR ] ≥60 mL/min/1.73 m 2 ) were included. Multivariable analysis identified the preoperative predictors of eGFR after RNU at early postoperative and late postoperative time points. Results A total of 163 patients had an eligible early post‐ RNU eGFR measurement and 172 had an eligible late eGFR measurement. The median eGFR declined by 32% and did not show a significant trend toward recovery over time ( P = 0.4). On multivariable analysis preoperative eGFR and patient age were significantly associated with early and late postoperative eGFR , while C harlson comorbidity index score was significantly associated with late postoperative eGFR alone. Conclusions In patients with normal preoperative eGFR (≥60 mL/min/1.73 m 2 ), renal function decreases by one‐third after RNU and does not show evidence of recovery over time. Elderly patients and those with pre‐ RNU eGFR closer to 60 mL/min/1.73 m 2 (lower eGFR in the present cohort) are more likely to be ineligible for adjuvant cisplatin‐based chemotherapy regimens because of renal function loss after RNU .

ABSTRACT Introduction Inflatable penile prostheses (IPPs) are associated with excellent long-term outcomes and patient/partner satisfaction. A small percentage of patients remain dissatisfied, despite acceptable surgical results. Aims This study aims to evaluate factors associated with patient satisfaction and dissatisfaction, define patient characteristics, which may identify elevated risk of postoperative dissatisfaction, and describe management strategies to optimize functional and psychological patient outcomes. Methods A review of urologic and non-urologic cosmetic surgery literature was performed to identify factors associated with patient satisfaction/dissatisfaction. Emphasis was placed on articles defining “high risk” or psychologically challenging patients. Main Outcome Measures Preoperative factors associated with patient satisfaction/dissatisfaction and character traits, which may identify elevated risk of postoperative dissatisfaction or otherwise indicate a psychologically challenging patient. Results Contemporary patient and partner satisfaction rates following IPP are 92–100% and 91–95%, respectively. Factors associated with satisfaction include decreased preoperative expectations, favorable female partner sexual function, body mass index ≤30, and absence of Peyronie's disease or prior prostatectomy. Determinants of dissatisfaction include perceived/actual loss of penile length, decreased glanular engorgement, altered erectile/ejaculatory sensation, pain, diminished cosmetic outcome, difficulty with device function, partner dissatisfaction and perception of unnatural sensation, complications, and extent of alternative treatments offered. Personality characteristics which may indicate psychologically challenging IPP patients include obsessive/compulsive tendencies, unrealistic expectations, patients undergoing revision surgery, those seeking multiple surgical opinions, feeling of entitlement, patients in denial of their prior erectile/sexual function and current disease status, or those with other psychiatric disorders. The mnemonic CURSED Patient is presented: “Compulsive/obsessive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric.” Conclusions Although the majority of IPP patients experience excellent, durable satisfaction and outcomes, a challenging subset of patients may be at increased risk of postoperative dissatisfaction. Appropriate recognition/prevention and management of this cohort may help to establish and strengthen relationships, reduce physical, emotional, and legal risk, and ultimately enhance patient satisfaction.