This study aimed to evaluate contemporary management strategies of pediatric renal trauma, focusing on the failure of conservative management and identifying its predictors. The National Trauma Database (2018-2021) was queried for pediatric patients (≤18 years) with renal injury, identified via AIS codes aligned with the AAST kidney injury grading system. Urological surgical procedures were identified via ICD-10 Procedure Codes. Patients were categorized into immediate surgical management (within 4 h), conservative management (no surgery), and failed conservative management (surgery after 4 h). Demographics, injury characteristics, and clinical data were analyzed using descriptive and univariate statistical analyses (Wilcoxon Rank Sum, Chi-square, Odds Ratios). Of 7266 pediatric renal trauma patients, most were white (63.4 %) males (69.1 %), aged 12-18 (76.6 %), suffering from unintentional blunt trauma (86.9 %). Most (n = 6610, 95 %) received conservative management; however, 4.5 % (n = 298) failed. Common surgical interventions included ureteral stent placement (n = 200, 59 %), renal IR procedures (n = 44, 13 %), and nephrectomy (n = 33, 9.7 %). Nephrectomy rates at low AAST kidney injury grades (I-II) were higher with upfront surgical management (n = 7, 3.5 %) than with failed conservative management (n = 0). Predictors of failed conservative management included higher Injury Severity Score (ISS) and higher AAST kidney injury grades (III-V) (p < 0.05). Conservative management failed in 4.5 % of paediatric renal trauma cases, associated with higher AAST kidney injury grade and ISS. Upfront surgical management correlated with a higher nephrectomy rate at lower injury grades compared to failed conservative management. Refinement of pediatric trauma protocols is needed for optimal care. III.

Background: Secondary penile cancer, despite the region’s rich vascularization, is a rare phenomenon with only around 500 cases ever reported, typically of genitourinary origin and in even rarer cases, of colorectal adenocarcinoma. Unfortunately, the underlying mechanisms are not well elucidated, and prognosis remains poor with a late onset and median overall survival of 9 months for colon adenocarcinoma. Secondary penile cancer often presents alongside concurrent metastases months or years following successful treatment of the primary tumor. However, we report a case of an isolated penile metastasis as the presenting symptom of colon adenocarcinoma with no identifiable primary lesion or history of malignancy. Case Summary: A 67‐year‐old African‐American male presented with a 1‐month history of voiding symptoms, whereupon follow‐up revealed a penile mass near the left base of the penis. Postoperative histopathological, immunohistochemical, and genomic analyses revealed characteristics of invasive and metastatic colorectal adenocarcinoma. Initial diagnostic testing revealed elevations in serum tumor markers CA 19‐9 and carcinoembryonic antigen, while whole body PET/CT scan and colonoscopy failed to identify any tumorigenic lesions or primary colorectal malignancy. Although hypermetabolic activity was noted near the base of the penis and bilateral inguinal lymph nodes, the patient is currently on chemotherapy with a modified FOLFOX‐6 regimen with active surveillance and no adverse effects. Conclusion: Here, we report a rare case of isolated penile metastasis as the first presentation of colon adenocarcinoma with no primary lesion. Regardless of origin, secondary penile cancer is a rare phenomenon with a poor prognosis. While the exact mechanism of spread is uncertain, the most probable mode of dissemination is through venous networks. There is also no standard of treatment relying on surgical, therapeutic, and palliative management. Although unclear, our unique presentation may portend a more favorable prognosis with continued treatment and observation.

Background: Intravesical Bacillus Calmette–Guérin (BCG) is the standard treatment for intermediate-risk, high-grade, and high-risk non-muscle invasive bladder cancer (NMIBC). However, it is associated with adverse effects, potentially causing treatment interruptions or discontinuation. Objectives: This study analyzed the tolerability and efficacy of induction BCG, with associated patient- and disease-related factors. Methods: A retrospective analysis was conducted on BCG-naive patients diagnosed with high-grade NMIBC, who received induction BCG at our institution between 2011 and 2021. Tolerability was defined as the completion of a 6-week induction course of BCG without treatment interruption or discontinuation. Multivariable logistic regression was performed to determine risk factors associated with the inability to tolerate treatment. Results: Induction BCG was given to 203 NMIBC patients, where 147 (72%) patients tolerated the treatment. Treatment interruptions occurred in 44 (22%) patients, while 12 (5.9%) patients discontinued the treatment. The median length of interruption was 1 week, primarily due to concerns about urinary tract infection (UTI) (n = 18, 41%) or gross hematuria (n = 5, 11%). No significant difference in 1-year recurrence rates was observed between those who tolerated BCG and those who did not (50% vs. 48%). Risk factors associated with the inability to tolerate induction BCG included male sex (odds ratio [OR] = 5.76, p < 0.01), hypertension (OR = 3.47, p = 0.02), and low pre-treatment hemoglobin levels (OR = 0.73, p = 0.03). Conclusion: Inability to tolerate BCG occurred in 28% of patients, with 5.9% experiencing discontinuation. Interruptions were short, mostly concerning UTI, and rarely leading to discontinuation. Poor tolerability was associated with male sex, hypertension, and low pre-treatment hemoglobin levels, highlighting critical targets for reducing the risk of BCG interruption or discontinuation.

Background and Objective: A standard of care for muscle-invasive bladder cancer (MIBC) is cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC). Given recent improvements in NAC and the morbidity associated with RC, bladder-sparing therapy has been investigated as a promising treatment for patients with MIBC who experience a complete clinical response (CCR) to systemic therapy. However, clinical staging is unreliable, making it challenging to determine ideal candidates for bladder-sparing therapy. Our primary objective is to review the efficacy of NAC, strategies for determining a CCR as a surrogate for a complete pathologic response, and the emerging role of imaging, tumor genomics, and biomarkers in selecting candidates for bladder-sparing therapy. Methods: We surveyed the literature for studies investigating the outcomes of current treatment modalities for MIBC and methods for determining a CCR following systemic therapy as well as the impact this has on pathologic staging. Studies employing imaging, tumor biomarkers, and genomics were included. Key Content and Findings: Clinical staging with cystoscopy or transurethral resection shows significant discordance with final pathology, with high rates of understaging. Multiparametric magnetic resonance imaging (mpMRI) has shown strong utility in determining the presence of MIBC, but it has yet to reliably identify CCR. Meanwhile, somatic DNA damage repair mutations and biomarkers such as circulating and urinary tumor DNA are strong predictors of recurrence, showing promise in predicting and monitoring a CCR to systemic therapy. Multiple ongoing trials are currently assessing the use of biomarkers and genomic analyses in determining eligibility for bladder-sparing therapy. Conclusions: While no one method has reliably demonstrated the ability to detect a true CCR, a multimodal approach involving imaging, biomarkers, and genomic analyses holds promise. We eagerly await the results of clinical trials investigating these tools, which may allow for the safe recommendation of bladder-sparing therapy.